We argue that ‘belonging’ can be fostered in local spaces with local people. Utilising ‘untapped’ local learning support and existing physical spaces mitigates geographical, cultural, and financial challenges, and provides academic and emotional support. We propose a coordinated network of physical study places and local people, including: regional ‘satellite’ campuses; regional study hubs; local public libraries; and schools, where online students can be supported, connected, and engaged in their studies whilst located in regional and remote communities.The higher education participation and success rates of students in low socio-economic status (SES), regional, rural, remote, and isolated areas – who often attend university later in life – is a persistent concern in Australia and beyond. This article focuses on mature-aged students in low SES, regional and remote areas in Tasmania, Australia, proposing that universities harness local belonging when providing learning opportunities. It draws on a thematic analysis of 19 semi-structured interviews with current and prospective university students, and community stakeholders. The study identifies time and place-based barriers to studying on campus: students’ commitments outside of university; and geographical, cultural, and financial challenges. However, existing local infrastructure, such as libraries, create opportunities for face-to-face interactions and learning support for students who study online in their regional or remote communities, provided by staff and local volunteers. These barriers and solutions are discussed using the concept of ‘belonging’, framed spatially and culturally. Current literature on regional and remote higher education students tends to emphasise ‘not belonging’  The difficulties of engaging in education in regional, rural, remote, and isolated areas have been well documented in Australia and internationally  Connect Library Program’ was one initiative that linked online university students with local libraries Stone, , and theWhile researchers have explored the experiences of regional and remote university students, less attention has been paid to the impact of geographical distance, transport, and travel on these students  for people living, working, and studying in low SES, regional and remote Tasmanian communities, rather than focusing on what needs to change to fit the norms and expectations of ‘belonging’ in/to city campuses. These considerations are informed by Roberts’  ‘rural sInterviews were conducted with community members/prospective mature-aged students; current mature-aged university students; and local stakeholders who worked or volunteered in roles related to education. The student interviewees were recruited through online surveys distributed to students currently or formerly enrolled in UTas’s University Preparation Program who met the inclusion criteria of being mature-aged and were living in a low SES and regional or remote area; survey respondents could indicate their interest in being interviewed upon completion of the survey. Community members/prospective students were recruited through local community events (where attendees were asked to complete a hardcopy survey and invited to express interest in being interviewed). The community events attended by members of the research team were in low SES communities; these communities were also in outer regional areas, which were surrounded by other outer regional or remote areas. Members of the research team attended four day-long or evening events in different parts of Tasmania. The stakeholder interviewees were recruited through their local workplaces and professional links to UTas.The article’s first author worked in UTas’s University Preparation Program for a number of years; in addition, one of the members of the research team had extensive connections with local stakeholders from prior outreach and equity programs conducted at the university. A mix of approaches – face-to-face ‘in community’; hardcopy and online surveys; and telephone interviews – were undertaken for recruitment and data collection. This combination helped mitigate the challenges of ‘distance’, time, and financial costs when undertaking such research.The findings reported include the qualitative analysis of 19 telephone interviews from the aforementioned participant groups. In discussing our findings, we focus largely on the accounts of the nine stakeholder interviewees, with supporting data provided by community members and students. The stakeholder participants worked or volunteered in local public libraries  belonging and distance. Practical impediments included minimal time, transport difficulties, and poor internet access. Some obstacles were based on universities’ practices, such as difficulties dealing with the mode of course delivery and a perceived lack of flexibility from teaching staff (lecturers/tutors). Physical distance to a campus was both a practical and financial obstacle, and impacted people’s senses of ‘not belonging’ in those spaces. Interviewees also proposed potential strategies, which included physical study spaces in their local areas, support from local people, and face-to-face study groups, which took advantage of their senses of local belonging.I wouldn’t study online [again]. I think online study takes too much time. Perhaps for younger people, but I can’t see any sense in studying if you don’t understand… I don’t know what it’s like now, but I think perhaps there is more help now, and I think they’re trying to do more, but once again they can only do so much… I don’t really agree with online learning because I think quite a few students see that [as] the easy way out, and it’s not.For students who cannot attend campus due to work, family, travel, or financial reasons, studying online is often presented as a realistic alternative by universities. However, interviewees highlighted challenges with studying online from their ‘distant’ local communities  that catered for ‘time-poor’ students, such as a learning experience where ‘it was all around weekend workshop-based work, and online work, you know, assignments, projects-based work that we could all manage, in amongst our busy family and work lives’. In this example, the Course/Unit Coordinator had designed the content and assessments to align with the needs of students living far from the ‘main’ campus, as well as those engaged in full-time work. Michelle praised the thoughtfulness of the Coordinator responsible for this ‘flexible’ delivery, noting that it was an exception and that some teaching staff ‘are just plain inflexible’. Throughout her degree, she encountered difficulties with distance and her related inability to attend classes, as she was expected to travel to Hobart, a five-hour one-way drive. As a result, she did not complete the course.Overall, stakeholders and students complained that course design tended to be inflexible for students learning ‘at a distance’, presuming that students were available on weekdays and able to travel to campuses. This perceived inflexibility was not necessarily due to academics’ lack of awareness; rather, structural and financial factors impacted their abilities to take a more regional/remote-centred approach. One factor informing ‘inflexible’ course delivery is the casualisation of the university workforce. Increasingly, university teaching staff are employed on short-term, precarious contracts, and are underpaid for this work  prestigious university he had been accepted to without financial support. He added that today, people in his local area faced similar problems:Other place-based barriers included feelings of discomfort and not fitting in at university campuses. Stuart, who managed a local library, described the strong sense of community in his rural area, noting that visiting spaces outside this locale could be confronting:I think for a lot of people there is a strong sense of local community, and I think some of it is that people feel very comfortable within their own sphere, within their own sort of small community, but they feel uncomfortable going out of that… it [the university campus] is only half an hour, 45 minutes up the road. For some people that’s almost like another world.Whilst the drive to the city campus might not be considered long in terms of time or kilometres travelled, particularly by Australian standards, it was nevertheless seen as considerable by some community members. Places were considered distant in terms of people’s behaviour, knowledge, expectations, and values. Stuart reflected on local community members whose families had lived in the small surrounding towns and rural areas for several generations. They found visits or moves to larger towns to be ‘outside their comfort zone’. This discomfort was about physical distance and ‘cultural’ difference, and was evident in people’s feelings of disconnection and ‘non-belonging’ on urban university campuses, in contrast to how they experienced their home communities.Stuart mentioned a physical landmark between his rural community and the urban campus, remarking that ‘the big saddle’ is ‘almost a geographical barrier’. He added: ‘It’s a big deal almost for some people to cross over the saddle because you’re leaving… your home community and you’re going into Hobart’. This geographical landmark appeared to signal a boundary between ‘belonging’ and ‘not belonging’. ‘Distance’ was not only a matter of time travelled, but was also judged in terms of the terrain and conditions of that journey. Tasmania’s unpredictable and often severe weather conditions meant driving-related challenges, such as black ice, as noted by Stuart. This added to the difficulties of travelling to campuses, which not only felt ‘like another world’ – one where regional and remote students did not feel ‘at ease’ with themselves or their surroundings May,  – but coFeelings of disconnection, non-belonging, and distance to urban centres also impacted whether students even contemplated further studies. Judy, who managed a neighbourhood house, pointed out that people in her outer regional area (and neighbouring remote areas) did not see themselves in the university’s advertising:[T]hese brochures that come out, about the higher education training… They don’t reflect our community… And I looked at the front brochure… all very nicely dressed, and I can tell you straight away, that my clients would look at that and that is not… that does not resonate with them because it’s not… that’s sort of like American TV to them. So straight away that’s a barrier that I see to engaging.For local people to consider university studies, Judy asserted that they need to see that people ‘like them’ attended university; they also need to have social contact with and receive academic advice, support, and mentorship from people ‘like them’, such as those living nearby with whom they felt there was less ‘distance’.Well, the libraries, I think they have – or there is TAFE of course – but at the library, they have computer training and I think… but I really don’t know… I found that the only place I would do this sort of study is at a university.Feelings of ‘not belonging’ were also connected to potential students’ limited knowledge about the possibility of higher education. Students appeared unaware of the local support already available, with Monica responding, when she was asked if she had access to any local support:Several of the stakeholder interviewees noted a lack of awareness of study opportunities and local study support in their communities. Peggy’s frustration was evident throughout her interview: ‘I would guarantee that, you know, we’re doing our best to promote what we have got, that most people wouldn’t have any idea, wouldn’t even think that they could go to the library to get help for their university studies’. Stakeholders like Peggy felt that community members were not taking advantage of local initiatives. However, as Judy highlighted, such initiatives were not necessarily well publicised, nor promoted effectively to potential mature-aged students in these communities. Overall, there were numerous barriers for students relating to ‘distance’ that intersected with students’ sense that they did not belong at university, including the cost or difficulties of travel and a sense of being different and distant to other university students. Meanwhile, they had little knowledge of the local support that might foster their sense of ease and belonging among other regional and remote, mature-aged, low SES students.The findings above suggest that local spaces and connections have a significant role to play in engaging and fostering belonging among regional and remote students. Several of the communities explored here had been providing study facilities, as well as academic and social/emotional support from staff and volunteers, for a number of years. Local libraries in low SES, outer regional areas in Tasmania provided computer and internet access, as well as free printing facilities and quiet rooms for study . A local trade training centre, situated alongside a secondary school, provided after-hours access to computers and internet in a computer lab (as noted by Michelle). Such physical spaces were invaluable for students who required reliable internet and access to free printing, and aimed to combat experiences of exclusion, distance, and missed social and educational opportunities  at their local libraries. Peggy explained that study groups had been a semi-regular fixture for many years, depending on interest:We just had a regular time basically, and we would address people’s questions and just help them as needed. We weren’t there to teach as such, but it really was a support role, so supporting them with the [Learning Management System], supporting them with the process. If they’re thinking, “Oh no, my assignment is going to be late, what do I do?” so helping them with who they need to call for that.Peggy noted the benefits for online students who, faced with feeling isolated and distant from their campuses, ‘almost without fail they said without this study circle we would not have done it’.Membership of study groups often consisted of students in UTas’s University Preparation Program, due to a collaboration initiated by the UPP Manager in 2013 with Libraries Tasmania . We elaborate on the ‘untapped’ potential of local people and spaces in regional and remote higher education, while considering the sustainability of community collaborations and funding arrangements.Our findings highlight practical, geographical, cultural, and financial challenges of university study faced by current and prospective mature-aged university students in low SES, regional and remote areas in Tasmania. Studying online is often presented as a viable alternative for people who juggle work and families, and do not have the time or finances for frequent travel to attend classes. However, online study also has its challenges, such as unreliable internet; unpreparedness for this mode of study; missed learning, career, and social opportunities; and isolation from peers and staff  campus or a regional study hub , they can complement their online studies with time spent at a physical space, benefiting from practical, academic, and emotional support from staff and peers  campuses and Regional University Centres. In this network of physical spaces, online students can be supported, connected, and engaged in their studies whilst located in their regional and remote communities.The value of local infrastructure has been acknowledged in relation to Australian regional and remote education. In a review of Australian higher education more than a decade ago, Bradley et al. , p. 111 Our findings highlight the need and potential of existing local infrastructure. Through looking beyond the metropolitan norm and adopting a ‘rural standpoint’ Roberts, , it becoMany regional and remote communities already tap into the knowledges and educational experiences of retirees and people relocating to their communities who, like Neil previously mentioned, are often eager to support education in their local area. The Tasmanian regional and remote student experience is regularly characterised by social isolation from peers and a sense of distance, a finding that mirrors previous studies (Currie et al., There is thus a need for long-term and place-based approaches to resourcing local study support in regional and remote areas. At present, the disappearance of previously successful programs – due to staff changes and short-term funding – appears to be commonplace. While funding is important for starting and maintaining initiatives, and paying staff, much of the necessary infrastructure and people are already in place. What is required is a long-term commitment – collaborations between universities, the vocational education and training sector, libraries, and communities – to coordinate, maintain, and sustain projects and networks. Certainty and continuity of funding for regional initiatives that centre local belonging and solutions, and moving beyond an approach that problematises their ‘distance from’ urban centres, is crucial. One of the key issues identified by interviewees was that local initiatives are intermittent, emerging and disappearing with changes in funding and student numbers. Resources become scarce and organisers move on. It is important to maintain the momentum in these initiatives, as re-starting previous projects can be costly and lead to lost knowledge and expertise. Funding for local study support – such as for coordinating a network of volunteers in local places – would not only benefit individual students and their communities, but also universities in terms of improved retention and completion rates and the resultant funding received.off campus with regional and remote peers. Others may benefit from intensive ‘adult outreach’ (see also Bradley et al., Moreover, initiatives need to be suited to and draw on existing social connections within their local contexts (Lähdesmäki et al., For mature-aged students who live, work, and study in regional or remote areas, relocating to study on campus is not, in most cases, a realistic option. Online study is one alternative, but it has well-documented challenges, such as isolation, exclusion, and non-belonging. These tend to be the focus of much research, yet emphasising the distance between regional and remote students and their on-campus counterparts often serves to hold up the latter’s experiences as something to be emulated (Jury et al.,


Medically speaking, physical decline starts after the age of 25. Generally, people do not sense such a decline at a young age, but most transition to some awareness by the age of 50. To enhance the physical and mental health of elderly people and to reduce the length of time spent bedridden, the thoughts and behaviors regarding health and health care among a target group aged between 55 and 75 years were investigated in this study based on the perspective of health beliefs. A total of 300 survey questionnaires were issued and all were returned. The results indicated that after the respondents were reminded of the unhealthy implications of bedridden time, they were willing to enhance their health-promoting behaviors in their diets and regular routines. In Taiwan, according to statistics from the Ministry of Health and Welfare, the Disability-adjusted Life Years (DALYs) of individuals in the country reached 8.47 years in 2019, which was a new record high over the past eight years. (Along with the issue of Disability-adjusted Life Year (DALY), attention must also be paid to the importance of healthy life expectancy. People find that with the progress of medical treatment, prolonging life is not out of reach, however quality of life is the real goal that should be pursued. As far as impact is concerned, when comparing the average life expectancy of people in different countries, World Health Organization (WHO) no longer only looks at the single figure of average life expectancy, but also looks at the average healthy and unhealthy life expectancy and “the longer average healthy life expectancy and shorter the DALY”, which is regarded as an important indicator of a progressive country). This means that the elderly are unable to live independently in their later years and need to be taken care of. Furthermore, their quality of life is poor half due to chronic disease or disability [In recent years, accidents involving sudden death due to cardiovascular problems or cerebral hemorrhages have become more frequent, and many people may have believed that they were still healthy even though they were very busy. It is easy for people to succumb to chronic conditions such as diabetes, hypertension, and cardiovascular disease after the age of 40. In the early stages of these diseases, one’s situation can be improved through life adjustment. However, after some time, people may need to take medicine to stay healthy in the long run. Therefore, it is necessary to pay attention to one’s health over time in order to reduce the likelihood of becoming bedridden in old age and to improve the quality of life in the longer life expectancy. This study hopes to increase the subjects’ awareness and anticipation of an unhealthy bedridden age by cognitively increasing their own health-promoting behaviors. With regards to changing health-promoting behaviors, increased knowledge through cognitive factors can reduce the excuse of not exercising due to being busy with work. It is important to increase health-promoting behaviors.The theme of this research is health promotion for middle-aged and elderly people. It is mentioned in the health belief model that changing behavior requires self-benefit. Previous studies have found that when adults are busier with work there is no time for them to engage in health promoting behavior. Awareness of the life expectancy of the subjects and the number of years spent bedridden made them willing to add health-promoting behaviors to their existing health behaviors. The study found that the life expectancy and healthy life expectancy of those who were over the age of 65, retired, and who have a high disposable income were higher. In terms of increasing health-promoting behaviors, having three meals at regular intervals and maintaining a positive mood are items that promote more behavioral improvement. This paper is divided into the following: First, we explain health promotion, the health belief model, and cognitive research on health promotion. Secondly, the research method includes the research object, research design and procedure. Third, a description of some health-promoting behaviors that can be implemented now. Finally, the conclusion and discussion, which illustrates the contribution and limitations of this research in terms of practical suggestions and theory.In 1986, the World Health Organization (WHO) held the first international meeting on health promotion in Ottawa, Canada, and the “Ottawa Charter for Health Promotion” was created. At that time, it was thought that “health promotion” was a process through which people could strengthen their control and enhance their own health. Green and Kreuter (1999) proposed that health promotion be understood as a planned strategy or action through which associations between education, politics, laws, and organizational support promote the healthy life of an individual, group, and community . GeneralHealth promotion emerged in the 1990s as a unifying concept which brought together a number of separate, even disparate, fields of study and has become an essential part of contemporary public health . “HealthDuring the early 1950s, the Public Health Service was oriented toward prevention, not the treatment of disease. The health belief model (HBM), influenced by the theories of Kurt Lewin, was developed and includes the motivation and perceptions of an individual. It is useful to explain the problem with health promotion programs . The serThe health belief model refers to the actions taken by an individual toward realizing certain health behaviors. It is related to the individual’s self-perception of their possible susceptibility to certain diseases (perceived susceptibility) and their self-perception of the serious consequences of suffering from those diseases (perceived severity). If an individual feels that they could easily acquire a disease and that the result would be very serious, the benefit of adopting certain behaviors to prevent the occurrence of such disease would far outweigh the loss of exploring other behaviors. If there is an appropriate cue stimulus, then the possibility of the individual adopting these behaviors will be greatly increased . After cThe focus of this study was on the use of self-benefit (non-bedridden status) to cross perceived barriers.Cognition presents a comprehensive review of cognitive psychology which includes sections on representation in memory, abstraction and iconic concepts, symbolic concepts and mental structures, mental operations, consciousness, and search strategies and problem solving . In the The respondents in this study were 55–75 years old and had a monthly disposable income greater than NT$30,000 (referring to the disposable amount after deducting necessary expenses) or owned real estate. Respondents were recruited via the snowball sampling method , which is a method of convenience sampling. The final recruited sample size was 300 for the questionnaire survey. All testing procedures were performed in accordance with the 2013 World Medical Association Declaration of Helsinki and were approved by the Research Ethics Committee of Chang Gung Medical Foundation Institutional Review Board in Taiwan (IRB number: 201801878B0C604). The main fieldwork was carried out by 12 trained interviewers between April and May 2020. All respondents provided a phone number, so corrections could be made by phone. This ensured that there were no missing data in the end.The survey questionnaire was designed based on secondary data collection and the anticipation of health behaviors. To prepare the draft of the quantified survey questionnaire, the questions were developed from the 2D factor dimensionality theory. The questions were then revised after expert discussion and pre-test procedures to settle on a final version. The survey questionnaire was then reviewed, revised, and adjusted in terms of its guide words by the Chang Gung Medical Foundation Institutional Review Board. The survey questionnaire was issued to targets conforming to case-receiving conditions; in the end, the number of returned survey questionnaires that were considered effective was 300.Social demography variables, including age, gender, present work situation, occupation, educational level, etc.Perceived health conditions: This was a self-report of the sample on their health status, including perceived health conditions, health level as compared to that of 3 years ago, prediction of self-health, and autonomous non-bedridden age.Living habit situation: After reminding the respondents of what unhealthy bedridden years were, the sample showed a stronger willingness to continue with behaviors that he/she had implemented, or increased behaviors that could be implemented presently. The contents included previous dieting methods, present dieting methods, previous physical activity, and present physical activity.The content of the survey questionnaire included the following parts:In total, there were 57 items, including 10 demographic items.Among those who responded to the questionnaire, 52% were female, and age was mostly in the range of 55–64 years old (60%). Regarding religion, the highest percentage (41%) were Buddhist. For educational level, those above senior high/occupational school comprised 77% of the sample. With respect to birthplace, Islanders and Southern Fujian comprised about 71%. A total of 56% were retired, and about 30% worked in commerce. For marital situation, married or cohabitating individuals comprised about 82% of the sample, and 78% were living with a partner/spouse. A total of 70% had experience taking care of parents. The demographic information with the largest proportion of personal basic information for the 300 questionnaire subjects is shown in (1)Self-health situationThe main results found from the questionnaire survey analysis are as follows:Those with a good perceived health situation (“very good” and “good”) comprised 54%, 42% perceived their health situations as fair, and 4% reported bad health situations. Those under the age of 64 who were presently employed with a higher disposable income tended to have a better health situation. The arrow in (2)Self-age predictionOf those in the sample, 49% felt that they might be able to live up to 81–90 years old and 12% felt that they might live beyond 91 years old. As the (3)Prediction of age of self-health and autonomous non-bedridden ageOf the respondents, 59% felt that they could not have a healthy, autonomous, and non-bedridden life before 80 years old, 36% felt that they could still have a non-bedridden life before 81–90 years old, and 6% felt that they could have an autonomous and non-bedridden life even after 91 years old. The average age at which individuals predicted that they would still be autonomous and non-bedridden was 81.5 years. Those above 65 years old who were retired generally felt that they would have autonomous and non-bedridden lives at a higher age. The detail of the subgroups, please refer the (4)Health situation compared to that of three years agoCompared to their circumstances three years ago, the differences in the respondents’ self-evaluated health situations were reported as follows “memory was worse than before” (69%), “physical strength was worse than before” (59%), “did not know the cause of waist and back pain” (31%), “red numbers appeared in health report” (27%), and “catching a cold more frequently” (7%). Only 8% did not have any of the above issues. Those who were still employed reported not knowing the cause of waist and back pain at a higher rate. People with a monthly disposable income of more than NT$50,000 had a higher tendency to report that their memory was worse than before. Those with a monthly disposable income of less than NT$30,000 reported not knowing the cause of their waist and back pain at a higher rate (see (5)Previous dieting methodThe dieting methods reported to have previously been adhered to were mainly and sequentially “less or reduced sugar in the diet” (76%), “fixed time and quantity in three daily meals” (72%), “having two kinds of fruits every day” (58%), “having vitamins or other health food every day” (53%), and “having three dishes of vegetables every day” (51%). Less than half of the subjects had the habit of “eating food containing husked rice or the five cereals”. Meanwhile, subjects above 65 years of age were more likely to eat two fruits and vitamins or other health foods every day, compared to those below 64 years of age. Moreover, a relatively higher percentage of retired people ate a fixed quantity at specific times for three meals each day, with two fruits and three dishes of vegetables each day.(6)Previous physical activityPrevious physical activity included, in sequential order, “maintaining a positive mood” (83%), “sleeping more than six hours daily” (79%), “maintaining autonomous exercise habits” (54%), “sitting for less than 90 min at one time each day” (43%), and “walking 6000 steps daily” (40%). Less than 30% had attended a sports club. Relatively speaking, people above 65 years old tended to have more autonomous habits than people below 64 years of age. They also tended to be less likely to sit for a duration of more than 90 min than people below 64 years of age. Those who were retired tended to have more autonomous exercise habits, were more likely to attend sports clubs, and were less likely to sit for a duration of more than 90 min. Meanwhile, people with monthly disposable incomes of less than NT$30,000 tended to be less likely to participate in sports and fewer have autonomous exercise habits Present dieting methodsFor the sake of their health, dieting methods presently employed were mainly and sequentially as follows: “having fixed times and quantities for three meals each day” (86%), “having less or reduced sugar” (85%), “having two fruits each day” (80%), “having three dishes of vegetables daily” (73%), “eating as much husked rice and cereals as possible” (65%), and “taking daily vitamins or other health foods” (63%). The number of people who were willing to watch their diets after completing the questionnaire survey is shown in (2)Present physical activityFor the sake of health, present physical activity were sequentially as follows: “maintain a positive mood” (89%), “sleeping for more than six hours daily” (85%), “having autonomous exercise habits” (72%), “walking 6000 steps each day” (62%), and “sitting for less than 90 min each time” (60%). The number of people who were willing to engage in more physical activity after finishing this survey questionnaire is shown in Among the 300 responses to the quantitative survey questionnaires, it was found that most of the participants thought that they could not have a healthy, autonomous, and non-bedridden life before 80 years old, even if dieting adjustments were made and physical activity levels were increased at the present time. Although body function deteriorates gradually, leading to the occurrence of more accidents, participants were still worried that they were insufficiently managing their health at the present time. Meanwhile, after reminding those of the significance of unhealthy bedridden years, in addition to the health behaviors that had been engaged in previously, respondents were willing to add more health promotion behaviors to their diets and daily routines in order to avoid the occurrence of bedridden situations. For this study we used convenience sampling and trained interviewers to collect the data. The results are not obtained from standard sampling procedures, so the power of the generalization is limited. The implication of these results should be mentioned in a conservative manner. In the future, studies should use more standardized sampling procedures.To avoid a bedridden life, it is necessary to change bad living habits and to have periodical health checks. Because diseases can accumulate from small actions, prevention is better than a cure. If people have little knowledge about the future, they tend to make no changes; however, after they learn about something that they might have to face in the future, they may be more likely to change their present situation. This may also reduce unnecessary expenses in national healthcare systems. Ultimately, the goal is for people to enjoy a healthy and happy life.


In recent years, researchers have become increasingly interested in exploring frequency as a source of variability in heritage speakers’ (HSs) knowledge of their heritage language (HL). While many of these studies acknowledge that frequency can affect the shape of HL grammars, there is still no clear consensus about (a) what “frequency” means in the context of HL acquisition and (b) how to operationalize its multiple subtypes. In this paper, we provide a critical overview of frequency effects in HL research and their relevance for understanding patterns of inter/intra-speaker variability. To do so, we outline how prior research has defined, measured, and tested frequency, and present—as well as evaluate—novel methodological approaches and innovations recently implemented in the study of frequency effects, including a new analysis of how self-reported lexical frequency reliably predicts HSs’ production of subjunctive mood in Spanish. Our aim is to highlight the immense potential of such work for addressing long-standing questions about HL grammars and to propose new lines of inquiry that will open up additional pathways for understanding HL variability. While every year heritage language (HL) investigators continue to expand the reach of their work in terms of linguistic content and methodological approaches, research in this field has primarily focused on two lines of inquiry. The first one is centered around rs e.g., . The secty e.g., —of diffety e.g., .In our estimation, the pursuit of these two lines of inquiry has led to the vast majority of what we now know about HSs and their grammars. Nonetheless, we must recognize that, as informative as they have been, neither line of research addresses certain fundamental—and often overlooked—puzzles of HL research, especially those that involve the study of variability at the intraspeaker level. In this article, we advocate for increased attention to two promising yet less commonly investigated areas of study, each of which we will summarize here and then elaborate upon throughout the remainder of the paper. Critically, both approaches open the door to fine-grained analyses of frequency, a variable that has thus far received much more attention in L1 e.g.,  and L2  researchbetween-speaker comparisons, that is, the analysis of the unique grammatical systems that develop in the minds of individual HSs. Although inter-speaker heterogeneity is a defining—and well-recognized—characteristic of HSs  variants  proposing that frequency-based analyses should play a key role in our study of between-speaker and within-speaker HL research and (b) sketching out future directions for investigations that follow this blueprint.In the present paper, we argue for the importance of prioritizing the inclusion of frequency-based analyses in future empirical work, which enable the exploration of inter alia). Thus, one would expect—all else equal—that a HS with extensive HL experience would perform in a less innovative (or more “target-like”) manner than a comparable peer whose use of the HL is relatively less frequent. Despite the consensus on this general—and perhaps obvious—point, researchers have dedicated relatively little attention to the question of how (and to what extent) between-speaker differences in HL usage/exposure/experience might lead different HSs to develop distinct patterns of grammatical knowledge with a given HL property. In fact, as noted by Regardless of theoretical background, HL researchers largely agree that HSs’ overall amount of experience with the HL, broadly conceived, will strongly affect the HL grammars that they ultimately develop . Critically—and in contrast with previous studies of HSs and subjunctive mood—More recently, two additional studies have strengthened the claim that HSs’ frequency of experience with their HL shapes the variability of their HL grammatical systems. What sets these studies apart from Perhaps the most thorough attempts to connect the linguistic experiences of HSs to the grammatical systems they develop are In the studies reviewed above, we have seen preliminary evidence that between-speaker differences—that is to say, differences in the grammatical knowledge of different HSs—seem to be caused, at least in part, by differences in HSs’ frequency of use of and exposure to the HL. Weakening this conclusion, however, are two major methodological and epistemological concerns. First, it is not yet clear that language background questionnaires offer an accurate or reliable assessment of HSs’ actual patterns of HL use both (a) at the moment of data collection as well as (b) in earlier stages of their lives. This is especially concerning if HL use/exposure is more impactful during early childhood, as suggested by several researchers e.g., . So how,before beginning school, a period of time that likely predated their study participation by 13+ years. In households where parents exclusively used Spanish—and required their children to do the same—such estimates may, in fact, be quite reliable. . In households with more varied language practices, however, it is difficult to imagine that college-aged HSs could accurately and reliably recall percentages of their overall language usage during childhood. Consequently, differences in the middle of the (estimated) HL usage spectrum—e.g., between HSs who reported using their HL 60% of the time vs. those who reported using it 40% of the time—seem far less likely to effectively predict differences in speakers’ command of the HL in adulthood. Critically, this might be the case even if the “true” difference between 40% and 60% HL use does have important effects on adult HSs’ eventual grammatical knowledge.If it is challenging for HSs’ parents to estimate their children’s (current) HL use, it is likely even harder for adult HSs to accurately pinpoint the percentage of the time that they themselves used their HL (at the time of data collection or—cumulatively—throughout their lives). The adult HSs in López-Beltran’s  study, fand HL proficiency were statistically significant predictors of HSs’ grammatical performance, making it impossible to isolate the specific influence of HL use itself. . Given this conceptual difficultywhere exactly do these differences emerge?A second (and related) concern with quantifying the effects of HL use, as mentioned in the preceding paragraphs, is that HL use/exposure is often strongly correlated with—and therefore hard to disentangle from—other potentially influential factors such as HL proficiency, age of acquisition of the majority language, and even formal education in the HL. As noted above, and indicative when subjunctive is expected, we will need to make within-speaker comparisons , which offer the micro-level perspective necessary for understanding individual HL grammatical patterns. In “Lexical frequency and its role in heritage grammars,” we elaborate on this point, using lexical frequency effects as an illustrative test case.To illustrate this conundrum, consider the following hypothetical. John and Carlos are both HSs of Spanish, though John reports using his HL two times as often as Carlos.  When John and Carlos complete an experimental task designed to assess their knowledge of mood morphology, John produces subjunctive in 80% of expected contexts while Carlos only does so in 40% of the same contexts. This hypothetical between-speaker difference would appear to indicate that Carlos’ HL usage affects his production of subjunctive mood. Nonetheless, this finding does not tell us where, at a fine-grained grammatical level, the two speakers differ from one another. It is possible, for example, that Carlos tends to use subjunctive with irregular verbs, or with forms that are more frequent, or even in contexts that are more likely to appear in academic/formal registers. In any case, the purpose of this example is to show that identifying between-speaker differences, though important, only provides indirect insight into individual patterns of HL development. To understand variability within a single speaker, that is to say, what factors lead Carlos to alternately produce both subjunctive, lexical frequency), which has recently emerged as an area of interest in HL research , addresses the question of how the rate of occurrence of certain forms or structures in the HL input/output may affect their representation, processing, and use  with which HSs use (and are exposed to) their HL. There is, however, another more fine-grained way in which frequency has been implemented to analyze patterns of language maintenance and change/innovation among heritage bilinguals. This second “type” of frequency , prove to be much more resistant to overregularization or simplification than less frequent counterparts  features being mapped onto specific (morpho) phonological exponents) provides us with a systematic way to model and predict how frequency in the input could either reinforce such mappings, or allow for a disassociation between them, generating a wide range of outcomes that could have consequences at the level of production as well as representation  the HL often observed among HSs provides the perfect backdrop for the study of lexical frequency effects, in part, because this factor establishes a direct—and quantifiable—connection between speakers’ linguistic experience and how they represent and use language. It seems feasible, for example, that the relatively reduced input to which many HSs are exposed could drive them to rely more extensively on highly frequent HL items or structures, likely at the expense of lower frequency forms with which they have much less experience. As a result, properties or forms that are highly frequent in the (baseline) input might become more entrenched in the grammars of HSs, leading to lower levels of optionality in their useentation .within speakers rather than between them. This change in perspective provides new and additional explanations to long-standing questions, such as why morphological variability tends to appear in certain forms but not in others, or how HSs’ lexical knowledge affects their overall linguistic development in the HL . In the context of HSs, this would predict that more frequent items—from a token frequency perspective—would be, as a result of their autonomy/strength, more easily recognized and decoded in comprehension and less likely to exhibit variability in productiontype frequency, likely the second most studied frequency category, captures the productivity of a particular pattern in language and accounts for analogical leveling in language acquisition, that is, the (over) application of a specific rule to forms that present relatively less common patterns do/−(a) do to the root of the verb, as in the case of llegar-llegado (‘to arrive/arrived’) or ser-sido (‘to be/been’). Irregular past participles, by contrast, can present a wider range of morphological instantiations, following patterns such as those in hacer-hecho (‘to do/done’), or poner/puesto (‘to put/put’). However, even within the subcategory of irregular past participles that end in-to, there are a number of different subpatterns, e.g., romper/roto (‘to break/broken’) or escribir/escrito (‘to write/written’), to give two quick examples. Thus, if we were to describe Spanish past participles based on their lexical frequency, we could do so in at least two different ways:Since token and type frequency interact with one another in complex ways , we belitoken frequency perspective, we could report and contrast their frequencies of occurrence in the input as documented by participant self-reports or by language corpora, such as the sido) are used relative to others . Though both sido and llegado are regular past participles, for example, sido is over five times more frequent; similarly, while hecho is an irregular participle, it is used about twice as often as the regular participle, llegado. These differences in token frequency—both within-and across-different types of regularity—could very well affect how HSs (and other Spanish speakers) learn and use participial forms.a) From a type frequency perspective, we could analyze the productivity of the different word-formation patterns involved in the forms under consideration. As proposed by sido and llegado, which present one of two different instantiations (−ado or-ido); and those observed in irregular forms . While the regular past participles-ado and-ido exhibit similarly high type frequencies, irregular participles have a wider range of different allomorphic subpatterns—b) From a hecho or puesto) tend to be overregularized—e.g., to hacido or ponido–, especially during the first stages of acquisition (ado/−ido) than irregular forms. Pattern productivity alone, however, does not explain the gradience of outcomes observed in language acquisition, where overregularizations appear to be resolved in some verbs earlier than in others  vs. resuelto (‘resolved’), as documented by Prior work on the acquisition of these structures among Spanish speakers  has found that irregular verbs (such as uisition . In someuisition . Mason (The effects of (type and/or token) frequency may also be examined by controlling their presence through careful study design and stimuli selection. This is precisely the strategy we adopted in our ongoing work on subjunctive mood among Spanish HSs in the US (see retenga (‘to retain’), which, though infrequent, still elicits a very high rate of subjunctive production, a finding that opens up new areas of inquiry concerning word compositionality and the opacity/transparency of seemingly compound verbs.  Overall, these findings not only provide additional insight on the effects of token frequency on subjunctive use, they also present a more nuanced description of morphological irregularity, which has generally been presented as a uniform, somewhat monolithic category.By controlling for type frequency, we were able to sidestep a key, potentially confounding variable and examine the effects of token frequency more directly, which gave rise to important differences across irregular verbs. The results in cut, for instance, includes all possible forms of this verb, such as {cutting, cut, cuts…}, as well as the word’s nominal variants {cut/cuts}. Choosing to analyze the effects of verbal or nominal lexical frequency from a lemmatic perspective carries theoretical implications regarding how words are represented and accessed in the lexicon. In particular, it is assumed that the (cumulative) frequency of the paradigm will affect the lexical strength of individual—morphologically related—forms, making them more/less recognizable and likely to be retrieved. Adopting lemmatic frequency might be suitable for research where individual word differences are not central  lexical frequency modulate the complexity of a text). Recent work dedicated to the study of frequency effects on morphological families, however, reports that the frequency of individual forms is more likely to predict variability in production, even if form similarity  might play a role in how related items compete with each other (comprará (‘(he/she) will buy’) [7936] vs. va a comprar (‘(he/she) will buy’) [3754]), or b) reporting the frequency of the complete paradigm in the form of lemmatic frequency (comprar [509875]). If we include the token frequency of all the forms involved, we would be able to explore whether (and how) the individual frequency of each inflection could affect HSs’ performance. The use of lemmatic frequency, in contrast, would limit our analysis to general frequency effects, allowing us to gauge the extent to which the frequency of a particular verb, regardless of its inflection, might drive HSs’ preference for one type of future over another. This broader perspective on frequency would allow us to capture verb-general effects, e.g., that Spanish speakers tend to use one type of future more with verbs that are collectively more frequent—that is to say, when all of its paradigms are collapsed together.Although less common, lexical frequency can also be examined from a lemmatic perspective, that is, considering the effects of all the inflectional variants of a particular form  all of which are represented with a single lemmach other . These fThe previous discussion highlights the potential contributions of lexical frequency (in its different instantiations) to HL research, underscoring how individual speakers’ experience with a HL might shape their grammatical knowledge and use. In the next section, we provide a summary of recent investigations that have examined the effects of lexical frequency on HSs’ morphosyntactic development of the HL. After summarizing these studies, we present novel evidence that HSs’ subjective assessment of lexical frequency more effectively predicts their patterns of subjunctive mood production than corpus-based frequency metrics.inter alia). As previously mentioned, the majority of the research in this area has focused on the domain of morphosyntax, with a particular emphasis on the acquisition of nominal and verbal inflection. Rather than manipulating it, some studies  was between 1 and 72 per 400,000 words. Additionally, the number of sentences that featured each governor was made proportional to its frequency, meaning that frequent triggers in the corpus appeared proportionally more often in the experimental task.  studies  have use studies  auditoryco CSCM; . SpecifiThe experimental designs adopted by decir (‘to say’) and repetir (‘to repeat’)—that represented both ends of the frequency spectrum, as seen in the contrasts illustrated in Lexical frequency, in particular token frequency, can also be manipulated to determine the extent to which it affects HSs’ ability to abstract grammatical knowledge from the input and generalize it across a wide range of lexical items. M = 0.65) rather than lower frequency (M = 0.51). Even though the type of matrix verb did not significantly affect HSs’ performance in a separate production task, a descriptive analysis of the data indicated that their probability of using subjunctive in jussive (indirect command) contexts was higher when the matrix verb was frequent (M = 0.64) than when it was not (M = 0.54). Token frequency has also been shown to affect intermediate Spanish HSs’ likelihood of using DOM in the expression of animate direct objects. In particular, M = 0.21), such as cuidar (‘to take care of’ [7531]) than with less frequent ones (M = 0.07), such as acariciar (‘to pet’ [427]). Crucially, this pattern was not replicated among advanced-proficiency HSs, suggesting that as experience/proficiency with the HL grows, so does HSs’ ability to employ grammatical morphemes across a wider range of lexical items.Results from a mixed-effects binary logistic regression indicated that Spanish HSs were more likely to interpret embedded clauses featuring subjunctive mood as commands, as would be expected in “baseline” Spanish, when the matrix verb introducing them was higher frequency . Using the N = 20), which included items along a wide frequency spectrum: from highly frequent forms  to very infrequent ones . Self-rated frequency was also examined using the results of a Lexical Experience Survey, which assessed participants’ (N = 42) use of and exposure to all experimental verbs using a four-point frequency scale where 1 meant that participants ‘never’ used a verb and 4 meant that they used that verb ‘very frequently’.The studies summarized thus far obtained (token) frequency information in two distinct ways: through language corpora or participant self-reports. To explore whether (and how) the adoption of these measures could affect how we conceptualize the effects of frequency in HSs’ performance, we reanalyzed data from parta (‘split/cut’)  or traiga (‘bring’)  appeared to be rather frequent for HSs in both use  and exposure , perhaps because these forms may be more common in the household setting. Participants’ ratings also provided information about asymmetries in exposure and use that simply cannot be captured by traditional corpus data. Verbs like proponga (‘to propose’), convenga (‘to convene’) and ceda (‘to yield’) are good examples of this: in each case, HSs’ average exposure [range: 2.21–3.27] easily exceeds their self-reported use [range: 1.65–2.83].The data reported in ß = 0.837, SE = 0.1538, t = 5.444, p < 0.001) and exposure  were statistically significant predictors of their subjunctive use, token frequency based on the Davies’ corpus was not . These findings suggest that relative to frequency metrics derived from large-scale corpora, self-reported frequency measures that reflect participants’ lived linguistic experience more accurately predict their likelihood of producing variability/grammatical innovations. Differences between these ways of capturing lexical frequency also emerged when we examined their statistical effects on HSs’ performance. To do so, we ran three separate binary logistic regression models—each with a different fixed factor (participants’ self-reported use (#1), exposure (#2) or items’ token frequency based on corpus data (#3))—and with subjunctive use, dummy-coded as 1 for subjunctive and 0 for indicative, as their dependent variable. In all cases, the best fitting models that converged included random slopes for Participant, as well as random intercepts for Itemp < 0.001). As observed in the graph, verbs that participants reported using rarely (2) or never (1)—marked by smaller-sized blue circles—usually yielded the lowest predicted probabilities of subjunctive production. In contrast, verbs that participants reported using somewhat frequently (3) or very frequently (4)—marked by larger-sized blue circles—were more likely to elicit subjunctive mood inflections. Interestingly, participants whose performance was categorical at both ends of the probability scale—almost 40% of the sample—were not as affected by frequency as those who exhibited more variability, as in the case of Participant 9, whose verb-by-verb data we highlight in The results plotted in As indicated in intra-speaker variability. However, despite the relevant role exerted by lexical frequency on HSs’ morphosyntactic development, we agree with The information summarized thus far suggests that the study of lexical frequency—whether it is at the level of type, token, or lemma frequency—grants researchers the opportunity to tap into patterns of The purpose of this article was twofold: first, we sought to clarify what is meant by ‘frequency effects’ in the field of HL acquisition research. To do so, we provided clear operationalizations of frequency both from a language activation lens, as well as from a lexical perspective. After laying out this critical groundwork, we then illustrated how further exploration of these frequency subtypes will help to illuminate two long-standing, yet relatively less studied patterns: (i) between-speaker variability, that is to say, differences in the linguistic knowledge of different HSs and (ii) within-speaker variability, meaning variability in individual HSs’ knowledge of particular HL forms . A second goal of the article was to serve as a point of departure for HL researchers who are interested in examining frequency—from either one (or both) of the perspectives mentioned—in their future studies. To this end, we presented a critical analysis of some of the field’s most relevant and recent work on frequency effects in the HL, paying particular attention to what should be considered best practices from theoretical as well as empirical vantage points. Among the most novel contributions of this overview, we believe, is the finding that self-reported lexical frequency—that is to say, HSs’ own subjective assessment of how frequently they hear/use certain words—appears to be a better predictor of their subjunctive mood variability than traditional, corpus-derived frequency metrics.Before going any further, we believe that a couple of key clarifications are in order. First, while the present paper has prioritized the discussion of between-speaker and within-speaker comparative analyses, it is not our intention to dismiss the importance of more commonly studied contrasts—namely, between-group and between-property comparisons—in the study of heritage bilingualism. In fact, as we noted in the “Introduction,” the vast majority of the foundational work in our field has emerged from those two lines of inquiry, a reality which should not be overlooked. Our claim, instead, is that different comparative vantage points—including those that we have showcased in this paper—have different epistemological blind spots, meaning, essentially, that in order to appreciate the immense complexity of HL grammars, we must look at them from a more diverse variety of viewpoints. Just like between-group comparisons—e.g., comparing HSs to a baseline/control group—cannot shed light on why individual HSs might alternately produce two variants of a single form in a single HL context, within-speaker comparisons—like the analyses of lexical frequency effects presented in “Lexical frequency and its role in heritage grammars”—cannot explain why some HL properties  appear to be more “vulnerable” for HSs than others While we recognize the enormous potential of the two varieties of frequency outlined in this paper, it is important to clarify, too, that neither is powerful enough to obviate other types of linguistic and non-linguistic explanations of HL grammars. In fact, as One reason to embrace frequency is that frequency-effects—broadly conceived—appear to be an empirical reality of HL grammars. At the between-speaker level, differences in HSs’ frequency of experience with the HL seem to result in differences in the HL grammars that they ultimately develop. Recall, to recap an example from “Between-speaker comparisons: frequency of heritage language activation,” that the simultaneous HSs in particular type of frequency effect observed?” Therefore, when Perez-Cortes (2022) documents token frequency effects on HSs’ interpretation and use of subjunctive mood or There’s another reason to pursue frequency-based analyses in heritage bilingualism research. Though frequency is not, to reiterate, an explanation itself, investigating it and identifying some of its previously undiscovered effects can open the door to a number of novel analyses and research questions, many of which have the potential to reverberate far beyond HL research itself. As For reasons of space, we will conclude this paper by presenting two brief—and hopefully, inspirational—examples of how reflecting on—and taking into consideration—frequency effects, broadly defined, could deepen our understanding of HL grammatical complexity and actually improve existing explanations of widespread HL patterns and phenomena. A substantial proportion of research on HSs has focused on what they do not know and how they diverge from so-called baseline speakers see , yet, coWe have seen, thus far, that being more intentional about lexical frequency might help us to gain a more reliable representation of what HSs really know about their HL. On a similar note, we believe that lexical frequency might also help us to understand the nature of promising—yet still relatively underexplored—explanations of between-speaker differences, such as HL literacy/formal education. To illustrate this final point, let us reflect on In any case, we do not wish to belabor the point, but frequency-based analyses, in our view, raise interesting—even stimulating—questions and broaden our perspective of heritage grammars and their speakers. In a field as relatively young as HL acquisition research, pursuing new empirical questions and charting new methodological paths can only be a positive development, especially if those new directions, in acknowledging new layers of complexity, push us to more deeply reflect on the near ubiquitous (yet still understudied) patterns of between-speaker and within-speaker variability.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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Oral healthcare is paramount and inextricably linked to well-being. Yet, the evidence indicates that culturally and linguistically diverse (CALD) migrant communities have unequal access to mainstream dental services due to several barriers. The purpose of this study was to investigate the oral healthcare experiences, attitudes and barriers to oral healthcare utilisation in CALD mothers.A qualitative study with semi-structured interviews was conducted within a social constructivism epistemology. CALD mothers who identified as non-English speaking, foreign country born, with a child under 12, were recruited though purposive snowball sampling. Questions probed oral healthcare experiences, barriers, enablers, and attitudes. Verbatim typed transcripts were thematically analysed using grounded methodology.Cost was the foremost barrier to oral healthcare services, followed by Confidence in quality care for the provision of services and treatment. Confusion in navigating a public and private healthcare system was highlighted and Competing priorities took precedence. Complacency referred to ‘no need’ or lack of urgency in dental care. Subsequently, dental hesitancy (superordinate theme) described the patterning of data as comprising the five ‘C’ factors and was theorised as the dental hesitancy phenomenon to explain the occurrence of delay or avoidance in utilising dental care.Thirty-three CALD mothers participated; twenty from India, five from Fiji, four from China, two from Nepal and one each from Israel and Macedonia. Languages included Cantonese, Fiji-Hindi, Gujrati, Hebrew, Hindi, Kannada, Mandarin, Maharashtrian, Macedonian, Nepalese, Punjabi, Sanskrit, Telegu and Urdu. dental hesitancy phenomenon unearthed within this study. CALD mothers explained five ‘C’ dimensions: cost, confidence, confusion, competing priorities and complacency as barriers to accessing timely dental care. Multisectoral collaboration between healthcare systems, universal health coverage and primary sector support is required to address dental hesitancy in CALD mothers. Further, this study contributes to the field of behavioural and social sciences in oral health and augments the literature on dental avoidance.Findings highlight the utility of the The online version contains supplementary material available at 10.1186/s12889-022-14513-x. Oral healthcare inequities and inequalities are widely reported amongst populations . The eviHealth sociologist Sarah Nettleton  identifiQuite a considerable literature investigates ‘dental avoidance’ to explain the psychosocial fear that inhibits oral healthcare utilisation . For insThe social constructivism paradigm (Vygotsky) informed the epistemological orientations of this study , 19. We An epidemiological review by Pham and colleagues  suggesten = 2) and those that did not meet eligibility criteria (n = 2). An Olympus digital recorder was utilised, and transcripts were typed verbatim in Word. Ethical approval was granted by the University of Sydney Human Research Ethics Committee (2021/101).A purposive snowball sampling method was undertaken. In 2016, the state of NSW comprised 30% of Australia’s total migrant population . DemograResearcher bias was minimised through iterative coding and ongoing reflections of the researcher . This waData analysis was performed using grounded methodology within the school of Strauss and Corbin . GroundeFollowing the above analysis, a theory was generated to describe the factors to oral healthcare utilisation in CALD mothers, which was grounded in the data. To situate this theory within the evidence base, a modified version of the vaccine hesitancy model was utilised, which was first devised by the WHO SAGE working group , 30. ThiThe resultant sample included 33 CALD mothers, who conversed in various languages and were born in either; China, Fiji, India, Israel, Macedonia and Nepal participated  for CALD families. A Medicare system was suggested by mothers, to help cover the cost of general cleaning. This was particularly highlighted when arriving from a foreign country in which the currency conversion rate is much lower to the Australian dollar … It is too much … especially when you migrate initially-in the initial stages, every dollar looks very big .Uh,  problems, because of it being expensive! Then I said, “Okay”. This Australia, this Nepal, the condition seems similar … .Affordability was the foremost barrier to oral healthcare utilisation in our study. In consensus, dental care in Australia is People from our background, from India, we do delay the treatment. We don’t try to seek that care which we should just because of the cost involved. We’re trying to heal or treat ourselves on our own. We are just taking painkillers but not taking good care or health care and not accessing, not seeking the dental care treatment or the cleaning services or the dental check-up that should be done.....Knowledge, attitudes and belief in regular dental visits to prevent severe oral health problems from occurring was generally shared by 60% of CALD mothers. This idea of preventive oral healthcare seemed to be well understood. Although CALD mothers displayed an understanding and knowledge about oral healthcare prevention, the delay in access and utilisation occurred, as predominately related to the costs involved.You know, you have to spend a lot, and then you’ll be like, “oh I’ll leave it this year, we can do it next year”. Something like that, I have like, five fillings to be done, you know … And then you’ll be like, oh, if I can avoid, you know, then you’ll avoid it. That’s one thing which I think is really expensive. You have to go back in India. It’s very cheaper over there....One solution to this issue of cost was dental travel to the home country. However, this largely related to multiple factors of family support, lower costs and/or known, trusted providers in the home country.But yeah, they (relative) were not cared for properly. And so, I just don’t know if there could be a regulatory body in that space as well to make sure the treatment which the dentist provides is up to the mark … She was unhappy with the dentist. And she said that yeah, it’s not worth it, you know, going and visiting a dentist. I keep up with the regular treatment but then there are things which are not right …. then you know, they stop having trust. So, that becomes a trust issue then, then you don’t want to go and see a dentist and then same thing you pass on to your kids … .Confidence was reported by participants as the desire for trustworthy, quality care providers, reiterated in terms of an ethical or ‘good dentist’. Some CALD mothers reported negative dental experiences with an inadequate provision of care in Australia (and/or in the home country) that occurred to the CALD mother and/or their families. The below excerpt is from a dental care experience that occurred in Australia.… kind of enforced, and you kind of felt like, you said it was, sort of, pushed into doing it … And then, you see it’s- when you’re sitting on the chair, you feel, worried, [chuckles] mouth wide open...That is not the time where you can say a lot of things...No, we can leave it in-I’m happy with that or things like that. Uhm, and she (Dentist) … “Okay, so you’ve got this black thing here. So, let’s get it out and I’ll just replace it with something else.” I’m like, Uhm, okay....uhm, I’m happy with what I’ve got, I don’t mind it. I’d rather leave it in … .Dental provider trust was further underscored whereby treatment decisions were enforced onto the patient. This however posed concerns about need and/or unnecessary work. For instance, a mother described unnecessary treatment, although she was unable to question the dentist at the time.I tried to ask why and why there is a gap...Somebody told me they took some deep clean, or they have some x-ray done...I’m not so sure whether they done … but I’ve still been forced to do that (x-rays) or why are you (dentist) just gonna charge me for the $180 for the first consult? .Dental billing concerns were raised whereby dental practices have the discretion to decide the fee amount, which invariably differs by each surgery. Some practices charged consultation fees or provided unnecessary work. CALD mothers who encountered such experiences, expressed avoidance of the specific dental provider/clinic for future dental visits for their own family. A mother reported that she was forced for an x-ray at a new clinic, when she already retained a recent x-ray from a previous clinic and didn’t wish to expose herself to radiation superfluously. The lack of standardization in billing or policies at provider centres was further questioned by CALD mothers in terms of patient interests or business profits.I think the way, way we were charged. Because they both say they did cleaning. But I don’t know what sort of cleaning they did. So, because cleaning I didn’t, I didn’t ask you to do cleaning, why you’re doing it? They charged us a hundred dollars for it, which was not needed. So, I didn’t like that. .Experiences of dissatisfaction with dental providers was also reaffirmed with a sense of frustration.… .though I’m working here, I don’t have much connectivity or knowledge about the local dentistry over here . The healthcare system in the home country was described as ‘easier’ to understand compared to the ‘confusing’ and very difficult to understand the difference between public and private  healthcare system in Australia. This perception was shared between majority (75% of participants), including mothers with tertiary qualifications and spoke with high levels of English proficiency. Co-designed suggestions were provided by mothers, for instance simple, graphical information (translated into other languages) that entails system information, and what is covered and where to access support. Navigating the healthcare system was more pronounced for new mothers to Australia, compared to mothers residing in Australia for over ten years....I think it might be a bit confusing when you- like the Australian system is- is not- it’s not private but it’s not public. It’s something in between. In Israel, it’s very uh, public uhm, more public. So, it was a bit confusing in the beginning to understand what is included in the insurance, what is not. Uhm, whose doctor work- works with which insurance? First, when you emigrate, you prefer uhm- [clicks tongue] you prefer not to have any out-of-pocket expenses.” .Maybe there should be a service where they can let you know what you’re, just like a Medicare thing...When they can let you know what you are, you know, ah, ah, you know entitled to and how to access some of the services. And I know, I know that some hospitals do you have dental care but you need to be on a waiting list ...I think this is only if you’re getting umm Centrelink payment.... But it’s almost like umm, it’s almost like a hush-hush...Like, people don’t really know about it. .The Australian healthcare system was described as confusing, particularly regarding the dual public-private healthcare system and lack of information. Uncertainty about where to begin within the dental system was reported In China if you feel some prob-problem, you can see the dentist uh right away more quickly, yeah, yeah, yeah. It’s different. Yeah, and here, I think normally immigrants don’t know you need to arrange this thing in advance yeah. Like, like you arrange a holiday, like few months before, yeah, it’s different. I think it’s the different culture. .A key distinction to the Australian oral healthcare system and the origin country was the need to plan dental visits approximately six months in advance. In this example, a mother referenced a specific provider who was associated to a private insurance company, which meant that no gap payment would be incurred. This experience was starkly different to healthcare systems from origin countries, with next day availability of dental appointments or walk-in clinics. Oral healthcare information was also requested by CALD mothers who lacked social and cultural support and/or were new to Australia (under 6 years).And having young kids, going to the dentist by myself is really, a really hard thing um, because I’m pretty much primary carer of the kids, so, it’s, it’s like I would need to organise babysitting to go to the dentist. .Starting anew in a foreign country required various changes in the lifestyle, system and processes. The Australian lifestyle was constantly reaffirmed as ‘busy’ and ‘hard’ in terms of juggling all else, which resulted in the delay in access or utilisation of oral healthcare services for CALD mothers. Child-family responsibilities also took precedence whilst time challenges added to the complexity when working full time or negotiating care for children …. the focus is on the children. You can’t get dental and general well-being, and like you always pushed yourself to the side . A regular dental clean/check-up was also not a priority due to competing health concerns that were considered more significant than oral healthcare. You know, there are many other more important issues to handle like day-to-day issues. My diabetes, you know, uh, my weight and stuff like that which I need to be in control. .Mothers reiterated Complacency encapsulated the concept of ‘no need’, self-efficacy and lack of oral health priority. Oral healthcare avoidance due to sociocultural beliefs of ‘no need’ and the perceived risk from a lack of regular oral healthcare was considered low. Sociocultural practices in origin countries differed, for which dental care was likely to be obtained when pain was experienced by 36% of participants. Dentist access or utilisation was further avoided if pain subsided. Several access barriers overlapped which led to dental delay or avoidance, as described by CALD mother, Gurpreet. The below example underlines differing sociocultural factors in terms of health education for prevention as well as system related policies to enable reduced oral healthcare costs.… one is no need. I don’t have any pain and the-- otherwise like ah it’s costly as well. So, I don’t want to go for like just for normal check-up. ....honestly until now, I have never been to a dentist for myself … They (people from community) don’t go to the dentist unless they are under severe pain. They postpone things. Okay, let’s go in tomorrow. It’s not ringing, paining or they’ll try to home medicine, then clove oil … They’ll have to wait and see whether it’s going up ... And then only at the later stage they will go to the doctor. Even if it comes to me, I will do the same though. It’s very hard for me to change myself. Um every time I say. Okay. I think I’ll do it from next week. I’ll do it from next week. Always from next week, but I,I,I don’t know how to do it along with how I’m living, you know. .Another aspect of complacency involved difficulties in behaviour change due to the multiple demands, time, norms or habits associated with living in Australia.dental hesitancy phenomenon. This phenomenon explains the barriers to underutilisation or dental delay for CALD migrant mothers as a result of five 'C' factors, as illustrated in Fig. dental hesitancy phenomenon was both inductively and deductively devised from within the study data.Several individual, social and system factors overlapped and interconnected. For instance, cost and competing priorities overlapped when discussing life and child caring responsibilities. Confidence incorporated trustworthiness and provider competence while complacency involved the lack of priority given to oral healthcare. Hence, the interplay between macro systems, provider and individual/family level factors align with the previous evidence . On a sedental hesitancy phenomenon within the Australian context. The phenomenon is used to explain both the dental hesitancy theme and the five ‘C’ determinants as barriers to accessing oral healthcare: cost, confidence, confusion navigating the healthcare system, competing priorities and complacency. Multiple intersecting factors that contribute to micro and macro level disparities in oral healthcare were evident. For instance, information clarity is required about the public-private healthcare system, particularly for new CALD mothers to the country. Illustrated by a CALD mother was the distinct sociocultural practices from the origin country to Australian norms. Metaphorically, this was depicted as the need to schedule dental care several months in advance, likewise, to planning a holiday. Hence, multipronged approaches at the policy, provider, community and family level that address the dental hesitancy phenomenon is required, to promote oral healthcare utilisation for CALD mothers. Despite the in-depth exploration of findings, caution is required when interpreting results. Our sample comprised mothers with an adequate to high level of English proficiency, despite various methods to recruit diversity in languages and countries. Moreover strengthening policy, programs and community support, in alignment to the WHO UHC resolution in oral healthcare . Fo. Fodentas health . For inss health  conductes health . Furthers health . This ‘rs health . For inss health . Associas health  and thusFindings from this study lack transferability to other contexts or population groups, due to the specific sample of CALD mothers interviewed. Outlying data unfit for inclusion within this dental hesitancy theme included CALD mothers who were unable to travel to the home country because of COVID related travel restrictions. This comprised 18% of the sample, who primarily travel for family purposes and then subsequently receive dental treatment. Reasons for overseas dental treatment generally intertwined with cost, confidence in quality care and competing priorities and thus was not included as a sub-theme. Considerations for study limitations included distinct socioeconomic positions of CALD mothers. For instance, mothers who utilised private health insurance to help reduce dental costs, in contrast to mothers without the ability to pay for dental services and treatment. This exacerbates oral healthcare inequalities whereby governing actors and regulating bodies have the power to influence and shape population health equity. Participant recruitment inequities occurred within this snowball approach whereby online membership to CALD specific community groups automatically excluded participants without access to this form of social and cultural capital. Language barriers were not reported in this sample, which is likely to differ to the needs of humanitarian and refugee CALD migrants. Perceived or experiential racism was not probed as participants in this study reported ‘respectful’ experiences. Again, this could be attributed to participants displaying English proficiency, tertiary qualifications and/or employment/income levels. More specifically, we did not collect qualification/income data as per ethical approvals, however just under half of the group voluntarily reported this information. The evidence indicates racial inequalities are experienced by differing population groups and thus further research with refugees and those with low levels of English proficiency is warranted. Implications from this study help inform oral healthcare services that are relevant for CALD communities. Further research is needed to assess the comprehensiveness of findings. This could include constructs in quantitative research methods that address questions pertaining to the 5C’s.dental hesitancy phenomenon as the delay or avoidance in access or utilisation of oral healthcare in CALD mothers. This phenomenon incorporates the combination of the dental hesitancy theme and attributing five ‘C’ factors: cost, confidence in quality care, confusion navigating the healthcare system, competing priorities and complacency. Multisectoral collaboration to address all ‘C’ factors is required. Explicitly, integration of the primary and oral healthcare systems, including policy development for improved and targeted programs and services, health education support and the provision of accessible and simplified information. Findings further support universal health coverage in oral health within the Australian context, to promote more equitable access to oral healthcare within CALD communities.Understanding the reasons for low uptake of oral healthcare utilisation in CALD communities, with first generation migrants whose first language is not English, is essential to promote population health equity. Findings from this study reveal the utility of the Additional file 1.


Owing to the pivotal role of grit in scholastic success, factors that help learners become gritty are worth to be studied. Accordingly, this research sought to inspect the impact of teacher respect and teacher support on Chinese EFL learners’ grit. In doing so, three reliable measures of the variables were sent to 613 Chinese EFL learners. Using Spearman correlation tests, strong connections were discovered between teacher respect, teacher support, and Chinese EFL learners’ grit. Multiple regression analysis was then performed to inspect the role of teacher respect and teacher support in increasing Chinese EFL learners’ grit. As a result, both teacher respect and teacher support were found to be highly influential in increased learner grit. The limitations and implications are discussed. Grit has been broadly viewed as a key predictor of learners’ scholastic success. Put simply, grit is believed to be of great help to learners who wish to attain desirable scholastic outcomes . BecauseAccording to Both personal and interpersonal factors are believed to considerably enhance language learners’ grit . An instBecause of the pivotal role of teacher respect and teacher support in the language learning process , a sizabThe concept of respect, in a general sense, means to show consideration for others . To WebsTo date, in spite of the value of teacher respect in instructional-learning contexts, only a small number of studies  have beeSupport for autonomy, structure, and involvement. The first dimension, support for autonomy, pertains to “teachers’ provision of choice, relevance, or respect to students” . Half of the participants were Ph.D. candidates (N = 121) or MA students (N = 186), and the rest were undergraduate students (N = 306). It is worth noting that taking part in this investigation was entirely voluntary.Maximum variation sampling, which is also called maximum diversity sampling, was utilized to choose the respondents of this investigation. Maximum variation sampling is an instance of a “n topic” , p. 34. L2 Grit Scale”  “When it comes to English, I am a hard-working learner”, and item (5) “Now that I have decided to learn English, nothing can prevent me from reaching this goal”. In this inquiry, the reliability of L2 grit scale was measured to be 0.72.To examine the extent to which Chinese EFL learners perceive themselves to be gritty, “t Scale”  was emplThe instructor is fair and reasonable,” item (7) “The instructor is sincere,” and item (12) “The instructor inspires students to work.” The reliability of TRS was 0.97 in this research.To evaluate perceived teacher respect, “Teacher Respect Scale (TRS),” developed by My English teacher pushes me to succeed”, item (16) “My English teacher encourages me to learn” and item (18) “My English teacher supports my goals for the future.” The reliability index of TSS for this inquiry was 0.98.The “Teacher Support Scale (TSS)” , which ivia the Spearman Rho correlation. Following that, multiple regression analysis was performed to identify how much of the variance in the Chinese EFL learners’ grit can be attributed to teacher respect and teacher support.Initially, through WeChat messenger, the electronic version of the consent form was sent to 850 Chinese EFL learners. Of those, 613 learners agreed to take part in this research. Then, the above-mentioned scales, including the L2 grit scale, TRS, and TSS, were distributed among respondents using the Wenjuanxing platform. To guarantee the accuracy and credibility of answers, all respondents were briefed on how to rate the items in the questionnaires. The answers were fully received in 20 days. The respondents’ answers were double-checked to detect and exclude any probable mistakes. Afterward, the correlations between teacher respect, teacher support, and learner grit were evaluated To begin, Kolmogorov-Smirnov tests were run to assess the normality of the collected data. The results of the tests are presented in the table below .As demonstrated in r = 0.739, n = 613, p = 0.000, α = 0.01). The results of Spearman correlation test also indicated a favorable relationship between teacher respect and learner grit . Likewise, a significant association was found between teacher support and learner grit . Taken together, the results of Spearman correlation test revealed that any enhancement in the indices of teacher respect and teacher support will cause an enhancement in the index of learner grit.As shown in Then, multiple regression analysis was run to inspect the power of teacher respect and teacher support in predicting Chinese EFL learners’ grit. The results of multiple regression analysis are demonstrated hereunder .As According to the beta column , teacherThe current research aimed to uncover the degree to which Chinese EFL learners’ grit is correlated with teacher respect and teacher support. The Spearman correlation analysis documented, first, a positive correlation between teacher respect and learner grit, and second, a favorable connection between teacher support and learner grit. In addition, a strong link was discovered between teacher respect and teacher support. Concerning the positive association between teacher respect and Chinese EFL learners’ grit, it is encouraging to compare this outcome with that discovered by This research also sought to identify the role of teacher respect and teacher support in increasing Chinese learners’ grit. To put it another way, the current study sought to determine whether improvements in the amount of teacher respect and teacher support contribute to increased learner grit. As the outcomes of regression analyses revealed, both teacher respect and teacher support were found to be influential in increasing Chinese EFL learners’ grit. The positive influence of teacher respect on Chinese EFL learners’ grit may be justified by the fact that students who are respected and valued by their instructors tend to pursue the learning process despite the hardships and challenges . BesidesThe current research was an endeavor to determine the role of teacher respect and teacher support in increasing Chinese EFL learners’ grit. The outcomes of Spearman Rho correlation and multiple regression analyses evinced that teacher respect and teacher support can remarkably increase Chinese EFL learners’ grit. Simply put, these interpersonal behaviors help Chinese EFL learners become gritty. This outcome appears to be insightful for all English language teachers, notably those who are currently teaching in an EFL context. Building upon the results of this study, EFL teachers need to support their learners and show esteem for their viewpoints in order to make them grittier. Likewise, this result seems to be enlightening for teacher trainers as some of the EFL teachers do not know how to effectively support their learners in the laborious process of learning. Thus, teacher trainers are expected to brief their trainees on how to support pupils in classroom contexts. Given the pivotal role of teacher respect in increasing learner grit, they are also required to make their trainees aware of the value of this communication behavior.Finally, a number of limitations need to be mentioned concerning the current research. First, a quantitative method was adopted to perform this inquiry. Accordingly, only close-ended scales were employed to delve into participants’ viewpoints. Future investigations into this subject are advised to adopt a different method of research  and different means of data collection  to come up with more comprehensive outcomes. Second, this research was fully conducted in China which is an EFL country. Thus, the outcomes may not be generalizable to English as a second language (ESL) countries. As such, it is recommended that future research on learner grit be implemented in an ESL country. Third, in this research, the probable effects of gender, age, and proficiency level on the correlation of the variables were overlooked. A future study assessing the effects of these factors would be interesting.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Zhejiang Gongshang University Academic Ethics Committee. The patients/participants provided their written informed consent to participate in this study.Both authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.