Widely and intensively used digital technologies have been an important featureof international responses to the COVID-19 pandemic. One especially interestingclass of such technologies are dedicated contact and tracing apps collectingproximity data via the Bluetooth technology. In this article, I consider thedevelopment, deployment and imagined uses of apps in two countries: Singapore, apioneer in the field, with its TraceTogether app, and Australia, a country thatadapted Singapore’s app, devising its own COVIDSafe, as key to its nationalpublic health strategy early in the crisis. What is especially interesting aboutthese cases is the privacy concerns the apps raised, and how these are dealtwith in each country, also the ways in which each nation reimagines itsimmediate social future and health approach via such an app. A striking feature of the COVID-19 pandemic has been the use of and appeal to digitaltechnologies – fusing together what these technologies might offer in terms ofefficacious communication and public health responses to help individuals andcommunities cope and contain the pandemic, on the one hand, as well as extendingresources for social practices, expression, making sense, persisting with andreconfiguring rituals, and conjuring with the profound affective dimensions wroughtby illness, death, loss, fear and isolation, on the other.In the pandemic, digital technologies have been used across societies, in a way thatharked back to earlier ideas from the 1990s of social life being nigh whollydependent on life in ‘cyberspace’, and ‘virtual communities’. With widespread accessto and ownership and use of Internet, mobile phones, social media, data, artificialintelligence (AI) and associated technologies already deeply, if very unequally,distributed globally, especially in middle- and high-income countries, the inceptionof the pandemic saw extended reliance on digital technologies – where terms ofdigital inclusion allowed for it. In a number of countries, governments also tookthe opportunity to issue calls to the acceleration of digitalisation, especiallyacross groups and demographics where digital inclusion and take-up had been low, dueto infrastructure, literacy and education, information and affordability.One stand-out area in this regard was apps. Apps have been around since the 1980s and1990s; however, it was the ‘smartphone moment’ of the launch of the Apple iPhone in2008, and subsequent development of the apps for Apple mobile operating systemdevices (iOS) and launch of its Apps store, that kicked off the process by whichapps became an integral part of everyday life for billions of users . From 20https://www.scl.org/news/11940-the-mit-contact-tracing-app-database),based on key questions from American Civil Liberties Union (ACLU) White paper  note,‘Australia’s experiment is further advanced than most [countries] that areattempting to build a system based on voluntary uptake, protected by legislation. The Australian government sought to deploy COVIDSafe as acentrepiece of its effort to re-open Australian society after the national and statelockdowns occasioned by the ‘first wave’ of infections from March to May 2020. Wherepublic concern regarding and discussion of privacy issues was clearly presented butpublicly muted in Singapore, in Australia there was furious debate.To explore the emergence, dynamics and implications of these two COVID apps, I willproceed as follows. First, I introduce and discuss Singapore’s TraceTogether, itsdevelopment and first phase of take-up and deployment. Second, I turn to Australia’sCOVIDSafe and consider its fast journey from incubation and policy idea to thetouchstone to warrant the country’s re-opening, a veritable ‘national service’ (asPrime Minister Morrison couched it). Third, I return to Singapore, to discuss therebooting of TraceTogether, after nearly 3 months of tepid take-up, as thatcountry’s leadership sought to reassure its population that conditions were safe tore-open social life. Finally, I offer concluding remarks about COVID apps, socialand technological imaginaries and digital media, as the nation state returns , andseeTo great fanfare, a dedicated contact tracing app was unfurled as a breakthrough inmonitoring outbreaks of COVID-19 at the population level. While many teams aroundthe world produced similar versions, the Singapore government rolled out the firstsuch app – called ‘TraceTogether’. TraceTogether is an open source app based onBluetooth, using the ‘Bluetrace’ protocol devised by a Singapore government team ledby the GovTech agency – who have a track record of developing new kinds of opengovernment apps, such as the Parking.SG app. In a 2018 interview, for instance,TraceTogether was made available for adoption elsewhere via GitHub. It is acombination of centralised contact tracing and follow-up  and ‘decentralised contact logging’. The user downloads the appand activates Bluetooth on her device. The app can then detect another device in itsvicinity, exchanging proximity information. To do so, the app uses informationgenerated by the Bluetooth Relative Signal Strength Indicator (RSSI) readings thatoccur between devices over time to estimate proximity and duration of an encounterbetween users . If a peReleased on 20 March 2020 by the Ministry of Health and GovTech ,TraceToMedia International Australia , and tightly managed immigrant and foreign worker ID andrecords, and digital government and technology capabilities, this evolving contacttracing system did not need to premised on an app such as TraceTogether, whichpresumably government was happy to allow to ‘fail fast’, given the bugs itfaced.Despite the effectively prototypical status of TraceTogether, one of the firstjurisdictions to adopt the technology was Australia. Prime Minister Scott Morrisonreferred to such an app as a key requirement in Australia’s ability make itstransition out of lockdown . In a raThis kicked off a heated debate about privacy implications, leading a high-profilemember of his own Coalition government, rural parliamentarian Barnaby Joyce todeclare that he would not be downloading the app – countered by many other publicfigures who promised to do so. Despite the widespread criticism and concern, therewas also significant support with some 2 million downloads in the first day of itsrelease, topping the 5 million mark in early May , then 6.The Chief Medical Officer’s advice is we need the COVIDSafe app as part ofthe plan to save lives and save livelihoods. The more people who downloadthis important public health app, the safer they and their family will be,the safer their community will be and the sooner we can safely liftrestrictions and get back to business and do the things we love. : para 4For the Prime Minister, the COVIDSafe app was a rhetorical centrepiece of his policyinitiative to vouchsafe a loosening of restrictions and begin to repair the economicdamage the virus caused:I’ll be calling on Australians to do it as a matter of national service. Inthe same way people used to buy war bonds, back in the war times, you know,to come together to support the effort . . . If you download this app you’llbe helping save someone’s life.  :I’ll be On 1 May 2020, Morrison announced that Australia had earned an ‘early mark’, withrestrictions being lifted in a week. In doing so, he spoke of the download numbersbeing a ‘critical element’ in deciding to what extent the easing would occur: ‘MrMorrison said not installing the app was like going into the “blazing sun” withoutwearing sunscreen’ .Australian FinancialReview, a piece by technology editor Paul Smith, entitled ‘Think like afounder’, reported, ‘Entrepreneurs and health technology experts have urged thegovernment to adopt all the tricks of the start-up trade to get more Australiansdownloading the COVIDSafe contact tracing app’  .In addi system’ .As well as the specific defects of the new law, then, the major issue it raises isprecisely the one feared by many experts and members of the public alike: that theapp-based contact tracing represented by COVIDSafe, and other apps around the world,represent a deepening of technologies of surveillance in social life. While suchapps and measures in which they are embedded are justified as exigent public healthmeasures crucial in the emergency conditions of a pandemic, there is well-foundedfears that this increase in surveillance will not be automatically or easily rolledback once countries feel the threat of COVID is ended or at least contained.As Australian debates over COVIDSafe privacy subsided, there was a slow return toTraceTogether emerging in Singapore as the country’s leadership gingerly consideredhow to effect its re-opening from its 2-month circuit breaker. A task all the moreurgent, given the ruling party’s dwindling time to call a national election.Singapore’s was regarded an international model of wise and swift response with itshandling of its ‘first wave’ of infections. However, in the second week of March2020, Singapore tightened its measures, enacting a general shutdown and stay-at-homepolicy that it dubbed a ‘circuit breaker’. Initially the circuit breaker wasannounced to last for 1 month, but with the rising tide of positive cases in thecrowded migrant worker dormitories, the government quickly extended for a secondmonth.A disturbing feature of Singapore’s data gathering and public reporting andcommunication during this period was the distinction clearly drawn and maintained inthe daily bulletins between; cases in the migrant worker dormitories; and ‘communitycases’ , migrant workers on work permits and workers onemployment passes) . The migAhead of the planned end to the circuit breaker on 2 June, the government made somemention of TraceTogether at various times in its public communications. However, itsmain focus remained racking movement and individuals’ location via check-in at thepublic places and business still open, such as convenience stores and shoppingcentres, or in taxis and ride-hailing services, especially via the SafeEntry appdiscussed above.As the re-opening loomed, there was increasing discussion in government, and inparliament, on measures that would need to be implemented to contain and reduce thenumber of infections via contacts with migrant workers, especially once they wereallowed to more regularly leave the dormitories, where they had been quarantinedduring the circuit-breaker period, and so circulate in the ‘community’. Thegovernment announced a new app, SGWorkPass, to ‘show which migrant workers can leavetheir dormitories for work’ . WorkersAt this stage, TraceTogether returned – this time, as a central feature of thestrategy. The government had been at pains to keep TraceTogether opt-in, withForeign Minister Vivian Balakrishnan, also Minister-in-Charge of the Smart NationInitiative, providing reassurance that the app would remain voluntary ‘as long aspossible’ . In earlAs policy researcher and commentator Carol Soon, from the Institute of PolicyStudies, noted, ‘Within a short span of three days, a petition against thedevelopment of the device attracted about 30,000 signatories’ . ConcernAt the time of writing, the pandemic rages globally, and the career of COVID-19contact tracing apps is still unfolding – with little evidence as yet of theirefficacy. However, there are already clear grounds for concerns.Do it for the people you love. Do it for the community. Do it for the NHS anddo it for all the frontline workers . . . you’ll have the knowledge thatwhen the call came you did your bit, at a time when it really mattered., without the kindof concomitant privacy rights and practices that would be expected in some otherjurisdictions such as Australia. The task of enlisting and normalising Singaporeansparticipation in these aspects of its surveillance-extensive ‘Smart Nation’policies, over cumulative implementation of technology is taken to be essential, butit is increasingly fraught . In the PersonalData Protection Act. At the time, legal scholar Simon Chestermansuggested that Singaporean had taken a ‘pragmatic approach’, potentially striking abalance between European and US approaches:In Singapore, at least, reform is not being driven by the desire to defendthe rights of data subjects; rather, it is based primarily on economicconsiderations, as well as the desire to position Singapore as a leader inthe region for data storage and processing. : 414.Such measures point to the differences in privacy laws and protections in Singapore,as compared to Australia. Whereas Australian Privacy Act dates back to 1988,Singapore only enacted its first comprehensive law in 2012, the The Singapore laws and approach to privacy and data protection have not substantiallychanged since . Yet cleFrom a broader perspective, the return of TraceTogether to the fore of theSingaporean government’s strategy, especially to assist with the re-opening processafter its ‘circuit breaker’, is very interesting indeed in the context of thecountry’s digitally underpinned governmentality . This isAll in all, in both these case studies, we see that the variations of the COVID-19contact tracing apps, and the technical, social, policy and design dynamics ofthese, offer rich food for thought when it comes to understanding apps. Healthinformation is an area of considerable sensitivity for most people. Trust is key,and with the widespread diffusion of mobile communication there has beenconsiderable work on how to design and implement systems that can supportcooperative and sustainable sharing of information between people and authorities tomap the spread of infectious diseases . However


The number of papers related to epidemiology and researchers who engage in epidemiology is substantially increasing. PubMed search using the keyword “epidemiology” demonstrated that 36,054 and 149,395 papers were published in 2000 and 2018, respectively . For epidemiology studies related to Japan, the number of available papers observed using PubMed search for “epidemiology” and “Japan” increased from 1,079 in 1998 to 5,499 in 2018 . Additionally, the members of the Japan Epidemiology Association increased from 1,115 in 1998 to 2,305 in 2018 . Moreover, the reason for this increase may be owing to the easier access to cost-free open databases and faster permission processes, such as those for accessing electronic medical records or administrative records, as well as the rapid advancement of statistical methods, which are relatively easy to run using statistical software, such as SAS, Stata, SPSS, or R. Moreover, recent developments in the utility of “big data” and “artificial intelligence” have accelerated this trend.Consequently, this trend must be welcomed. In addition, following the experience of working with new researchers of epidemiology, numerous tips and pitfalls have been identified that need to be summarized and noted before applying new statistical methods in epidemiology. For example, directed acyclic graphs (DAGs), multiple imputations, or propensity score matching analysis are extensively utilized, but there are several considerations. Furthermore, numerous tips are useful but not exactly given in textbooks or papers. Therefore, for those who engage in epidemiology studies, a summary of these pitfalls and tips for these new methods would be beneficial. In this series of new special articles, it is planned to discuss the following epidemiologic methods for both analysis and measurement:1) Causal diagrams  (in this issue)2) Marginal structural model3) Propensity score methods (matching and inverse probability weighting)4) Mediation analysis5) Machine learning1 DAGs were first introduced by Greenland, Pearl, and Robins in 1999,2 and they have been widely used by epidemiologist to select covariates. DAGs are a useful tool for summarizing the association between various variables, and numerous educational review articles have already been published.3 DAG was described in A Dictionary of Epidemiology, 5th edition as follows: “A graphical display of causal relations among variables, in which each variable is assigned a fixed location on the graph  and in which each direct causal effect of one variable on another is represented by an arrow with its tail at the cause and its head at the effect. Direct noncausal associations are usually represented by lines without arrowheads. Graphs with only directed arrows  are called directed graphs.”4 Therefore, we usually draw an arrow from explanatory variable “X” to outcome variable “Y,” but these main variables, as well as other covariates, need to be included in the graphical explanation.For the first special article in this theme, Suzuki et al summarized pitfalls and tips for causal diagrams, which are known as DAGs.4 This description is very important, since we would like to infer the causal association. Thus, bidirectional association or cyclic association should not be used for a causal association. Further description is as follows: “Algorithms have been developed to determine from causal diagrams which sets of variables are sufficient to control confounding and for when control of variables leads to bias.”4 Use of DAGs allows researchers to carefully consider covariates, which include confounders, colliders, and mediators. Furthermore, these methods are useful not only for researchers of epidemiology, but also for the audience of the research.Hence, the description continues as follows: “Graphs in which no variable can affect itself (no feedback loop) are called acyclic.”Journal of Epidemiology Editors that this series will provide a meaningful learning opportunity for researchers.In the current issue, Suzuki et al raises 10 pitfalls and tips for utilizing DAGs, which are useful and have been underreported the field of epidemiology. By utilizing this review article, researchers should feel more confident and avoid pitfalls when applying DAG to investigate research questions by properly selecting confounders and mediators. Furthermore, to advance the skills for employing new statistical methods in epidemiology, it is the anticipation of all


Background: Chronic pain is a growing public health concern affecting 1.5 million people in Canada. In particular, it is a concern among the expanding immigrant population, because immigrant groups report higher pain intensity than non-immigrants. In 2011, the Indian population became the largest visible minority group and continues to be the fastest growing. Though the prevalence of chronic pain among Canadian Indians is unknown, research has found a higher prevalence among Indian women than men in India, Malaysia, Singapore, and the United Kingdom, with women reporting more severe pain. An understanding of how pain is experienced by this particular group is therefore important for providing culturally sensitive care.This study explores the lived experiences of chronic pain among immigrant Indian women in Canada.Thirteen immigrant Indian women participated in one-on-one interviews exploring daily experiences of chronic pain.Using thematic analysis informed by van Manen’s phenomenology of practice, four themes emerged: (1) the body in pain, (2) pain in the context of lived and felt space, (3) pain and relationships, and (4) pain and time. Women revealed that their experiences were shaped by gender roles and expectations enforced through culture. Specifically, a dual gender role was identified after immigration, in which women had to balance traditional household responsibilities of family labor and care alongside employment outside the home, exacerbating pain.This research uncovers the multifaceted nature of chronic pain and identifies factors within the sociocultural context that may place particular groups of women at greater risk of living with pain. It is a growing concern among immigrant communities, as Canada has a large and growing number of immigrants, who make up approximately 22% of the total population.4 In 2011, the Indian population became the largest visible minority group and is the fastest growing community in Canada.5 Based on quantitative studies, more Indian women than men report constant and severe pain in both India and the diaspora.6 Thus, an understanding of how chronic pain is experienced by Indian women, especially in Canada, is necessary and will contribute to knowledge-based and culturally sensitive care.7Chronic pain is defined as persistent pain that lasts longer than the normal time of healing8–10Culture is defined as “the patterned ways that humans have learned to think about and act in their world; it involves learned, shared styles of thought and behavior which replicate the social structure of their world.” Culture is also a significant factor in shaping pain communication, beliefs, and coping behaviors,12 as well as perceptions of pain.10 Therefore, in order to better understand pain experiences among diverse populations, an exploration of culture in shaping these experiences is paramount.Considerable research has examined pain from a biological perspective; however, studying the influence of culture—beliefs and practices—is a relatively new and growing area.15 The collectivist nature of Indian society prioritizes group norms and goals over individual gains and successes.16 This thinking has an influence on gender roles, with women most often sacrificing their own wants and needs for the happiness and well-being of their families.16 From childhood, young girls are socialized to prioritize others.15 In their natal homes, women tend to focus on the needs of their own parents and siblings; after marriage, their priorities shift to their husbands, in-laws, and children.15 Married women’s roles largely focus on household responsibilities to maintain loyalty and obedience to the family, such as cleaning and preparing food, performing religious duties, and child-rearing.17 This, however, has consequences for their own health and well-being,15 as Indian women suffer far worse health consequences than men.14With respect to Indian culture in particular, research has shown that cultural norms, roles, and expectations uniquely influence women’s perceptions and expressions of self, body, overall health, and pain.15 Pain is often viewed as God’s will and therefore patience and endurance of pain are valued over open expressions.18 One qualitative study exploring the lived experiences of breast cancer symptoms among a group of immigrant Indian women in Canada found that women tended to downplay their pain by attributing it to physical work, rather than viewing it as a sign of greater illness and seeking medical help immediately.19 The study also found that when pain became unbearable, women expressed fear of how it may affect their ability to care for their children and husbands.19 This further demonstrates women’s prioritization of family members, even when their own health is compromised.In regards to pain specifically, research shows that Indian women tend to ignore or downplay their pain, as well as restrict its expression in the presence of others, due to cultural beliefs. It is also important to keep in mind the diversity that exists within cultural groups—for example, the many Indian subcultures and religions  that are present—which may influence intracultural variations in pain experiences.The study of culture is therefore necessary when examining experiences of pain cross-culturally, because beliefs, practices, and norms shape “pain expression, pain language, the cultural context of suffering, traditional healers and lay remedies for pain, [as well as] social roles/expectations. …”21 Immigration is another key factor influencing pain experiences due to social and cultural changes that occur upon arriving to a new country.20Acculturation—“… the extent to which an individual who migrates from the country in which they were born adopts the values, beliefs, culture and lifestyle of their host country”118—is often a construct used to understand differences in pain experiences among immigrant groups.23 A study in the UK, for example, examined the prevalence and severity of pain among Indian, Pakistani, Bangladeshi, and European men and women in relation to immigration and found that acculturation was associated with heightened self-reports of pain. Indian immigrants with the highest acculturation scores also had less widespread pain compared to those with lower acculturation scores.24Culture is not static. It shifts and changes with time and place.25 In particular, changes in housing and working conditions are known to have a negative impact on chronic pain experiences among immigrant populations.26 Thus, immigrant status, identity, and structural barriers within host countries27 may also influence the experiences of pain for immigrant populations.However, focusing solely on acculturation does not consider other factors associated with the immigration process, such as loss of identity, isolation, structural and economic barriers, and discrimination, which have also shown to have deleterious effects on the health experiences of immigrants in the West.28 The current study therefore aimed to determine (1) immigrant Indian women’s lived experiences of chronic pain and (2) the role of culture in these experiences.Few studies have qualitatively explored the meanings and experiences of chronic pain for immigrant Indian women in Canada.This research was part of a larger study that employed both semistructured one-on-one interviews and photovoice methods. Only findings from the qualitative interviews are presented here. The study was reviewed and approved by the University of Toronto Research Ethics Board .29 phenomenology of practice. We used this framework because it focuses on lived experiences and the meaning of these experiences as embedded in social, cultural, and historic traditions. This approach calls for a thoughtful and mindful orientation toward the phenomenon and those experiencing it, which allows for an understanding of individuals’ situatedness and “being-in-the-world (p. 38).”30 As a methodology, it orients toward a practical approach of “producing action sensitive knowledge.” In this context, then, the purpose of understanding lived experiences is to apply it to theoretical knowledge and help inform practice in relation to chronic pain.32 In this vein, it can be employed to understand the multiple dimensions of chronic pain from the perspective of the individual’s lifeworld or the “human world of lived experience.”7We took an interpretive phenomenological approach to explore the lived experiences of chronic pain among immigrant Indian women, particularly drawing on Max van Manen’sWomen were recruited by nonprobabilistic, purposeful sampling , through the aid of religious centers and nonprofit community organizations tailored specifically for culturally diverse women. These organizations posted recruitment flyers and personally informed women who met the inclusion criteria for the study. If these women showed interest, the lead researcher then contacted them with further questions and details about the study. Once recruited, participants were interviewed at one of the community organizations or within their homes, whichever was most convenient for them.1; (2) were between the ages of 40 and 60, plus or minus 3 years; (3) were first-generation immigrants to Canada (people who are born outside of Canada)34; (4) had immigrated to Canada from India in the past 10 years (to capture the recent influence of culture and immigration); (5) identified as female; and (6) were able to communicate in English, Hindi, or Urdu. Exclusion criteria included women who (1) had pain associated with cancer; (2) had been in Canada longer than 10 years; (3) were outside the age range; and (4) spoke a language other than English, Hindi, or Urdu. Women of any religion were accepted into the study.Inclusion criteria included women who (1) had chronic muscle and joint pain (as defined by pain that has exceeded 3 months)36 However, because of the diversity of Indian women due to various subcultures and religions, we increased the recruitment target to 10 to 15 women.38A sample size of six participants is suggested for phenomenological inquiry, because this number is sufficient to produce thick descriptions and interpretations about the phenomenon.Ten interviews were conducted by the lead investigator in English, two in Hindi, and one in Urdu (no translator was used). Interviews were approximately 1 h and women were asked a number of open-ended questions with respect to their pain experiences; for example, location and duration of their pain, how pain affected their lives, and how they managed pain on a daily basis. In order to further understand the context of their pain experiences, participants were also asked general questions about culture and their experiences of immigration. When these issues naturally arose, women were probed further to explore the influence of the social and cultural context on their experiences of pain. For example, women were specifically asked what cultural beliefs and traditions related to pain and pain management were important to them, as well as how they felt being an Indian woman influenced their experiences of pain.The interviews in English were transcribed verbatim using the qualitative data analysis software QSR International NVivo. For interviews conducted in Hindi or Urdu, a research assistant who spoke these languages (in addition to English) translated and transcribed them into English. The translations and transcriptions were then reviewed in detail by the lead researcher in order to ensure that meaning was accurately captured. A pseudonym that represented their cultural and religious affiliation was also given to each participant corresponding to their participant number.29 phenomenological reflection and thematic analysis to analyze the transcripts. Although themes that emerge from phenomenological studies are diverse depending on the research, van Manen29 identifies four thematic structures to be reflected on more generally while exploring lived experiences: lived body, lived space, lived human relation, and lived time. A research assistant worked closely with the lead researcher to discuss impressions, observations, and emerging themes from the interviews. Once themes were identified using van Manen’s selective highlighting approach,29 they were written in phenomenologically sensitive paragraphs referred to as “linguistic-transformation.” The lead researcher also kept a research journal in which she routinely took notes about the women in the study, including observations of participants’ homes and behaviors during interviews, as well as her own reflections.We used van Manen’sNo one declined to participate in this study. Thirteen immigrant Indian women participated, and informed written consent was obtained from each of them. The average age of participants was 48 and the average time in Canada was 8 years. These women had immigrated from various regions in India  to the Greater Toronto Area in Ontario, Canada. They had diverse religious affiliations, including identifications as Hindu, Muslim, and Christian. All women reported chronic musculoskeletal pain and identified pain in knees, legs, hands, or joints. Although some women took over-the-counter pain relief, none of the women were prescribed or were taking prescription pain medication. The average number of years of chronic pain was 7, with some experiencing pain for more than 10 years. 29 emerging themes were grouped under the broad headings of lived experience: (1) the body in pain, (2) pain in the context of lived and felt space, (3) pain and relationships, and (4) pain and time  as spreading throughout the body and (2) as a consequence of workload and a sign of deterioration.Women spoke of pain beginning in one discrete area and then slowly spreading to other parts of the body. Many described it as starting off localized, in either the neck area, knees, or hands, and then becoming a negative sensation that took over their entire bodies. One participant, Sophia , described it thus: “[The pain] it’s practically all over. It started with my knees but then it’s all over now. My hands, my legs, the joints, the fingers, so you know, every part of my body.”Bodily restriction and lack of mobility were part of this spreading. Diya said, “… it started from the back and now from the back. … I feel that if I stand up my knees will start hurting, then I feel that my shoulders are freezing” . Naira said, “… pain in my body started and it took over. It spread everywhere, now it’s in my throat, I feel like I can’t breathe at night” .Women identified that they could no longer move as freely as they once used to because the pain began to affect multiple parts of the body. Diya highlighted that it felt like her “whole body [was] becoming bound.” Therefore, along with multiple body regions of pain sensation, there were also feelings of helplessness, suffocation, and paralysis associated with the pain.Shalini corroborated this: “[In Canada] sometimes you don’t realize, but you do a lot of work yourself. You do a lot … and you’re always [running] errands doing things and you don’t realize your routine, your body and your life, everything is changing …” .Women spoke a great deal about the physical strains put on their bodies through a never-ending workload since their arrival in Canada. They described a significant increase in the amount of work—both within and outside their homes—required daily since immigrating. Housework—such as errands, taking care of children, cleaning, and cooking for their families—was highlighted as their sole responsibility because they were women. This was exhausting and tiring, as well as harmful to their bodies. Maryum said of her extra workload, “… I had to do everything. Even if it was cold or raining … I had to bring and take the kids, do the work at home, go to the bank, pay bills, go to the doctors, everything I had do to. The struggle was there because I was alone” .Pain was also described as a weakening and/or deterioration of the body. For example, Naira described her chronic pain for the past 7 years as feeling like her “bones [were] breaking.” Some associated pain with deficiencies in their body; for example, with a vitamin D or iron deficiency. Some also spoke of their bodies becoming weak after pregnancy and childbirth, which added to, and intensified, the pain they felt. Women felt weak, which was described in terms of no longer being able to do basic day-to-day tasks. For example, Sophia said, “There is muscle and nerve weakness [in my body]. So, my grip … like I cannot carry things. So you know … I was straining my nerves … which over time made my muscles and nerves weak. So, because of all these undetected and untreated ailments … over time it became chronic.”Women described their pain in terms of the space surrounding them, particularly in relation to the new spaces, including geography, upon immigrating. Many women attributed the severity of their pain to the change in climate, speaking of having left a warm climate for a cold one. Many said that their pain only began after they moved to Canada, pinpointing the exact beginning of their pain with their immigration. They laid this at the feet of weather. Women highlighted that the cold was not an environment that their bodies were used to. For example, as Diya described, “Climate changes here … you move here from a hot climate place to a cold climate place … what if the cold has settled into your bones?”Women expressed the losses of leaving their homeland, one of which was a loss of domestic help. A common discussion throughout the interviews was about having maids back home to help with household tasks, such as cleaning, cooking, and looking after children. This help was easily available to women and accessible at an affordable cost. Having this additional help relieved women of their gendered work—household responsibilities—giving them more time for themselves. Participants were more likely to spend time as they wished back home, were able to pick up hobbies, and had more time to spend with family and friends. This was not so in Canada; the burden of the household chores fell entirely on them after immigration. This played a significant role in the severity of their chronic pain. For example, Sophia stated, “[A] lot of immigrants, I would say, they lose out on or they miss the most on the domestic help which was affordable, you know, outside Canada.”Moving to Canada and adapting to a new environment also came with the added challenge of losing one’s close social network and cultural familiarity, which meant that they were no longer surrounded by those who understood their gendered roles and values. One woman, Isha , referred to her family and friends in India as a “cushion,” symbolizing comfort and familiarity. She noted that coming to Canada meant that she no longer had this cushion in her life. Immigration and adjusting to a new place caused stress and added to the severity of chronic pain. Isha said, “When we leave everything back home and we just come here wiping off everything … it will increase your stress [and affect] … your physical health also, everything it affects.” Sophia said, “I think initially when I landed, the stress of adjusting, acclimatizing yourself to a new country, new culture … that played I think a very major role in my health.”There were comparisons between life in India and in Canada in relation to seeking help for pain. Women described trusting the medical system and methods of treatment for pain in India compared to Canada. They spoke of feeling comfortable with, and better understood by, doctors back home and were reluctant to visit medical staff for pain in this new country. Feelings about the Indian care were associated with a sense of belonging, trust, and comfort: “[An Indian doctor will] understand probably because we may be able to connect at that level, but if you are not socially connected to a [doctor], they may not even understand what you are talking about” . In addition, Naira said, “Sometimes I think I should go back to India and get treated there, there are good doctors there. Over here, the doctors don’t give you time … you talk to them for 5 minutes, that’s it. What am I supposed to say in that time?”Canadian employment also contributed to women’s pain. Participants highlighted the need to help their husbands financially in order to afford the cost of living in Canada. Though many women were well educated in India—more than half had completed undergraduate degrees from Indian universities and one woman had completed a PhD in botany—almost all complained that their degrees and work experiences were not accepted in Canada and they were therefore forced to work in “survival” jobs (Isha). These were jobs in which women had to work on their feet for long hours; for example, in retail stores, factories, warehouses, and food service jobs. There was talk of how this type of physical labor took a significant toll on their health, not only giving them aches and pains throughout their bodies but—for those who had had pain in India—causing complaints that seemed minor in India to turn major and chronic. Chronic pain in the knees, legs, feet, and hands was commonly discussed in context with this type of work. Isha, for example, discussed how this work was not only difficult but also very different than any type of work she had previously done in India: “So much [stress], we have to push ourselves in warehouses, such kind of jobs, because we haven’t done this in our life before.” Thus, this new place was associated with emotional, resource, and job loss, as well as physically demanding work, all leading to chronic pain.Women also spoke a great deal about their pain experiences in the context of their relationships, most often those with their husbands and children. Women identified family stress associated with their responsibilities and duties as another reason pain became chronic in their lives. They also indicated that due to their gender roles, most of their lives were spent prioritizing the needs of others, especially their husbands and children. They felt that they often neglected themselves due to this role and these relationships.Women spoke about the expectations and pressures they felt from their families to emotionally and physically support them, even after a long day of tiring work. For example, women were expected to drive children to and from school and extracurricular activities, as well as take care of the elders who often lived with them in a joint family setting. Women felt that these responsibilities, which were associated with their gendered roles and socialization from India, caused them stress in Canada. As Naira noted, “My kids don’t do anything. When I cook, they’ll eat. They’ll maybe wash their plates. Not once have they helped me clean or anything. Cleaning or washing, they don’t do it. … If I am not there, the work will pile up for me.”Women focused on their families’ needs to the neglect of themselves and their own health. They explained that even if they were in pain, they tended to ignore it in order to complete their household duties, staying true to their collectivist cultural values. Women indicated that they felt guilty if they were unable to do these tasks because of their pain. Ayesha  said that if she focused on her pain, she would not be able to look after her children: “Because every other day if I am in pain … I wouldn’t be able to take care of kids.”Neglecting themselves and prioritizing their family were two reasons why women’s pain intensified over the years. They spoke about taking on too much work, thinking that they would be able to handle duties inside the home as well as the pressures of employment outside the home. As Shalini described, “I did not prioritize myself and I overestimated my stamina, my capacity, you can say, to do things.”Not only were there family expectations but women also placed those very expectations on themselves. They accepted that these were their responsibilities as women, and despite the outside workload adding stress and pain, they continued to carry on because this was culturally what was expected of them. Shreya said: “You always have to cook … so that kind of puts an expectation of course. Coming from a specific ethnic group does affect that, because of how you have been raised.”Pain and time were linked in two ways: (1) duration and intensity of pain and (2) having no time for pain management.All women described pain as constant and increasing in intensity with time. In fact, the main focus of their health concerns was being in pain all the time, which they found punishing and inescapable. As Ayesha described, “… and with the years, the passing years it got more, more stronger and more I would say, it would last longer … throughout the day, throughout the year … at this point I cannot feel free [of pain] even a minute in 24 hours.”Women described having almost no time to manage their pain. Although they felt that it would ease their pain to relax, have massages, and rub topical creams on the painful parts of their bodies, due to their busy schedules, their family’s needs, and their work responsibilities, they could not find the time to actually carry out these pain management methods. Though they acknowledged that seeking a doctor’s help was important, as in the case of self-care, there was no time to go to the doctor. Women instead continued their work despite their pain in order to attend to their families, again prioritizing well-being of the collective, rather than themselves. Aditi  stated, “Even if there is pain, still [we Asians] work. And when we are asked to go to the doctor, we don’t get the time.”Interviews conducted with immigrant Indian women with chronic musculoskeletal pain revealed their lived experiences of chronic pain as multilayered and as having corporeal, spatial, relational, and temporal dimensions. These aspects of pain experiences were heavily tied to their gender roles as Indian women, specifically with respect to the division of household labor. The increased demand to work outside the home also led to changes in gender norms after immigrating to Canada. Both continuing and shifting norms had a significant impact on their experiences of chronic pain.15 identified that Indian girls are raised to bear pain, as well as to practice tolerance and self-restraint, which are deeply “… rooted in a consciously cultivated feminine role which is embedded in and legitimized by culture and cultural ideology.”(p17) She, as well as other scholars, highlighted that women in India are raised to display feminine attributes, which dictates the way they walk, talk, sit, and express themselves, and are expected to be docile and maintain a “culture of silence.”40 All of these gender constraints played into their accounts of pain.Women’s narratives centered heavily around their gender role as Indian women. Women’s physical pain experience was described as “bodily restriction” and “paralysis,” echoing gender norms for women in the comportment of their bodies. Their pain narratives were embedded in accounts of family duties. Dube42 In marriage, tasks and duties are gendered.43 Women are given the responsibilities of cooking, cleaning, washing clothes, and attending to family members. This “feminine” work is associated with notions of service and sacrifice, implying that it is a woman’s duty to take care of those around her and sacrifice herself.44 These gender norms not only shaped our participants’ chronic pain experiences but also exacerbated them.Women were also overwhelmed by work. They spoke of being entirely responsible for the household as well as working outside the home; they identified that this burden of work, which included cleaning, cooking, washing, and running errands, took a significant toll on their bodies. However, even after attributing this workload to their chronic pain, women continued to carry out these chores and described them as mandatory—enacting the gendered division of labor they had in India.17 that follows immigration. These factors have been associated with an increase in pain, bodily aches, sleepless nights, and depression, which are found among Canadian immigrant populations.45 For the women in our study, the same was true but, in addition, the process of rebuilding and reestablishing their lives in a new country stressed their gender roles, which played out in their chronic pain. This tension affected settlement processes, as women aimed to maintain their traditional, gendered family roles while at the same time dealing with the exigencies of their new environment21 and socioeconomic status. The dual roles of homemaker and wage earner increased their pain.Gender and immigration intertwined to affect our participants’ chronic pain experiences. Research has shown that the health of the growing immigrant population in Canada “is primarily affected by dislocation, isolation, loss of identity [and] culture …”46 Thus, isolation, heavy domestic workload, and child-rearing responsibilities increase immigrant Indian women’s health problems and chronic conditions, as has been noted for other immigrant women.47–49Almost all women in our study noted heavy workloads both inside and outside the home, as well as being homebound by child-rearing and care of elder household members. They associated these burdens not only with taking a physical toll on their bodies but with forcing them to neglect taking care of their pain. In this, our participants are like immigrant Indian women in other studies whose burdens are deemed to have a negative impact on their physical and mental health.50 These poor working conditions, alongside traditional gender roles, result in a severe decline in health for particular immigrant groups of women.51 This study extends these findings and shows that the additional burden of adjusting to novel demanding work in a new country particularly places immigrant Indian women at risk of severe chronic pain.In addition to the clash of gender roles and increased work burden, women had simultaneous space adjustments; they had to acculturate to a new country and climate as well as find employment in spaces new to them, such as factories and warehouses. Most women who had worked in India were accustomed to jobs in an office or university setting, which did not place a heavy burden on their bodies. In support of women’s experiences from this study, other research has shown greater employment downgrading in both type of work and income for immigrant women compared to men of the same background.47 Almost all women in our study spoke of having had domestic help in India, creating the additional burden of unaided household work after immigration. Previous research has also shown that this extra workload placed on immigrant women from the Indian subcontinent specifically has been linked to a deterioration in their health.47 This study therefore extends those findings, showing that this type of housework, coupled with additional stresses of acculturation in a new space, influences women’s experiences of pain.As women immigrate from India to Canada, many lose family support and important resources such as paid domestic help.A strength of our study is that it obtained rich descriptions of immigrant Indian women’s chronic pain experiences. We were, however, unable to restrict our interviews to only one ethnic or religious Indian group. Although all women who participated in the study were born and raised in India before immigrating to Canada, they were from diverse regional and linguistic backgrounds; some were from northern India, and others were born and raised in southern India. Some were Muslim and others were Hindu or Christian. This represents a wide range of cultures with their own gender norms and cultural traditions. Nevertheless, we did find a uniformity of concerns about pain that focused on gender and immigration. Future work would benefit from teasing apart the norms of a given region examining how, and in what ways, they may influence women’s understandings and experiences of pain.Secondly, although we explored culture in this study in relation to women’s experiences of pain, our aim was not to paint all immigrant Indian women’s experiences with a broad brush. Instead, we wished to explore the influence of cultural context at large on these women’s lives and did so by grounding our findings in women’s personal narratives, stories, and voices. Therefore, the inclusion of non-English-speaking women was a significant strength of the study because a diverse range of pain experiences was captured.52The implications of our study for public health systems, clinicians, and health care providers are that Indian women’s cultural values and norms, as well as their daily lives, play a crucial role in their experiences of pain. Their stories are rife with accounts of the tensions they face at the intersection of gender and immigration. Women’s stories can provide information about the triggers of pain, as well as how pain affects their lives, potentially improving both understanding and communication of pain between patients and providers. This, in turn, has the potential to increase culturally responsive pain practices.In any kind of diagnosis or treatment, it is important to understand the context of the disorder and the patient’s own understandings. It may be, for example, that Indian women will seek health care for what they consider more pressing concerns than pain but, underlying them, they may have chronic pain. Therefore, it may be important to ask about chronic pain directly. Given that the women are serving at least dual roles with little time for themselves and the self-sacrificing gender norms, it is important to consider treatments that may not be seen as time-consuming or selfish. It may also be important to involve other family members as part of the treatment plan.Exploring the lived experiences of chronic pain using an interpretive phenomenological approach allowed us to identify the multilayered dimensions of pain experiences for immigrant Indian women in Canada. We found that the lived experiences of chronic pain for women in our study have corporeal, spatial, relational, and temporal components. Our findings reveal that the larger cultural context in which women are raised shape their experiences of chronic pain. Under the umbrella of culture, unique pressures and expectations are placed on immigrant Indian women to continue to fulfill traditional gender roles in the context of immigration challenges. These tensions strongly shaped their experiences of pain. By uncovering the intertwining role of culture, new social structures, gendered lives, and immigrant experiences, we see the complexity of chronic pain and open new doors for therapeutic understanding.


Individuals with body integrity identity disorder (BIID) seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative biomedical model of health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be. In 2000, reports that surgeon Robert Smith had carried out two privately funded, therapeutic healthy-limb amputations as a means of addressing what he believed to be cases of body integrity identity disorder (BIID) drew the attention of the world’s media Smith . BIID isUnsurprisingly, the provision of “healthy” limb amputations in BIID cases draws considerable controversy, with arguments presented by opponents and proponents of the practice alike. A common argument employed by opponents to surgical interventions in BIID centres on the principle of nonmaleficence and the medical injunction of “first, do no harm.” Opponents argue that to amputate a medically healthy leg inflicts serious disproportionate harms upon that individual, not only through the amputation process itself and its associated risks but also by inflicting disability onto a previously non-disabled individual. According to this argument, using therapeutic healthy-limb amputation as a means for treating BIID breaches the principle of nonmaleficence as it invariably causes significant harms to the individual as it makes them irreversibly disabled. In response, those who tentatively support the procedure in cases of BIID argue that the harms, including the generation of disability, are potentially outweighed by the benefits, such as a significant decrease in suffering and the minimization of potential future risks  Finally, once the limb is gone, it is gone for good. Acceding to a request to be mutilated would amount to abandoning the patient. Smith One of the central tenets within medical and clinical practices is that of or harm” , 152. AsThe cure is not to yield to the illness and conform to the obsession. And this is not just about “do no harm.” It’s also about whether (sufferers) are competent to make a decision when they’re running around saying, “Chop my leg off.” The comparison W.J. Smith attempts to make between the belief that one’s appendix is cancerous and BIID in this passage is false. The belief that one’s appendix is cancerous is framed as non-factual and as such can be considered a delusion, an idiosyncratic belief maintained despite a contradiction with empirical reality. However, those with BIID recognise that the body part in question is theirs and is healthy. Their issue is that it does not correspond with their bodily image or identity, something which cannot be said to contradict empirical fact. Therefore, such a belief cannot be said to be delusional, merely unusual. However, W.J. Smith’s view on healthy-limb amputations remains clear. For him, to provide such amputations equates to a harmful medical service, a relinquishing of the patient’s best interest to that of their condition resulting in a literal surrender to the desire. Caplan also expresses similar views and argues that healthy-limb amputations would violate the Hippocratic Oath because:For Caplan, providing healthy-limb amputations disregards other potential treatment options such as psychotherapy, cognitive behavioural therapy, or psychopharmacology, and instead harms the patient at their request.According to the principle of nonmaleficence physicians must not perform amputations without a medical indication because amputations bear great risks and often have severe consequences besides the disability, for example, infections, thromboses, paralyses, necrosis, or phantom pain … Above all, an amputation causes an irreversible damage that could not be healed, even if the patient’s body image would be restored spontaneously or through a new therapy Müller , 41.Müller provides a similar argument against healthy-limb amputations in cases of BIID when, while discussing appeals to the principle of nonmaleficence, she argues:Müller makes explicit the distinction between the potential harms associated with surgical intervention in general, which will be referred to as acute harms, and the purported harms that come as a direct result of amputation, which will be referred to as chronic harms, the generation of what Müller categorizes as a disability, one which results from “leglessness.” Differentiating between the two, particularly in the BIID/healthy-limb amputation debate, is significant because there are arguments that adequately address the concerns regarding the acute harms in amputation: first, the ambiguous nature of the principle of “first, do no harm,” second, the justification of the provision of similar surgical procedures through an appeal to a cost–benefit analysis. Pre-existence of these arguments is decisive because by addressing the acute harms associated with healthy-limb amputation via these arguments, it allows the debate to move forward and consider the chronic harm of an absentee lower limb separately.net harm”  The SMD offers an alternative to this mechanistic understanding of the body by shifting attention from the individual to factors within their environment, including social oppression, cultural discourse, discriminative prejudices, economic influences, and physical barriers. The SMD’s goal, according to Shakespeare, is to provide “the structural analysis of disabled people’s social exclusion”  rather than its complement. Disability is unnatural insofar as it is the result of an accident : It is, by definition, both an aberration and an abomination and as such, is literally undesirable Sullivan , 584.Opponents to healthy-limb amputation in BIID cases who appeal to the principle of nonmaleficence often indicate an allegiance towards biomedical models of disability. This is characterized by Sullivan who, when discussing Bruno’s views on BIID, writes:Those who oppose healthy-limb amputation utilizing the principle of nonmaleficence often show a similar preference for addressing the identity incongruity those with BIID face via an alteration of identity, rather than of the physical embodiment. Amputation gives someone “an aberration and an abomination.” As such, opponents appear to wish to preserve what they consider a complete and healthy body and thereby avoid the creation of disability.However, according to the SMD, such a biomedical approach may impact the surface-level, “symptomatic” expression of disability, but not its source. Environmental factors would still create and reinforce disabilities that discriminate against those with atypical constructions. The way to address the creation and persistence of disability, according to the SMD, is through societal adaptation, not biological uniformity. Such adaptation would result in those of all bodily constructions being able to access available opportunities, regardless of impairment, elective or otherwise. This goal is, of course, subject to real-world limitations, complications, and resistance when it comes to the ability and willingness of individuals and societies to adapt to accommodate better those with atypical constructions, with some impairments requiring more alteration than others. However, this paper would contend that the degree of alteration required should not be a foundation for an exclusionary argument for those with more complex impairments, but rather a call for more investment and considered planning in how these individuals can be better brought into the mainstay of society.Barnes’s attempts to address whether it is acceptable to create an impairment where none existed before.6Amy and her nondisabled friend Ben work in a lab. After hours one day, they are playing around with lasers. Ben is not wearing any protective eyewear, and Amy knows that if she directs the laser beam at his eyes he is at risk of permanent vision loss. Nevertheless, Amy does not take any precautions to avoid directing the beam at Ben’s eyes. Ben becomes permanently blind. When Ben confronts Amy angrily about what she has done, Amy explains that she hasn’t done anything wrong. It’s not any worse to be disabled than to be nondisabled. So while she has made Ben a minority with respect to sight, she hasn’t made him any worse off Barnes , 95.Firstly then, to facilitate the discussion around the ethical considerations at play when an autonomous adult causes another autonomous adult to become impaired, Barnes uses the following example:Barnes assumes that readers, in response to this case, would feel that Amy had done something grossly wrong when she blinds Ben. Barnes supports this initial reaction to Amy’s actions via an appeal to three arguments: the non-interference principle, the risk of such action, and the transition costs.The non-interference principle, as understood by Barnes, requires of us that “you shouldn’t go around making substantial changes to people’s lives without their consent ” Barnes , 95. By eudaimonia, or “flourishing.” Barnes posits that Ben may, after his blinding, adapt well to his new impairment and lead a life full of flourishing. However, there is the substantial risk that this will not be the case, and in fact that Ben will perceive his blindness as something which limits him, his choices, and his overall life satisfaction. This exposure to risk is a harm, and as Amy is not in a position to know which of these two outcomes is more likely, she acts unethically by exposing Ben to such a high-risk factor, regardless of whether he eventually flourishes in his new impaired state or not.The risk factor of such an action refers not to the potential physical harm that such behaviour could lead to, but the risk to an Aristotelian concept of … there’s a big difference between being disabled and becoming disabled. Many people find being disabled a rewarding and good thing. But there is an almost universal experience for those who acquire disability—variously called adaptive process or transitions costs—of great pain and difficulty associated with becoming disabled. However happy and well-adjusted a disabled person ends up, the process of becoming disabled is almost universally a difficult one Barnes , 96.Finally, Barnes refers to the transition costs of moving from non-impaired to impaired, writing that:There is a strong case that those with impairments do have fulfilling lives, more so than typically presumed by the non-disabled and unimpaired  are competent to make a decision when they’re running around saying, ‘Chop my leg off’” Dotinga . However


Virtual reality (VR) exergaming may be a promising avenue to engage adolescents with physical activity. Since parental support is a consistent determinant of physical activity in adolescents, it is crucial to gather the views of parents of adolescents about this type of intervention.This study aimed to interview parents of younger adolescents (13-17 years old) about physical activity, gaming, and VR as part of the larger vEngage study.Semistructured interviews were conducted with 18 parents of adolescents. Data were synthesized using framework analysis.Parents believed that encouraging physical activity in adolescents was important, particularly for mental health. Most parents felt that their children were not active enough. Parents reported their adolescents regularly gamed, with mostly negative perceptions of gaming due to violent content and becoming addicted. Parents discussed an inability to relate to gaming due to “generational differences,” but an exception was exergaming, which they had played with their children in the past . Specific recommendations for promoting a VR exergaming intervention were provided, but ultimately parents strongly supported harnessing gaming for any positive purpose.The current study suggests promise for a VR exergaming intervention, but this must be framed in a way that addresses parental concerns, particularly around addiction, violence, and safety, without actively involving their participation. While parents would rather their children performed “real-world” physical activity, they believed the key to engagement was through technology. Overall, there was the perception that harnessing gaming and sedentary screen time for a positive purpose would be strongly supported. Sufficient physical activity protects against noncommunicable diseases  and is aDespite the importance of promoting physical activity in adolescents, it is not yet clear what works. A recent meta-analysis of 17 cluster-randomized trials of school-based interventions, including children and adolescents up to 18 years old, found these did not affect accelerometer-measured MVPA . MultidiGaming constitutes a significant part of an adolescent’s voluntary leisure time behavior, with some estimates of more than 90% playing for at least an hour per day . Gaming Earlier generations of exergames such as Dance Dance Revolution released in 1998 and Nintendo’s Wii Fit 2007), which sold over 22 million copies worldwide, and more recently, Pokémon Go, downloaded over 800 million times, are examples that have had huge commercial success 07, which. ResearcVirtual reality has the potential to enhance the impact of exergaming by allowing the user to feel present and immersed in the virtual environment . VR owneSmall laboratory-based studies in adults have found that VR exergaming increases enjoyment and levels of physical activity but with lower perceived exertion than standard exercise conditions -39. For Parental involvement is likely an important factor in the uptake of physical activity in younger adolescents . We qualThe aim of this study, therefore, was to interview parents of adolescents (13-17 year-olds) to understand their views of physical activity, gaming, and head-mounted VR in order to gather evidence and build more understanding around this, in line with the Medical Research Council (MRC) Framework for developing complex interventions . The MRCThis study formed part of the development work for the vEngage project . ParentsA semistructured interview schedule was developed to guide interviews . AccordiFramework analysis  was used to synthesize the data. Framework analysis is a systematic and effective approach for analyzing qualitative data in health research . It is aTwo researchers (LM and NF) independently analyzed three transcripts and generated a set of codes. The researchers then met to discuss, compare, and adjust the codes in order to develop the final analytical framework. The final framework was used to code all 18 transcripts by one researcher (LM). No particular software was used in coding the transcripts; however, the final set of themes and subthemes were collected with supportive quotes in an Excel spreadsheet (Microsoft). The data were then analyzed to explore emerging themes and identify common themes. Analyses were conducted with guidance from an experienced qualitative researcher (KN). The principal investigator (AF) independently reviewed the Framework Matrix and themes before the final interpretation.Participants were recruited through two local secondary schools in South London, UK (n=6), the University College London (UCL) network (n=8), and social media (n=4). Thirteen participants were mothers , and five were fathers  see . Six hadAwareness of physical activity guidelines for adolescents was low. Only one participant knew that the adolescent physical activity guidelines were 60 minutes of MVPA per day. In total, 17/18 (94%) did not know the guidelines, and most were unaware that the guidelines existed. Some participants made accurate guesses.Parents emphasized the importance of engaging adolescents in physical activity for lifetime health benefits. However, most specifically linked the importance of physical activity to their child’s immediate mental health:I think it is very [important] because I’m very, very active, and I know how good it is for your mind. (16F)I think anything that will get her moving more and doing more exercise will be good. (13F)Only two participants (11%) felt their child was engaged in enough physical activity. Most believed their child “should be doing more” (16F). All strongly believed that it was extremely important to encourage physical activity in adolescents:Oh, it’s massively important. I would put it one of the highest things, that and eating correctly. (13M)All parents (100%) reported their child did some kind of gaming most days of the week, usually reflecting that they felt this was too often and this was associated with a level of guilt: “Probably six out of seven days a week” (16M) and “Every day and far too long. I feel guilty as a parent” (13M).Nearly all participants  had negative opinions towards their child’s gaming. All (100%) participants were concerned about gaming being violent. Most participants  reported trying to limit gaming, a sentiment generally raised by parents of younger adolescents:Oh, I absolutely hate it. (14M)I do think they’re incredibly addictive and then you get issues with trying to manage the time. (13M)I don’t like the bloody, shooting kinds of things. I think some of it is a little too realistic. (16F)I wouldn’t be letting him just have it in his bedroom overnight and that kind of thing. (M13)Participants did perceive some benefits to gaming, including skill development, such as becoming adept at using computers, developing visuospatial skills, and improving cognitive functioning. Another particularly common perceived benefit of gaming was social interaction:A social aspect to it as well and even though it’s not physical and in-person, there definitely is a lot of banter and a lot of chat, and they’re very much in touch. I find that hugely beneficial. (13M)Participants felt that due to generational differences, they were unable to relate to gaming. However, 12/18 (67%) participants acknowledged that, when played in moderation, gaming could be fun:I think it’s just I find it hard to relate to because it’s not something that I do. (13M)I think in moderation, it is a source of enjoyment. (13M)Unlike sedentary games, participants shared experiences of taking part in exergames with their children. Only 2/18 (11%) participants reported positive experiences with exergames such as the Wii Fit , but these were referred to as something done in the past. Despite concerns around gaming, participants accepted that gaming and technology were parts of life and could be used as a force for good. Participants felt that they could not fight against technology, that it was a reality of modern life:It feels like an ancient device now, but at the time, it was one of those things that came along, and everybody was really excited about it. (13M)Technology is here, it’s not going away, and that’s fine if it has benefits for his health, then, yes, I’d always be up for that. (14M)A majority of participants  highlighted the social pressure on adolescent gaming, particularly in terms of owning certain consoles and games. There was a general view that adolescents were influenced by peer and social pressure, then persuaded parents, rather than the reverse. Nearly all participants  underlined the role that the peer group plays in adolescent interests:So that’s the thing is to try and get something that becomes the really cool thing to do. (14M)Most participants  had only a limited understanding of VR, and most had not tried it. A few had tried phone-based headsets. The same number of participants expressed an interest in VR, and some said that it seemed exciting. Others recognized it had potential:It seems like you’re actually in there, and you’re moving within that space. And it’s a whole lot more realistic, you’re actually in the game rather than watching. (13M)I think it opens possibilities, definitely that’s something I think that’s really the future. (17F)A majority of participants  were more concerned about violent games in VR than in regular gaming:Involving killing people, and that would not be appropriate in a virtual reality kind of scenario. (13M)It’s quite a weird idea that you then have no idea what it is they’re experiencing. (13M)Similarly, participants expressed safety concerns around multiplayer VR games as they may be unaware of whom their child is interacting with:That she might be playing or getting in contact with people who she doesn’t actually know. (13F)Further health and safety issues that participants mentioned concerned the practical matter of the space that VR would require.I wouldn’t want it taking over the sitting room. (16M)While participants suggested that gaming could be a social activity, they were concerned that VR gaming could be isolating:It seems solitary, another solitary thing that, she’ll be up in her room on her own. (13F)All parents cited cost as a barrier:Obviously, there’s the cost of it. (13M)A third of the participants  suggested they would overcome their concerns if VR presented a tangible health benefit. Participants recognized that outside of gaming, VR could have the potential to be educational, and this was viewed as a positive thing:If they (parents) can see the benefits of technology, then they’re quite happy to invest in it. (13M)I’m sure there’ll be some educational aspects to it that it could be used for as well. (13M)Participants did express concern that a VR fitness game could be a fad or novelty that comes and goes . However, participants suggested that if the game could maintain their child’s interest, they would be more likely to invest:It might be one of those fad things—they use it all the time for the first month, and then it’ll die off slightly. (16F)Providing that it has some kind of stickiness in terms of it wasn’t just a five-minute thing. (13M)A few participants  expressed that it would be important to regulate and manage the usage of the intervention. A majority of parents  expressed that they used technology and did not want to appear hypocritical:It would need to be regulated really so that it’s not just taking over. (16M)I think it’s fine. I mean, we use technology for everything now, don’t we? So it’s an inevitable march. I’ve got no problem with it. I’d be a bit of a hypocrite if I did, considering I work in technology. (F14)Half of the participants  felt strongly that physical activity in the real world would provide greater benefits. Participants showed a preference for outdoor activities and team sports. Nearly all of the participants  thought their child would be excited to try a VR fitness game, and that they would embrace it:I would see it as inferior to physical activity in the real world. (13M)I feel they’re sitting indoors, on the computer, when they could be outside doing other things. (14M)They love new things, and they love the next step up technology-wise. He would love it, I’m sure. (13M)However, 5/18 (28%) participants perceived that adolescents might be less keen to engage in something that their parents were actively encouraging. Participants also expressed the view there may be gender differences relating to a VR fitness game, such that boys may be more engaged than girls and that girls may engage differently.I think that all teenagers and young people are developing a separation from their parents, and not necessarily wanting to do what their parents say. (13M)Maybe girls wouldn’t be as into it as boys or maybe the time you have to give, you know, different challenges, different games. (14M)Participants also had ideas as to what may make the game appealing. These included levels, competition, a social element, and a challenge that requires skill:I suppose some kind of score, so you could either beat people or beat your own score. (16F)Participants also reflected on the fact that adolescents expect the best in terms of quality and graphics:They are tough consumers. If it’s not on-brand, if it’s not hitting their buttons, then they will just drop it and say, or won’t even pick it up. (13M)All participants welcomed the potential of gaming with a positive purpose, particularly mentioning being active during screen time:If somebody has already lost them to screen time, having part of their screen time as exercise could be fantastic couldn’t it? (13M)All participants in our study strongly believed that encouraging physical activity in adolescents was important. Most participants felt their children were not active enough. National datasets in adolescents using objectively measured physical activity suggest this perception is likely correct, with less than 15% meeting minimum guidelines . AwareneParents tended to have negative perceptions of gaming, particularly expressing concerns about addiction. Reflecting and perhaps exacerbating parents’ concerns, “gaming disorder” is recognized in the International Classification of Diseases (ICD-11) , highligParents reported they managed their child’s gaming to some extent , but acknowledged that adolescents should be allowed some autonomy, particularly as they approach young adulthood. This impression was supported by a study of 500 families using latent growth curve monitoring to demonstrate that parental media restriction decreases throughout adolescence . Except Harnessing novel technology, such as the mobile game Pokemon GO, social media interventions and immersive VR games have been identified as an effective way of increasing physical activity in adolescents ,56,57. TParents identified several benefits to gaming. These included socializing, becoming skilled at using technology, moving, or utilizing screen time for health benefits, the development of visuospatial skills and strategy. Participants were aware of VR but had a limited understanding of its use. Perceptions of VR were generally positive, with many participants describing it as interesting, intriguing, and as having potential. However, there was uncertainty around VR and its applications, and participants expressed concern about their child using violent games would be used in VR and have damaging psychological effects. Therefore, when developing the intervention, these factors should be considered, with violence avoided and, for example, providing guidance to help protect against addiction.Parents reported they managed their child’s gaming to some extent  but acknowledged that adolescents should be allowed some autonomy, an effort supported by a study of 500 families using latent growth curve monitoring to demonstrate that parental media restriction decreases throughout adolescence . ParticiDespite concerns such as “novelty wearing off in 5 minutes,” participants said they would support their children’s use of VR if they knew there was a health benefit or educational element. Thus, despite reservations around VR, parents see the potential of the technology and would be open to it should it present a tangible health benefit. While some participants seemed to embrace technology and its potential for promoting health and fitness, others appeared merely accepting of technology and surrendering to its applications. These responses show that, while in different ways, all parents were open to using technology to improve the health of adolescents . With thParents reported a strong preference for real-world physical activity and felt that exercising using VR would be “better than nothing.” There was a strong message for VR having the potential for adolescents who do little or no physical activity, which is the majority . TherefoIt may be important that the game is marketed directly to adolescents rather than to their parents since adolescents strive for independence . ParentsOnly one adolescent child had a known disability, Asperger Syndrome. It was interesting to see that the mother of this child stated that she believed that gaming and head-mounted VR would help her child because “it takes away the pressure of having to interact with other people” (13M). Her feedback was interesting, but due to the aims of this study, we did not explore this further. While we recognize the potential for the benefit of exergames in children with disabilities, we felt that any disability that impacted movement might impact parent’s perceptions of physical activity. Exergaming would best be excluded from the scope of our study.The sample size was sufficient, according to Clarke and Braun’s  recommenOur sample comprised of more mothers than fathers and more parents of boys than girls, despite there being low levels of physical activity in both adolescent girls and boys. It would be useful to investigate whether parental concerns differ depending on the child’s gender. Further research should also explore ways to engage boys and girls with the intervention equally. Social desirability bias may affect participants’ answers since parenting methods can be a sensitive topic, but participants were open about how they knew their child should be engaged in more physical activity.Adolescents have previously raised parental support as being an important factor in the intervention success , consistThe results of this study provide support for developing a head-mounted VR intervention to promote physical activity in adolescents. The findings provide useful insight for intervention development. Parents had negative associations with gaming but are accepting of it and embracing its potential. It is important that concerns are considered in the intervention development and negated, where possible, to maximize adoption and, ultimately, the efficacy of the intervention. Overall, parents believe encouraging physical activity in adolescents to be of importance. Therefore, while parents have reservations, it seems they would welcome anything that may improve their children’s health, including if it involves harnessing a behavior like gaming and using it as a force for good. Recommendations for the next stage of intervention development would be to further research how best to educate and inform parents to reduce uncertainty around VR and the intervention. Additionally, shaping the game with an adolescent steering committee is recommended in order to ensure it is enjoyable and has longevity.