Using textual analysis, the community- and campus-based performance scripts were coded for themes related to stigma. Both ethnic groups reported that stigma is a barrier to expressing emotional vulnerability, seeking help, and acknowledging mental illness. We found that Caucasians’ experiences were more individually oriented and Native Americans’ experiences were more collectively oriented. Understanding the cultural bases of experiences with stigma related to mental health treatment for suicide is necessary to create educational programs to reduce stigma for diverse groups of adolescents and young adults.Stigma against suicidal ideation and help-seeking is a significant barrier to prevention. Little detail is provided on what types of stigma interfere with help-seeking, how stigma is expressed, and how to reduce it. Five groups of two ethnically diverse community theatre programs were formed to analyze differences in Eastern Montana Caucasian and Native American adolescents and young adults’ experiences with stigma about mental illness and mental health treatment that affect help-seeking for suicidal thoughts and experiences. Over a ten-week period, a grassroots theatre project was used to recruit members from the same population as the audience to write and perform a play on suicide and depression ( In 2016, the rate of suicide in Montana was the highest in the United States—almost double the national average at 26 per 100,000 people, compared to 13.4 per 100,000 people nationwide . This leGoffman  defined Stigma can take emotional, cognitive, or behavioral forms. For example, self-stigma is a process in which a person with a mental illness internalizes stigmatizing attitudes and beliefs held by the public . People Scholars have identified three primary mechanisms to explain how stigma contributes to suicide. First, according to the stress-coping model of stigma, stigma is seen as a social stressor that promotes “negative emotional reactions, social withdrawal, and hopelessness among people with mental illness, especially if the perceived threat of stigma and social rejection exceeds the coping resources of the individual”  (p. 4). Based on comparative studies across countries, Schomerus et al.  posited Emerging theories of suicide consider how cultural meaning influences suicidality . CulturaGoffman  defined Anthropologists have conceptualized stigma as a communal moral judgment, conferring a morally ambivalent status onto the stigmatized group . KleinmaNiederkrotenthaler et al. and Kleinman and Hall-Clifford ,33,34 caCommunity-based theatre programs can be used to illuminate local cultural attitudes about a health threat ,41. As sCultural differences in the causes and manifestations of stigma, and attitudes towards suicide, are not uniform across populations . Many stRQ1. What mental health issues are reported by Eastern Montana adolescents and young adults?RQ2. How does stigma about mental illness and mental health treatment affect help-seeking behavior among Eastern Montana adolescents and young adults?RQ3. What are the differences in collective vs. individual orientation expressed by NA and Caucasian adolescents and young adults?Our research team designed the study presented here to assess young adults’ experiences with and perceptions of stigma surrounding mental illness. We also investigated barriers to accessing prevention services for depression and suicide. The study involved a textual analysis of the scripts from community- and campus-based theatre performances written and produced by students in Eastern Montana high schools and one state university in 2012–2015. The objective of this process was to shed light on attitudes towards suicide prevention resources among members of the participating community—both the writer-actors and the audience members. We analyzed transcripts of the performances to gain a systematic understanding of the messages they contained. This paper addresses two research questions (RQs 1 and 2) that were developed prior to the project, and one research question (RQ3) that emerged after the plays were performed:The performances under analysis in this study originated through five theatre workshops to address the risk of suicide. The theatre workshops were conducted by professional theater directors (with Master’s of fine arts degrees) recruited from the university’s theatre department, in conjunction with licensed professional counselors at each workshop location. The theatre directors worked with a project coordinator to recruit student volunteers for the plays at high school and college venues. Volunteer writer-actor groups met for 2–3 h biweekly at prearranged after-school locations or university campus facilities for 10 weeks to share personal experiences with suicide and/or major depression; each group collaboratively wrote a unique play based on their members’ experiences. Throughout the playwriting process, student-actors shared memories, songs, and poetry to develop a creative script based on their own experiences with depression, suicidal ideation, suicide attempts, and grief over a friend’s or family member’s suicide. The narrative development process included any part of the students’ life experiences related to suicide and depression (including among friends and family) they felt comfortable sharing. At the end of the writing–rehearsal period, the students staged performances for their peers to demonstrate how communities could talk among themselves and with mental health professionals about mental illness, suicidal ideation, loss, and prevention. Montana State University Billings (IRB00001622) approved this study.Community-based programs that engage community members in storytelling and performance, such as this theatre production, offer a potentially effective approach to revealing underlying attitudes and beliefs about sensitive issues, and can be used as a research tool to generate interpersonal dialogue ,41,43. On = 33) were recruited via classroom announcements and word of mouth (face-to-face recruitment), asking volunteers to take part in writing and performing an original play about suicide and depression. Two of the five theatre workshops were recruited from Native American high-school after-school programs (HS 2 and HS 4); the remaining three theatre workshops comprised Caucasian adolescents and young adults from local high schools and one college . In addition to the theatre directors and counselors, researchers were present once per week to introduce themselves and observe the script development process. Field notes were taken during these observations, but no audio or video recordings were taken until the final performance of each workshop. The researchers’ presence was restricted to ensure that students had an opportunity to develop narratives without the potential inhibition caused by a researcher’s gaze. For the first meeting, an outside specialist administered QPR  suicide prevention gatekeeper training, which provided the initial platform to talk about such a personal and painful topic. At the rehearsals, theatre directors gently probed the writer-actors’ experiences with stress, anxiety, depression, alienation from school and home, and relationships. These prompts were not standardized across the directors; each director was given the freedom to develop their own prompts and questions to engage participants in discussion around the themes of suicide, depression, loss, and help-seeking. As related themes emerged, the directors were encouraged to incorporate these subthemes into the emerging scripts. By contributing creative non-fiction based on their own experiences—with self-harm , suicidal ideation, suicide attempts, and grief over a friend’s or family member’s suicide—the writer-actors collaboratively created an original narrative theatrical performance ,56   was convened to analyze the text. All members of the team had extensive experience with qualitative research methods and analysis. The research team members all had a part in designing and implementing the community-based theatre project. Student writer-actors recruited for the plays were introduced to the research team members and their role was explained. The team conducted a textual analysis, using grounded theory and content analysis, because established qualitative data analysis techniques  would alBetween 2012 and 2015, the research team recorded video footage from the five theatre performances described above, along with conversations among performers and audience members in post-play question and answer sessions. The textual sample consisted of the entire population of such plays produced by the project under study. Digital video recordings and transcriptions of each play were entered into the qualitative analysis software MaxQDA . None of the transcripts were returned to the theatre workshop participants for feedback. Three members of the research team  made up the coding team. One of the five play transcripts was selected at random to serve as a subsample for initial code development. The team’s analytical approach was informed by coding methods laid out by Miles and Huberman , Corbin After achieving consensus on the main categories, the team began open-coding a subset of the transcripts, using both the a priori categories, and identifying additional ideas as they emerged. As needed, the team refined the categories, re-naming codes  and usinn = 452) included any scenes or statements in the transcripts that fit into one or more of the main categories, according to the coders. Each coder identified the main category/-ies and subcategory/-ies that best fit each passage. The team first practiced coding using subsamples of the video footage to become familiar with the variables and to resolve emergent questions. Once the codebook was established, the coders worked independently to assign codes to all the remaining performance transcripts. Codable passages (Reliability was assessed by measuring the agreement between each of the independent coders. Based on Wimmer and Dominick’s  recommenn = 153); “communal vs. individual orientation” (n = 52); and “stigma” (n = 94). Stigma was measured both as a standalone main category and as a subcategory under “barriers to help-seeking” and “factors of suicide”  performances . Passagesuicide” . Addition = 153, 34%, see n = 32), that is, a person’s belief that they have no options to improve their own situation. Hopelessness is illustrated in the statement, “It’s not fair… there’s, there’s no place to go. Nowhere to run, no one to turn to. I’m completely lost” . In response to RQ1, “What mental health issues are reported by Eastern Montana adolescents and young adults?”, the most frequently identified main coding category from the transcripts consisted of self-reports of mental health issues  was the second most frequently coded subcategory, exemplified by the statements:My brother [died by] suicide a few years ago. I fell into depression. Today I still have depression, but it’s not as bad as it was. I still miss my bro, always….How do I get self-esteem up to par where I can feel like I’m worth even in my adult age? How do feel like I’m worth what other people see in me?Depression .Depression related to grief was described by Native American participants, as well as a view that depression is a common experience in adolescence:n = 18), exemplified in passages such as:I wish I could get this all done and over with. It’s just so hard living in hell. Maybe I should end it or maybe not. What should I do?I’ve been in dark places myself and I’ve thought about it. And, and it was actually the concern over my child that kept me from doing anything. And I didn’t probably, I do understand how despair can be, you know, I can understand how she could feel alone. But she, she shot herself in the face.As I’m driving, I’d like to just drive off the road. Or when I’m in the kitchen, if I could just use a knife or when I’m home alone. If I could just get to my dad’s gunWhy do I think of death when I should think of life? Why do I feel sad all day?I was literally worried about my friend, she was literally about ready to commit suicide that week and she told me that she was going to. I literally went to my counselor and I’m like, “I don’t know what to do. This weight has been on me like for a week now.”.Suicidal ideation was the third most frequently mentioned mental health issue  Public stigma ; (b) internal stigma, known as self-stigma (endogenous beliefs), including fear of being shunned, experience of being shunned, disconnection from others, thwarted belongingness, perceived burdensomeness; and (c) stigma of help-seeking, which was evidenced through comments that we labeled “defensive-avoidance” . A total of 94 (21%) of all segments were coded under the main category of stigma, pertaining to reports of what is being stigmatized, as opposed to reports of experiences with stigma. Emotional vulnerability, needing help, mental illness, and mental health treatment emerged as subcategories of stigma. Suicide, a touchy subject no one wants to talk about. But it needs to be talked about. It seems no one wants to talk about it until it’s too late. Suicide affects everyone, teachers, families, friends, and even co-workers. But the teens are affected the most. Still, no one wants to talk about it..In response to RQ2, “How does stigma about mental illness and mental health treatment affect help-seeking behavior among Eastern Montana young adults?”, our results indicated that defensive-avoidance reactions fueled fears that others are negatively judging emotional vulnerability and mental health treatment and may constitute a significant barrier to help-seeking among Eastern Montana adolescents and young adults. The literature has established stigma as a well-documented factor contributing to suicide ,15. BaseBy contrast, other barriers to help-seeking, such as limited access to resources, and low awareness of how to find help, were not frequently found in the transcripts.My collection is different. Some would say it’s odd, and most heads turn away when they see, but I don’t care. Well, I collect scars. Crazy, right? It’s true though. Scars in all shapes and sizes. You see, I don’t like collecting that happy crap; I collect what matches me: depressed, angry, completely helpless. I collect scars because it’s who I am. Of course I notice reactions. All eyes are on me, or some just refuse eye contact period. But it doesn’t make a difference. They both mean the same thing. My collection is frowned upon in society.Of the passages coded as stigma, 23 (5%) were coded as public stigma. Below, one female high school student revealed that her sense of alienation is based on her perception of being rejected by others. The quote represents the cyclical relationship between perceived public stigma  and self-proscribed deviant behaviors or attitudes that contribute to self-stigma.We saw a lot of these teenagers depicting very seemingly and realistic scenes of dealing with the stresses that teenagers have in their daily life, and also dealing with many of the roles and stereotypes that they perceive are forced upon them. Now you take all of that and add an additional layer of the stereotyping that is felt by the teenagers in our Native communities.Another comment reflected students’ perceptions that other people are negatively judging them: “Look at all those people out there, staring at you, waiting for you to mess up like you always do” . Clearly, the interplay between external judgment and internal fears is a blurry one. When external judgement involves societal discrimination, the line between internal and external judgments becomes clearer. Native American participants described racism as an added layer to the stigma they experience as individuals. One NA audience member responded to the play by commenting:Of the passages coded as stigma, 46 (10%) consisted of expressions of self-stigma, which we subcategorized into: (1) Fears of being shunned; (2) thwarted belongingness; and (3) perceived burdensomeness. Fears of being shunned. Comments reflected fears of being shunned for accessing treatment, fears of being shunned in general, and experiences with being shunned. For example, one segment coded both as “fears of being shunned” and “self-stigma” consisted of:How come they think I’m full and funny, but I don’t? Why do I wear a mask over my emotions? Why do I seem happy but inside am dark, too dark to see the faintest light? Should I end it all right now?Here, a high school student explains how he does not feel like he fits in with his peers, and, specifically, that he has to hide his darker or negative emotions in order to be accepted. These thoughts lead directly to thoughts about suicide. An example illustrating the perception of stigma against admitting one’s emotional vulnerability appears in this passage: “Should I let them [emotions/thoughts] out? What if people laugh? What if people cry?”Thwarted belongingness. Two coding categories that were categorized as self-stigma are “thwarted belongingness”  and “perceived burdensomeness” . You know, maybe I shouldn’t, no. No, no, no, things’ll be better this way. Soon they won’t have to deal with their nothing of a son and, and nothing will leave this world, just, just as nothing entered it. People will go on with their lives, and lives and, and maybe, maybe I shouldn’t…[My mother] gets inside my head, makes me feel like I’m nothing, makes me feel like I should just jump off a bridgeis unmet  (p. 197)In these two examples, individuals express their sense of being a burden to both their immediate social circles and society at large. The overlap in descriptions of thwarted belongingness and perceived burdensomeness is a direct result of the intricate relationship between these two feelings as experienced and described by adolescents.n = 25, 6%). “People try to control their fear by suppressing thoughts of the danger (defensive-avoidance) or by reacting against the communicator or message ” , on the reservation, [sic]… ask [people] like “what’s your problem?” … they’ll have trouble with, you know, reading your song, and then like, you know, they get all defensive.For example, the comment below depicts the stigma surrounding mental health and the challenges of trying to reach out to encourage someone else—in this case, a fellow Native American—to discuss emotional vulnerabilities:And [the counselor’s] like, “Why didn’t you come to me sooner?” and I’m like “I had to think it over in my head, what I was gonna say and if I should come to you or help her not to, like, do anything.”Despite what the literature shows about collective agency among Native Americans, the above quote illustrates that fear of disclosure is prevalent in both tribal and nontribal communities, and that this fear is sometimes masked by defensive or angry responses. Similarly, a Native American female adolescent described her hesitation to seek professional help on behalf of a friend who was suicidal:n = 25) of the 94 stigma codes. Passages coded as behaviors symptomatic of defensive-avoidance reactions included truancy (skipping classes), alcohol and drug abuse, and cutting (self-harm). For example, the following segment of dialogue among three high school students was coded as truancy and alcohol abuse—both defensive-avoidant behaviors:Female 1: “So I heard this girl call saying you’ve been skipping classes.”Male: “No, I haven’t been doing that. I’ve been going to all my classes.”Female 2: “Sure, and you haven’t been drinking your dad’s beer.”We subdivided the defensive-avoidance category based on expressions of defensiveness, denial, or reactance , collectively made up 27% . Witte  assertedIn response to RQ3, “What are the differences in collective vs. individual orientation expressed by NA and Caucasian adolescents and young adults?” a total of 52 of the 452 passages were coded as having a strong communal or individual orientation. Communal orientations were ascribed to passages designating both the locus of a problem and the solution in the community, rather than the individual. Individual orientations were defined as passages indicating the perceived problem as located within an individual or pertaining specifically to individual characteristics. “Individualism implies that the self is permanent, separate from context, trait-like, and a causal nexus; that reasoning is a tool to separate out main points from irrelevant background or context; and that relationships and group memberships are impermanent and non-intensive”  (p. 12).Okay. Well, Natives, we are different. We don’t really open up as much as we should. And a part of that is because growing up on the rez, you’re, it’s, it’s hard. It may seem difficult and, so until you’ve actually lived there. You know that it takes skills to survive on the rez. When you’re brought up with sort of this—defense mechanism, an inner, inner sort of system of defense they use.A strong ethnic difference was revealed in the collectivist vs. individualist passages. An example of collective notions of depression and mental health problems was articulated by one Native American male:I know exactly what you all think I am. I’m some Judd Nelson character with my fists in the air and I smoke to rebel from the social norm. I don’t give a damn about the social norm…. I mean, I really don’t care what they think of me so they can pinch their noses or say their prayers or whatever, but I’m going to keep doing whatever the hell makes me feel not like crap, and they can come to whatever conclusions they want. But that they think for a minute that they know who I am? They’re dead wrong.In the above quote, a young man talks about how members of his tribe share a common tendency to hide their emotional vulnerabilities. What is interesting is that he depicts this challenge (fear of disclosure) as a common problem, not an isolated affliction. By contrast, Caucasian students in our sample described their experiences with depression as a personal problem, one that is partly caused by the rejection or negative judgment of their immediate circles of support. Not only do we not hear Caucasian students describe a maxim requiring them to help each other out, but just the opposite, they speak frequently of rejecting others and being rejected by them. An example was given by a Caucasian high school female:I would say it’s the words that hurt most, but honestly it’s the silent judgment that comes from the peering eyes of those around me. It’s the whispered words that appear as my back turns to the cowardly. It’s the complete lack of understanding that takes place in this melting pot of awful. Now we’re asked to be who we are and embrace the weird, but how can we do that when society demands we reject ourselves?Caucasian students described their experiences with mental health crises from an individual perspective—they feel that they must suffer alone and help themselves recover from the crisis alone. This orientation is prevalent, even though the writer-actors know that seeking help from others is imperative for recovery.I think it’s part of what we are longing here is what we’re doing this evening. I then have to share with you my own experience with depression and suicide attempts in my family in order to serve as your master of ceremonies.In identifying solutions to the suicide epidemic, Native American students talked about group or public efforts, such as ceremonies—including the current theatre performance—as pathways to change. The following quote reflects a group and familial identity in relation to suicide:We reject the weird and soon the unreasonable hate of others becomes the unreasonable hate of ourselves and then what? Do we just fly away like Superman? No. No, there is no Superman. No one to shield us from those words that sting like bullets. No one to save us, the weird, the outcasts, those just trying to hang on.By contrast, Caucasians tended to describe the potential solution for alienation as rooted in another individual, rather than a societal intervention:I want a different path. One where perfection is easy. One, one where my parents don’t tell me I’m going to hell whenever, whenever I’m not perfect. When we have real friends, ones who care, ones who don’t tell me that I don’t have the guts whenever I confide in them.Another strategy for individualized suicide prevention was articulated by a Caucasian female high school student who described the solution to her depression as coming from friends who care and parents who leave her alone:My grandpa Peter once said that in order to get your way in this life, you know, you have to help each other out. And later on in life, the creator will help you on the days that you will be sad. And the days that you will become ill or just physically and spiritually sad…and that we all gotta help each other to get into this world and, you know, help each other out.Meanwhile, NA students expressed an intergenerational and spiritual orientation towards suicide prevention, reflecting the group identity continually found in our sample:In this statement, we hear family dynamics (“grandpa”) and larger spiritual community (“the creator”) both calling upon people to “help each other out” on both ends of life, birth, and death. According to this young man, the NA community  moral code calls for communal helping of others.Based on the above, in response to RQ3, “What are the differences in collective vs. individual orientation expressed by NA and Caucasian adolescents and young adults?”, we found that the cultural differences in how Native American and Caucasian young adults view stigma is rooted in their perspective of mental health problems, and depression in particular. Native American youth tended to speak of help as something that is the responsibility of each member of their community, and the barrier was described as the failure of community members to step up to the plate and help each other. By contrast, Caucasian students described mental health problems as individual in nature, and the barriers to help as caused by specific individuals’  failure to care.Similarly, Caucasian youth tended to describe depression and alienation as an individually unique experience, typically caused by one person not fitting into the social norm or being rejected by significant others in their life. By contrast, Native American students described depression as something their entire tribe (or even everyone) experiences, and that the feelings are common.Finally, the collective vs. individual orientation represented a difference in how each group viewed suicide. We found that Native Americans were more likely to see suicide as a result of not living in the present, failing to let go of painful experiences, and failure of others in the community to reach out and help one another. Caucasian students described the cause of suicide as a result of being rejected by others, not belonging, not fitting in. An empirically based, thematic textual analysis verified the important role that stigma—both public stigma and self-stigma—plays in preventing young people from seeking professional help to reduce the risk of suicide ,8. In response to RQ1, “What mental health issues are reported by Eastern Montana adolescents and young adults?”, salient mental health reports included hopelessness and depression. Together with the stigma described in the Results section, these psychological states reveal a web of challenges that permeates many aspects of adolescent and young adult lives in Eastern Montana in relation to mental health and help-seeking. Our study also showed that hopelessness, the belief that one is unable to do anything to resolve a health threat (similar to defensive-avoidance), was the most common self-reported mental health problem by both Caucasian and NA youth. Here, it is possible that the self-reports of mental health challenges may reflect our findings on stigma—an internal and external pressure to avoid violating local cultural norms—that may prevent young people from varied ethnic backgrounds from seeking treatment for their mental health challenges and increase the likelihood of hopelessness. In response to RQ2, “How does stigma about mental illness and mental health treatment affect help-seeking behavior among Eastern Montana adolescents and young adults?”, the analysis revealed prominent barriers to help-seeking involved both public and self-stigma (defensive-avoidance and thwarted belongingness). Many of the experiences reported by adolescents and young adults in this study were common across ethnic and racial lines. Fear of being publicly stigmatized seemed to clearly limit a person’s willingness or ability to seek help for a mental health risk or experience of suicidal thoughts. Self-stigma was also shown to mitigate a person’s willingness to take any action on their own behalf when confronted with a health threat—especially when they perceived the threat to be stigmatized. Corrigan, Larson, and Rusch posited that self-stigma results from internalized stereotypes and prejudices, which in turn lower self-esteem and confidence, resulting in reduced achievement and abandonment of goals, i.e., the “why try” effect, ultimately ending in lowered self-efficacy . Thus, iIn examining self-stigma in this analysis of the youth theatre performances scripts, the construct of thwarted belongingness did reveal differences along ethnic lines. The feeling that one does not belong among one’s peers or significant others and the experience of social isolation was frequently mentioned or described by Caucasian youth but not Native Americans . While NIn response to RQ3, “What are the differences in collective vs. individual orientation expressed by NA and Caucasian adolescents and young adults?”, our results indicated that stigma, suicidal ideation, and help-seeking are described quite differently by Caucasian youth compared to NA youth. While NA participants described experiences of loss, suicidal thoughts, and helping others as both an affliction and an obligation of each member of a community, Caucasian young people described their experiences with suicidal thoughts as an individual affliction typically caused by alienation from their immediate circles of support. Although it is a mistake to assume Indigenous people fall under one category or one culture, and although each NA nation has its own unique cultural beliefs and traditions , one keyHowever, it should be noted that while we did not see direct reports of racial discrimination, Native Americans experience suicide at 1.5 times the national average and are ethnic minorities in the United States [A limitation of our research stems from the qualitative nature of our approach. Because the majority of textual analysis involves the subjective interpretation of data, care was taken to ensure the validity and reliability of results. Construct validity was achieved through clearly defined research questions and operationalized themes and concepts, while reliability was ensured via the use of multiple coders. Data generated via textual analysis cannot be generalized to an entire population and, because it relies on subjective human beings as the research instrument, it cannot be assumed to be completely objective; nevertheless, there are many strengths of textual analysis as a research method. It generates rich, detailed data not always possible with more common methods like surveys. In addition, much of the information used in textual analysis can be gathered unobtrusively, so that the act of being studied does not influence the behavior of the subjects.A second limitation of our work is the use of a superficial dichotomy between individualist and collective cultures. While it is indeed true that cultures vary widely in their orientation regarding collectivist vs. individualist thinking, it is impossible to draw far-reaching conclusions about an entire culture based on the few comments analyzed in this text. Furthermore, subcultures vary widely within parent cultures; hence, we are not able to draw conclusions beyond the small group of students interviewed, much less their entire tribes or communities, and we certainly cannot extend or apply our conclusions to entire races or ethnicities. Nonetheless, the contrasting orientations under discussion may have implications for individuals’ ability or inclination to help others at risk of suicide .We feel our work adds to a body of research on interpersonal storytelling, narrative medicine, and suicide prevention research. Our project is novel in that it qualitatively categorized voices articulated through a community-based suicide prevention setting. The hope is that community theatre of this type can provide a research tool for identifying life stressors and sources of cultural support that may ultimately contribute to programs to increase the use of suicide prevention resources in remote communities where counseling and discussion of mental health problems are largely taboo. By identifying the particular barriers that young adults of varying ethnic backgrounds face in accessing mental health treatment and interpersonal communication about suicide and depression, we hope this paper may provide a crucial link between exhibited warning signs and access to care. Our findings supported prior research indicating that communal mastery is common among NA cultures. We feel, based on these findings, that such a collective orientation should be emphasized as a cultural strength when designing suicide prevention programs targeted at NA communities. As mentioned, communal mastery has been shown to increase resiliency in response to stress and reduce depressive mood and anger . If it iThese findings add a new dimension to existing research on stigma against mental illness, which, to date, has mostly addressed the development of scales to measure stigma, models to increase our understanding of how to diminish stigma’s impact, and explanations of stigma by examining the social cognitive elements of the stigmatizer . By expl


Neonatal bloodspot screening (NBS) identifies conditions to offer early intervention and minimize irreversible damage. NBS policies guide a comprehensive system including processes for storage of neonatal dried blood spots (NDBS). NDBS retention and secondary use policies have been subject of public debates internationally, suggesting that the public’s perceptions of NDBS policy are not always on par with existing policies. The current study aims to provide insight in relevant factors for new parents in the Netherlands regarding retention and secondary use of NDBS. These factors can be taken into account when developing or updating NDBS policies.n = 753), focus groups , and individual in-depth interviews (n = 7). The discussed topics included: parental information, obtaining informed consent, support for retention, and support for secondary use. The study population consisted of Dutch-speaking new parents: pregnant women (≥20 weeks) and/or their partner, and parents of at least one child (≤5 years).A mixed methods design was used combining an online survey  use of NDBS, clearly described safeguards for privacy, a more active consent process, regulation for the actors conducting NDBS research, and parental involvement in decisions on secondary use. Overall, participants were positive about prolonged retention and different types of secondary use if those needs were met.While parental involvement is a challenge, our study is an example of gauging parent’s perspectives on NDBS policy and contributes to including these perspectives in the current policy discussion on longer retention. Prolonged retention could be a feasible option in the Netherlands if several prerequisites are met. Therefore, implementation studies involving parents are needed.The online version of this article (10.1186/s12887-019-1590-8) contains supplementary material, which is available to authorized users. Most neonatal bloodspot screening (NBS) programs identify a selection of rare, serious, congenital conditions for which timely detection and treatment early in life prevents or minimizes irreversible damage . NBS hasIn the Dutch NBS program Table  NDBS areRetention only takes place in the Netherlands if parents did not opt-out from retention and secondary use of their child(ren)‘s NDBS . The optInternationally, NDBS policies were often implemented without public debate on what would be acceptable, relevant, and responsible policy . Public n = 1272) showed about 70% of the respondents had a positive perception of prolonged retention of NDBS .” - Survey respondents were asked if they would like to receive information for three situations: 1) when their child’s NDBS is potentially used in secondary research, 2) about the results of the secondary use research project and 3) when the storage length changes. Approximately half of them wanted to receive information for all situations. Both FG-participants and interviewees would like to receive information on retention and secondary use, but in many FG it was also mentioned that the information currently provided is not adequate.2 = 15.82, p = 0.000) and trust in the current decision-making process  were associated with whether survey respondents wanted to receive information on all three situations versus information on one or two situation(s) or no information. People who had lower trust in the current decision-making process and perceived low transparency of the NDBS management wanted to receive more information Besides general information on NDBS in the NBS leaflet, FG-participants suggested access to more detailed information about research purposes for secondary use to increase support.n = 578, 76.8%).Many new parents in FG and interviews believed it would be sufficient if access to information on secondary use is facilitated for example on the RIVM-website. Informing parents when their child’s NDBS is used, is mentioned several times, but would entail a link to personal information, which interviewees considered worrisome with regard to anonymity of the samples. A majority of the survey respondents also indicated they would like to have access to information on results of secondary use on the RIVM-website The NBS leaflet that includes information on retention and secondary use of NDBS is currently handed out twice: at approximately 36 weeks of gestation at the midwifery practice or hospital, and when the newborn child is registered at the municipality . The timIn contrast, other FG-participants argued earlier information would increase the likelihood of forgetting, and supported the current information timing. Other FG-participants indicated information should be provided later, during regular check-ups at a child healthcare centre. In that case consent for retention and secondary use should also be obtained at a later time point.Consent for retention and secondary use is currently obtained with an opt-out approach at the time of the bloodspot collection.n = 539) of the respondents supported the current opt-out procedure, 40.5%  preferred an opt-in approach. According to some individual interviewees and FG-participants, not everyone takes an informed decision or makes an active choice with an opt-out approach. FG-participants also felt that at the first few days postpartum it is difficult to make an informed decision.“I think when you sign [in both cases], then you see which box [yes or no for four years retention and anonymous scientific research] is ticked, that would be better for me. Then I see: well, ‘no or yes has been selected, that is the answer I gave, then it is alright’.” Some FG-participants preferred the current opt-out approach, where parents only sign if they object. Many FG-participants preferred an opt-in approach, where parents need to sign regardless if they consent to retention and secondary use or not. While in the survey 71.6% The survey showed that half of respondents know that they could object to retention and secondary use Table . AnotherSome FG-participants supported opt-out when they would have access to detailed information about secondary use of NDBS.n = 497). Not objecting is not associated with socio-economic status (p = 0.507) or level of education (p = 0.170), but is associated with knowledge on the current NDBS policy (p = 0.023) Most survey respondents A frequently asked question by FG-participants and interviewees was whether longer retention would add value, because that would determine whether they would support longer retention. Also interviewees mentioned uncertainty about the added value, but stressed that the child should be able to decide at some point in time.“The legislation can change and technology goes so much faster. And if you store something for 16 years, I have no idea what the world looks in 16 years and what they will be able to do.” On the other hand, worries on prolonged retention were shared in FG, such as unforeseen developments in politics, legislation and technology.n = 410, not shown in Table “Not that something would happen, but for me personally, [cybercrime] would be just a very scary idea. Suppose that one of [my children] has a disease,[and then] that’s just out in the open, because you never know when you get it back, sort of say. Once it’s open and exposed. Yes, it may be that it’s really a fear and that I see ghosts everywhere or whatever, but that is why I find this [longer retention and secondary use] so interesting.” NDBS retention is currently managed and facilitated by the RIVM, which was supported by FG-participants, interviewees, and half of the survey respondents  the blood, do something with it. If the card is discarded, yes I find it almost a waste to throw it away. I think as long as the scientific and medical world might learn from it, and can achieve something with it, it is always valuable to use it” - Both secondary use for biomedical research to improve NBS and general public health research were highly supported by FG-participants, interviewees, and respondents. The latter scored with a large majority “somewhat good” or “good” on ‘What do you think of use of the heel prick card of your child for research that potentially improves public health but does not benefit you child directly?’ . […] What kind of influence has this on our privacy? How will people judge us when this happens? However, it depends on why they are looking for someone.” - Alternative purposes for secondary use, such as victim identification, were generally supported in all research arms Table , but con“I think that it [research with NDBS] has to have healthcare purposes. It is fine if it [NDBS] goes to anywhere, but it should not be the case that a company profits commercially and it has no health benefit” Secondary use can be conducted in research projects by different organizations. Survey respondents and FG-participants indicated that they did not fully support secondary use by companies Table . Accordi“Insurance companies that, at a certain moment, when you are twenty-five, tell you that you cannot buy a house. Like, you get nothing because we already know about the heel prick card, you do not know it yet, but we already know that you have a degenerative disease or something.” - On the other hand, secondary use of NDBS by universities or governmental organizations that serve public health was highly trusted by interviewees, FG-participants and survey respondents Table . Worries“It seems like a good idea to involve parents [in the committee]… Not that it (the committee) should consist of parents only… Parents must also be included, like you involve them in your research right now, and they must be well represented…In a careful manner, so that not everyone could just participate in the committee and you should not include a hundred people.” – “You know, because there are medical doctors, academics, scientists and patients represented [in the committee], but ordinary Dutch parents, who know nothing about it… It is about the blood of their children. They could ask some critical questions that trigger further consideration about the possible consequences or the after-effects. So I think it would add something to the current committee.” Current decision-making on secondary use includes a multidisciplinary committee including a medical, ethical and patient perspective. Table On the other hand, some FG-participants and interviewees were critical of parental involvement because of time issues, lack of knowledge on NDBS, or overrepresentation of people with negative opinions.The current study aimed to provide insight in new parents’ perspectives on NDBS policy. New parents expressed needs for easily accessible information, adequate communication on the retention and  use of NDBS, clearly described safeguards for privacy, a more active consent process, regulation for research conducted with NDBS research, and parental involvement in decisions on secondary use.By using sequential mixed methods we were able to present quantitative data as well as a more in-depth understanding of themes. Nonetheless, this study has several limitations. The survey is not validated and framing of questions and topics in the survey and in the interviews sometimes differed due to the difference of the nature of the research approach. All participants were higher educated than average, and women were overrepresented. However, we did succeed to organize interviews and FG in four different regions in the Netherlands to gather different perspectives. With the survey we were able to reach a relatively large sample size, while we did not check if respondents took the survey twice, we consider that a low risk due to the length of the survey and the need to fill out personal details to enrol in the raffle for the voucher. Both interviews and FG achieved data saturation.New parents are generally not very familiar with retention and secondary use of NDBS . While iOther studies found distrust in authorities because participants believed that the government would store the NDBS longer than was communicated , 30, 33,Engaging parents in decision-making has been discussed by several authors , 35, 36.Our study contributes to parental involvement regarding NDBS policy. As such it contributes to including parental perspectives in the current policy discussion on longer retention. Our study shows that prolonged retention could be a feasible option in the Netherlands if several prerequisites are met.Additional file 1:Interview guide for the focus groups, consisting of an agenda for the focus groups and scenarios. (PDF 178 kb)Additional file 2:Interview guide for the individual interviews, consisting of the topics for the individual interviews. (PDF 295 kb)Additional file 3:Coding list of the codes used for the focus groups and individual interviews. (PDF 193 kb)


Diverse plasticity mechanisms are orchestrated to shape the spatiotemporal dynamics underlying brain functions. However, why these plasticity rules emerge and how their dynamics interact with neural activity to give rise to complex neural circuit dynamics remains largely unknown. Here we show that both Hebbian and homeostatic plasticity rules emerge from a functional perspective of neuronal dynamics whereby each neuron learns to encode its own activity in the population activity, so that the activity of the presynaptic neuron can be decoded from the activity of its postsynaptic neurons. We explain how a range of experimentally observed plasticity phenomena with widely separated time scales emerge from learning this encoding function, including STDP and its frequency dependence, and metaplasticity. We show that when implemented in neural circuits, these plasticity rules naturally give rise to essential neural response properties, including variable neural dynamics with balanced excitation and inhibition, and approximately log-normal distributions of synaptic strengths, while simultaneously encoding a complex real-world visual stimulus. These findings establish a novel function-based account of diverse plasticity mechanisms, providing a unifying framework relating plasticity, dynamics and neural computation. Many experiments have documented a variety of ways in which the connectivity strengths between neurons change in response to the activity of neurons. These changes are an important part of learning. However, it is not understood how such a diverse range of observations can be understood as consequences of an underlying algorithm used by brains for learning. In order to understand such a learning algorithm it is also necessary to understand the neural computation that is being learned, that is, how the functions of the brain are encoded in the activity of its neurons and its connectivity. In this work we propose a simple way in which information can be encoded and decoded in a network of neurons for operating on real-world stimuli, and how this can be learned using two fundamental plasticity rules that change the strength of connections between neurons in response to neural activity. Surprisingly, many experimental observations result as consequences of this approach, indicating that studying the learning of function provides a novel framework for unifying plasticity, dynamics, and neural computation. Synaptic plasticity mechanisms shape the spatiotemporal dynamics of neural circuits that implement brain functions –4. TheseThe interplay of this diverse range of plasticity mechanisms with network dynamics gives rise to complex spatial and temporal neuronal activity in which neurons fire in a very irregular way with variable spike timing and fluctuating firing rates , 15–18. Some studies have developed models of plasticity by fitting to these detailed experimental results, for example the spike triplet based models , 26. HowPlasticity mechanisms give neural circuits the ability to reorganise themselves for learning. In theoretical models and applications, effective learning in neural networks requires that plasticity mechanisms are carefully orchestrated by an overarching learning algorithm that is linked to performing a required task . As wholHere we show that diverse plasticity phenomena can emerge from a fundamental perspective of learning the function of a neural circuit. Specifically, we consider unsupervised learning in which each neuron learns to encode its own activity in the population activity so that the activity of the presynaptic neuron can be decoded from the activity of the postsynaptic neurons. In doing so, we extend the concept of an autoencoder in machine learning to recurrent networks . Both HeWe then demonstrate that a great variety of experimental observations emerge from this function based model. For synaptic plasticity mechanisms, the model contains the classic exponentially decaying timing dependence of STDP, as well as the frequency dependence of both STDP  and non-We further illustrate that when our plasticity rules are incorporated into a biologically realistic neural circuit of spiking neurons that are stimulated by a real-world visual stimulus, balanced excitation and inhibition is self organised and related to the stability of the neural dynamics. We show that approximately log-normal distributions of synaptic strengths emerge and are organised into receptive fields, all while the circuit learns to encode the complex real-world visual stimulus. These results thus present a novel, unified account of plasticity, dynamics and neural computation.Typical approaches to learning in artificial neural networks define a global error function for a chosen set of ‘output’ neurons and compute a gradient of this error with respect to connection strengths for use as plasticity rules . HoweverInstead, we begin by considering the function of neural circuits, focussing on local properties of individual neurons and their spiking activity using the concept of an autoencoder in machine learning . In clasA(t), as in j’s spikes into postsynaptic activity, A(t), is familiar and is described by the neuronal and synaptic dynamics. The non-obvious part is how to describe the decoding of presynaptic neuron j’s activity from its postsynaptic activity, A(t), and ensuring that it approximates the actual activity of neuron j.Specifically, each neuron learns to encode and decode its own activity into and from a period of the population activity of its postsynaptic neurons, j’s actual instantaneous firing rate, rj(A(t)), from the postsynaptic activity A(t). In a network operating in discrete Δt timesteps (as is the case for simulations) we can relate this to the conditional probability of presynaptic neuron j spiking in conjunction with the pattern of postsynaptic activity A that happens to occur during the time window from t to t + τA, that is We define j has access to, so that neuron j has the ability to directly encode and decode its own activity. The purpose of learning is to modify the network so that the encoding and decoding processes are able to (approximately) invert each other, since in any arbitrary configuration the decoding of presynaptic neuron j’s activity from its postsynaptic activity, A(t), will likely be poor.Although we have not yet defined the decoded instantaneous presynaptic firing rate, W, and the postsynaptic activity A(t). We use this to translate the learning rules that operate directly on the decoded instantaneous presynaptic firing rate, W, and demonstrate learning in a spiking neural circuit with a real-world, complex visual stimulus. We do not model the detailed physiology of the synapses represented by W and the mechanisms by which they change, but it should be noted that the resulting neural dynamics can depend on these lower level details, for example, if synaptic changes are presynaptically or postsynaptically expressed [We continue by applying learning rules directly to the decoded instantaneous presynaptic firing rate, xpressed .rj(A(t)). Firstly, the number of times that postsynaptic activity, A(t), occurs, and secondly, the number of times that presynaptic neuron j spikes (within an arbitrarily short Δt) in conjunction with postsynaptic activity, A(t). This second event is a Hebbian event as it consists of both postsynaptic activity, A(t), and a presynaptic j spike, while the first event is non-Hebbian since it only consists of postsynaptic activity, A(t) [Given a long period of activity in a network, there are two events that need to be counted to estimate the instantaneous presynaptic firing rate, ty, A(t) , 5. ThusRH, and non-Hebbian, RnH, learning rules to the decoded instantaneous presynaptic firing rate, rj(A(t)). After a time period in which a particular pattern of postsynaptic activity, A(t), occurs N times, a series of iterated operations of the non-Hebbian, RnH, and Hebbian, RH, rules are applied to the initial value of the decoded instantaneous presynaptic firing rate, A(t), noting that the Hebbian rule, RH, is absent if presynaptic neuron j does not spike coincident with postsynaptic activity, A(t).We apply Hebbian, RnH and ΔRH are the changes to RnH, and Hebbian, RH, learning rules, respectively. This relationship describes how the Hebbian and non-Hebbian changes should be related so that they cancel each other and no change occurs when A(t), equals r(A(t)), the actual presynaptic firing rate given A(t).From the decoding target RnH, and Hebbian, RH, rules must slightly decrease and increase the decoded instantaneous presynaptic firing rate, To ensure convergence, the non-Hebbian, Now that we have established a relationship between Hebbian and non-Hebbian learning rules acting on the decoded instantaneous presynaptic firing rate, synapses .j spikes at t, j’s contribution to generating its postsynaptic spikes, as shown schematically in j in population α at time t, decoded from postsynaptic neurons in population β, and therefore control the gains of interactions between different populations of neurons.In recurrent networks it is necessary to relate learning to the stability of the network to ensure that the network is stable . Indeed,i caused by a presynaptic spike in neuron j, decayed according to the leaky dynamics of the postsynaptic neuron, is well approximated a short time after the presynaptic spike occurs by wij(Vi(t) − VE/I)et/τ−Δ/C, where Δt is the time since the presynaptic spike and VE/I is the excitatory or inhibitory reversal potential of the synapse, τ is the decay constant of the postsynaptic neuron’s membrane potential, wij is the synaptic conductance from presynaptic neuron j to postsynaptic neuron i, and C is the capacitance of the postsynaptic neuron , for each postsynaptic neuron in population β. Only the first spike is considered since the reset and refractory state mean the presynaptic spike does not contribute to further postsynaptic spikes   . This tij. This creates competition between postsynaptic neurons and thus diversification of neural responses, including the development of receptive fields  [ϵ is a small learning rate. The negative and positive signs are for excitatory and inhibitory synapses respectively and ensure that the weight change is  positive, thus implementing LTP.The weight change is chosen to depend on the postsynaptic neuron’s contribution to the decoded instantaneous presynaptic firing rate, timulus) . So,Δwij’s postsynaptic neurons. We do not describe the biological mechanisms that might implement this. However, it seems plausible that this information would be available to j by integration of signals from its postsynaptic neurons; though this is a weaker locality than is often assumed, where locality is restricted to neurons on either end of a synapse [The decoded instantaneous presynaptic firing rate,  synapse .The inclusion of the decoded instantaneous presynaptic firing rate, RH, and non-Hebbian, RnH learning rules described in Other plasticity rules can be constructed that together still obey the required relationship between the Hebbian, tk < t < ti. We integrate this over the time period between subsequent postsynaptic i spikes to yield a discrete weight change applied in response to postsynaptic neuron i spiking;tk is the time of the postsynaptic i spike before ti ..(ϵ/r^)×pw ∼ ϵpre(post − ρ0). In [ρ0, and so the activity of the network is directed toward this fixed firing rate.This weight change is similar to that presented in  where pl ρ0). In  the fixeρ0 as in [r can take any value and is a target for the decoded instantaneous presynaptic firing rate, The crucial differences to the plasticity rules presented here are that firstly, here the fixed point involves the presynaptic, not the postsynaptic activity. Secondly, the decoded instantaneous presynaptic firing rate, ρ0 as in . Insteadρ0.It is possible to use the same approach we have taken to develop plasticity rules that perform supervised learning in which input connections to a neuron are learned and thus directly control postsynaptic firing rates, with a variable target postsynaptic firing rate provided by an external agent. This supervised learning formulation leads to a weight change of the form ented in  as implet are repeated at a fixed frequency [We next show that these plasticity rules Eqs  and 6 rerequency .V(t), and the decoded instantaneous presynaptic firing rate, V(t), the decoded instantaneous presynaptic firing rate, w, the learning rate, ϵ, the capacitance, C, and the neuronal time constant, τ, in Eqs Fig 3a), , in Eqs  and 6)..V(t), an = 20 ms , one fifwnH, indicated by the red line in wH, decays exponentially with Δt indicated by the green lines in t = 0, and LTP for presynaptic before postsynaptic spike timing, decreasing as Δt becomes large. When t. This is consistent with reports of LTP changing to LTD for postsynaptic spikes 20 ms after a presynaptic spike [τ and the stimulated pair frequency are also important. When the pair frequency is much larger than τ, again LTP transitions to LTD for large positive Δt.The non-Hebbian weight change, Δ of STDP , consistThese results are consistent with observations in  which ret where LTD dominates and is less affected by changes to For postsynaptic before presynaptic spike ordering and the LTD regime, the Hebbian plasticity change is small due to its exponential decay with the delay between presynaptic and postsynaptic spiking. In this case the non-Hebbian plasticity change dominates, meaning that LTD in this regime does not depend on initial connection strength as observed in the experiments. This behaviour can also be seen in STDP experiments in rat visual cortex document a dependence of plasticity on the frequency of spike pairs where LTP is promoted at high frequencies , 40. Ourt = 10 ms as in [wnH. This frequency dependence also applies to postsynaptic before presynaptic spike pair ordering with Δt = −10 ms as in [t. At low frequencies there is a large time delay between pairs and therefore the Hebbian plasticity change, ΔwH, is small and the depressive non-Hebbian plasticity change, ΔwnH, dominates. However, as the frequency increases, the time delay between pairs shortens and the Hebbian plasticity change, ΔwH, becomes larger and dominates.This frequency dependence is a prediction of our model strongly attributed to the spike timing dependence of the non-Hebbian plasticity rule, see ms as in    6) to a r〉 = 53.3 Hz and 〈r〉 = 53.6 Hz for the excitatory and inhibitory populations, respectively   6) accorFor STDP presynaptic before postsynaptic timingFor STDP postsynaptic before presynaptic timingFor postsynaptic, presynaptic, postsynaptic tripletsFor presynaptic, postsynaptic, presynaptic tripletsThe spiking neural circuit model is based on that used in  and is si at time t as Vi(t), with dynamics given by the following:C = 1 nF, the leak conductance gL = 50 nS, and the reversal potentials are VL = −70 mV, VE = 0 mV, and VI = −80 mV for the leak, excitatory, and inhibitory conductance, respectively [VT = −55 mV, a spike is generated and the membrane potential is reset to the reset potential VR = −70 mV for a refractory period τref = 5 ms. The synaptic conductances are as follows:tk is the time of the k-th spike emitted by the presynaptic neuron j. The time course of the postsynaptic conductance is given by the following:We denote the membrane potential of a neuron ectively . If the The plasticity rules described by Eqs  and 6)  6) are ahttps://github.com/BrainDynamicsUSYD/SpikeNet. The file /SpikeNet/cases/generate_learning_config.m is a MatLab script that can be used to generate a configuration file that will instruct the simulator to implement these plasticity rules. Further information on installing and running the simulator can be found in the readme /SpikeNet/README.md.Code for these simulations is available at μs temporal precision, with a minimum 15μs between sequential events for each pixel. This ability to record events at fast timescales makes it much more suitable as a visual input to a SNN model than conventional frame based video cameras whose frame updates are typically every few tens of milliseconds and are much slower than the neuron dynamics that evolve significantly over millisecond timescales.In this neural circuit we include a 128 × 128 population of stimulus neurons whose spiking activity is controlled by an external data source. This population connects feedforward to both the excitatory and inhibitory populations. The stimulus dataset used in this work was recorded using a Dynamic Vision Sensor (DVS) . The DVShttps://www.ini.uzh.ch/∼tobi/dvs/ and is a recording of a person juggling, viewed front on.Each pixel in the DVS records an event when the light intensity on that pixel changes above a threshold value. The DVS is therefore sensitive to movement, changes in lighting or changes in reflective properties of objects. The absence of events means that there has been no change, not that the visual scene is empty. The dataset was obtained from Dropout is a simple and effective technique used to reduce over-fitting in artificial neural networks by adding noise to the network through probabilistically deactivating neurons. Dropout can be thought of as a form of model averaging and leads to better generalisation .Here, we also inject noise into the learning scheme to reduce over-fitting; however, unlike in dropout we do not probabilistically omit the transmission of spikes between neurons, but only omit spikes from the learning scheme by omitting applications of plasticity rules involving dropped spikes. Because of this no rescaling of weights is required after learning as in dropout, thus this form of regularisation can be implemented online and is biologically plausible. All spikes are communicated between neurons so this does not represent synaptic failure; however, it would be possible to modify the form of noise or synaptic dynamics to investigate effects like synaptic failure or short term depression and how they may enhance or degrade learning.S1 AppendixAdditional details underlying the relation between Hebbian and non-Hebbian rules, stability of learning rules, comparisons to STDP and its frequency dependence, spike triplets and the organisation of tightly balanced currents.(PDF)Click here for additional data file.S1 Videoτ, corresponding to the best possible decoding from the neural populations, rD. (b) Decoding of the stimulus from the excitatory population, Decoding of the stimulus from each of the neural populations after learning, at one point in time. The stimulus is a recording of a man juggling viewed front on. An outline of the juggler’s body and the juggling balls are visible in the stimulus itself and each of the decodings. (a) Stimulus spikes smeared exponentially in time with time constant (MPG)Click here for additional data file.


Low- and middle-income countries (LMICs) are vital to the global tobacco market. The pack is key to cigarette branding, and review of cigarette packs revealed English as a common feature. The prevalence of English and its potential branding utility is explored.Every available unique cigarette pack was purchased from diverse retailers in six LMICs where English is not the official language . Packs’ front panels were coded for English on pack fronts. English penetration was quantified by country and a comparison of English use between multinational and national brands was undertaken. A qualitative analysis of symbolic and utilitarian usage of English was conducted.n = 876) included some English. English text conveyed product information and usage instruction. English was more prevalent for multinational brands. Qualitatively, English use frequently connected cigarettes with concepts of quality, style, luxury, and aspirational lifestyle.Of 1303 unique cigarette packs analyzed, 67% (Restricting English use should be incorporated into plain packaging policy to protect populations from deceptive branding practices, specifically presenting cigarettes as an aspirational product. In the twentieth century, the global market for cigarettes centered around the creation of demand in high-resource countries (Jha and Peto An important condition for the creation or expansion of the cigarette market in LMICs is the emergence of a “consumer class” that has newly acquired discretionary spending power (Ustuner and Holt 2010). Over a century ago, Veblen  developeTo “brand” a product is to go beyond the attributes of the physical entity to construct associations and meanings for the product that have value to the consumer that transcend price and utility Carter . UltimatThe pack has become increasingly a key to cigarette marketing, and to creating and maintaining brand image . There is the potential opportunity for inclusion of brand information on each panel (side), within the pack, and on the stick itself  producers?What are the possible communicative utilities of English on English-only and some-English packs as part of branding?As we have coded branding elements on packs collected through the TPackSS study . Data collection methods are detailed elsewhere  countries that represent five of the six World Health Organization regions. These are also countries in which English is not an official language. We purchased and analyzed 1303 unique cigarette packs from these six non-Anglophone LMICs. All coding was undertaken by the Baltimore-based TPackSS research team; the inclusion of data from 6 countries meant that it was not possible to include researchers who were embedded within the various specific cultural contexts.Each pack in the sample was first coded by two independent coders to determine prevalence of any English on packs as well as exclusive use of English. We estimated the level of intercoder reliability using percent agreement, a kappa statistic and the prevalence-adjusted and bias-adjusted kappa (PABAK) statistic. We established a total observed agreement of 97.5% (95% CI 96.6–98.3%), a kappa of 0.943 (95% CI 0.923–0.962), and a PABAK of 0.951. Relative to commonly used thresholds of reliability, these results would be considered “almost perfect”  were considered as a single data point. Text used in health-warning labels was excluded (even when on the front of the pack) as this language is determined by governmental policy and is not intended to convey brand messaging. In addition to analyses of English presence within each country, we compared English presence between multinational and more localized manufacturers.Symbolic enhancement: Associations between English terminology and stereotypical American and/or British cultural attributesStandardization utility uses and extensions: English conveying product information or English phrasing that may be consistent across national contexts.Next, our communicative analysis consisted of an illustrative, qualitative taxonomy of utility and meaning conveyance of English on the pack front. From the initial pack review, we generated themes pertaining to the content conveyed by English on the pack, including use of English to describe color, place, sensation, historical references, quality, tradition, technology, romance, processing, flavor, size, and strength. In our analysis, themes were then matched with ideas from the literature on English utility Kuppens  and symbA team of two independent coders reviewed packs to classify English use for subthemes of either symbolic enhancement or utility usage when coding was compared. Where there was discordance in coding application, the coders discussed and made modifications where agreement could be reached. In instances where differences in perspective or confusion remained, a third coder was used and consensus was reached through further discussion. This aspect of process was qualitative and explicitly more interpretive than the coding for English presence and exclusive English, and no intercoder reliability measures were deemed appropriate or undertaken. In the findings section, beyond noting the extent of English on a pack and within a country’s sample, we do not quantify the thematic coding, but rather provide and discuss illustrative examples for each. Given that our goal was to elucidate rather than quantify use variation, we do not present concordance data for the coding process.n = 876) included some English in the appeal content of the pack’s front panel. By country, English was most pervasive in Egypt where 95% of packs (n = 55) included English in appeal, in comparison to only 35% of Chinese packs (n = 157).First, we analyzed the text on pack fronts that was neither brand name nor health-warning label; we labeled this text “appeal”. English was pervasive in appeal (see Table n = 529) of packs had an English brand name. This ranged from 77% in Brazil (n = 100) to 13% in China (n = 61). Combining these two components provided, an overall assessment of English prevalence in branding on pack fronts- ranging from 98% in Bangladesh to 40% in China.When considering the actual brand name, 41%    by brands that are international versus those that are not. Use of English was significantly more common for international brand packs. Any use of English was found on 79.9% of international packs versus 50.1% of national  packs , between 52% (China) and 98% (Bangladesh) of such packs were only in English  as well as to Britain and colonialism . The use of such terms was often accompanied by imagery that referenced the US or Britain. English brand names also made clear references to iconic and potentially aspirational places in both the USA  and in Britain (“Bond Street”). English brand names made connections with power  as well as elegance, opulence and quality . Brand names also made connections to romance .There were also complexities in consideration of the use of English in brand names. Brand names like “Dunhill”, “Rothmans”, “Shelton” and “Marlboro” are not actual English words, but do have a British or American connotation in their construction. In addition, we saw (but excluded) occasional use of words associated with non-English speaking European countries, including “Monte Carlo”, “Capri”, “Armada”, and “Delta”. There was also an instance mixing of languages within a single brand—namely “Septwolves”.See Fig. Beyond brand names, we identified various examples of English present on pack fronts that serve to connect the product to countries with which English is associated . Such connections often took the form of mentions of place, such as “Quality American Blend”, “Finest Virginia Tobacco”, “New Orleans”, “Park Avenue New York”, and “London since 1879”.English was also frequently used to make connections between the product and concepts of quality , style , luxury , authenticity , tradition , exceptionalism , natural , and wealth .English text served to connect with possible audience aspirations related to lifestyle , or a memorable and positive experience . English was also used to connote characteristics of the consumer .See Fig. We also noted numerous instances of English text on the pack fronts that primarily conveyed relatively basic product information, including place of manufacture, number and size of cigarettes, type of tobacco and filter, and comparative performance characteristics . English was also used (sometimes incorporating novel terminology) to convey information about how a consumer should engage with the product , as well as expected experiences of product consumption , and attributes of a specific product presentation .By comparing packs across countries, we see that English served as part of branding consistency extending beyond national boundaries. Our coding included branding taglines or varietal descriptions that were common to multiple countries including “blend no. 555”, “classic”, “full flavor”, “master blend”, “superslims”, “super activated carbon filter”.See Fig. In our analysis, we found English to be nearly ubiquitous on cigarette packs purchased in six diverse, non-Anglophone low- and middle-income countries. English was commonly used as part of brand differentiation, both in the brand name, and in key communicative text on the primary pack face. One way to understand the widespread presence of English on the pack fronts is that this is result of the English proliferation that has been a key element in globalization as a factor in the asymmetrical flow of products, ideas and discourses that favor the perspectives of more powerful countries/cultures  as well as to aspirational lifestyle qualities such as a notion of “the good life”, and connotations of relaxation and socialization. Prior research using tobacco industry documents has demonstrated how companies have sought to create brand identities that have value for populations with relatively low power  in conveyance of attainment of aspirational status or lifestyles , we were able to establish that English was commonly included on packs in all six countries, with China being the only country with only a minority (40%) of packs having English present on the branding space available on the front panel. English was prominent in brand names, and was included in descriptive language about product and consumer attributes. English conveys instructional information about the product and its appropriate use. In a policy context in which the pack itself is becoming more regulated (moving toward plain and standardized packaging), we argue that it is important to consider meaning conveyance in any remaining text on the pack (including brand name), as this may be an important channel by which companies seek to establish and maintain cigarettes as a status and identity-affiliated product.


We regret any confusion or inconvenience this error may have caused.Because of an author error, references in the appendixes of the article “Trends in Mortality Among Females in the United States, 1900–2010: Progress and Challenges” were incorrectly numbered. The article was corrected on May 30, 2018, and can be found at


The article explores this notion of rlung and its relationship to body and mind, in order to examine its role in the causation and treatment of various forms of “mental illness”, before analysing some similarities and differences between rlung-related categories and biomedical classifications of mental illness.This article presents an analysis of the way in which  The sanity we are born with: A Buddhist approach to psychology, or Dorjee et al.’s The spiritual medicine of Tibet: Heal your spirit, heal yourself.nyon mongs) of the Buddhist tradition: delusion (Tib. gti mug); attachment (Tib.’dod chags), and aversion (Tib. zhe sdang) , which is fundamental to Tibetan conceptions of the mind and body, and is thus integral to understandings of mind, consciousness, and mental health. One of three “energies” (Tib. nyes pa) in the body, wind is described in detail in the predominant medical text, the rGyud bZhi (Four Tantras), where there are descriptions of sixty-three kinds of disorder related to its disturbance (Millard sems nad) in the Tibetan context, it is this concept which often recurs, as both lay Tibetans and medical specialists discuss prevention, causation, and treatment. Here, the single term “rlung” is often used to denote both the concept of “wind” itself, and also any condition/illness understood to result from a disturbance to it. Thus people will describe “having wind” or perhaps “high wind” to denote a wind-related condition.I encountered some similar perspectives during my own research, examining the indigenous Tibetan medical tradition known as “Sowa Rigpa”, Millard . Indeed,. rLung is understood to be intimately connected to the mind, and we often hear the explanation that “the mind rides the wind like a man rides a horse”: in other words, the man (mind) needs the horse (wind) for movement/energy, but the horse (wind) also needs the man (mind) for direction.In this article, I will use examples from my fieldwork within a Tibetan community in Darjeeling to illustrate some contemporary understandings of this notion of “wind”. In this high-altitude corner of West Bengal, a significant community of first-, second-, and third-generation exiles live both in and around the town itself, and at the nearby Tibetan Refugee Self Help Centre. In Darjeeling, I interviewed medical and religious professionals as well as lay members of the community on the topic of mental health, illness, and healing, and the notion of “wind” was widely discussed in this context. However, Darjeeling is an area of cultural and medical pluralism, where the Tibetan community lives amongst the majority Nepali and Indian population. As a result, the town is home to an array of medical and healing facilities, including two Tibetan Sowa Rigpa clinics—a branch clinic of the Tibetan government-in-exile-affiliated Men-Tsee-Khang (MTK), and a clinic run by the independent Chagpori Tibetan Medical Institute (CTMI)—and a plethora of Ayurvedic and biomedical clinics and hospitals (both private and government). Tibetans in this area are therefore exposed to a variety of medical systems, each with its own explanatory frameworks regarding health and illness. What was notable during my fieldwork was the endurance of long-standing Tibetan notions of mind and body, particularly in relation to this notion of windrlung” is in fact a conflation of two different Indian/Sanskrit concepts: vāta and prāṇa. Vāta refers to one of the three Ayurvedic doṣa which correspond to the three Tibetan nyes pa of wind, bile, and phlegm in the medical sense. Prāṇa is a Tantric concept often translated as “life force” or “breath”, and it is the focus of many Tantric meditative and bodily practices which aim to manipulate its movement within the body. There are many such Tantric practices in the Tibetan Buddhist tradition too, but in this article I will give an overview of the notion of rlung in the medical context, examining how this conception of “wind” relates to the mind and consciousness, and exploring what this means in terms of mental health and illness. I will give an overview of the different types of wind said to flow in the body and the diverse physical and psychological symptoms understood to result from its disturbance, before exploring the diagnosis and treatment of wind-related mental illness in the Sowa Rigpa medical tradition. Finally, I will address the question of whether it is in fact possible to equate some of these rlung-related illnesses with biomedical categories of mental illness, as has been suggested by a number of Tibetan and Western practitioners and researchers.It is important to note here that Tibetan understandings of “wind” have been adapted from Indian Tantric and Ayurvedic ideas about the mind and body. As a result, the Tibetan notion of “nyes pa) of wind (Tib. rlung), bile (Tib. mkhris pa), and phlegm (Tib. bad kan)Four Tantras. This twelfth-century, four-volume medical text encompasses original Tibetan medical concepts alongside influences from Sanskrit and Chinese texts —such as poor diet, karma, or spirit affliction for example—to cause illness.In the Sowa Rigpa tradition,nyes pa are associated with different periods in a person’s lifetime, with different times of day and the different seasons. For example, wind is associated with older age/the latter portion of life, dawn and dusk, and the rainy season—meaning that individuals are more likely to suffer from a wind disturbance at a wet time of year, and in a rainy, windy place or during the monsoon season  is in fact rather misleading  in the Tibetan system, these three constituents are often understood to actually be “exclusively negative in nature”  in which the wind is said to flow, which are the focus of much of the discussion—particularly when we are talking about the mind, consciousness, and mental health. This is because, as I mentioned above, the wind is said to be intimately related to the consciousness, with the mind “inseparably linked” to the body through the wind  in the body. These channels are said to number in the tens (or even hundreds) of thousands  and the channels each side of this—one each to the left (Tib. rtsa rkyang ma) and the right (Tib. rtsa ro ma) , but again there is debate over exactly how many of these chakras exist. Over the last few decades, as many Sowa Rigpa practitioners have become increasingly knowledgeable about Western scientific theories of the body, health, and illness, and many Westerners have become interested in Sowa Rigpa (and Tibetan Buddhist Tantra), there have been a number of attempts to “map” these channels onto Western anatomical maps and biomedicalrGyud bZhi medical text. For example, “wind” is said to have six characteristics—rough, light, cold, subtle, hard, and mobile ; pervasive (Tib. khyab byed rlung); fire-accompanying (Tib. me mnyam rlung), descending (Tib. thur sel rlung) and life-sustaining (Tib. srog (’dzin) rlung). Each of these wind “currents” is understood to be located in a different area of the body, associated with a different element, and related to different functions of the body and mind. As a result, disruption or disturbance in any one (or more) of the wind currents will result in diverse physical and psychological symptoms. These five wind currents have been described in detail elsewhere  rlung). Described variously as being located in the centre of the body  which is said to run from the throat down to the chest, and is understood to support the life force and hold the consciousness. Yoeli-Tlalim describes how this wind current “governs the body/mind system”  are understood to potentially disturb the flow of any of the various wind currents. It is clear from these descriptions that both physical and psychological factors may negatively impact the flow of the winds in the body. However, there is often a focus on the psychological factors when we talk about rlung and conditions related to its disturbance—much more so than in discussions on bile or phlegm.In addition to the quite specific factors listed above as potential causes of disturbance in the various rlung-related illness with Tibetan informants, who were often quite familiar with both its various causative factors and its treatment. For example, when I discussed this topic with Dolkar (55),rlung disturbance: “If I am worrying about my son in Delhi [in the past he had been very ill with TB]—if I am worrying about his health, and what will happen to him, I will get rlung… [But] if you can control , then it’s ok”. Similarly, at the CTMI clinic, Sowa Rigpa practitioner Amchirlung currents: “When the mind is disturbed or worried—due to family worry, or work stress, or whatever it is—that would disturb the energy of the wind, and then illness would manifest”.In Darjeeling, I discussed cause psychological symptoms of various kinds. Dorjee et al. provide an explanation of how this can occur: “An increase in this [rlung] energy can cause us to become unstable and susceptible to external occurrences… The mind will weaken and we find that we are increasingly vulnerable to sadness and depression”  illness. In addition, wind, bile, and phlegm are said to be ultimately caused by the three “mental factors” of delusion, attachment, and aversion, with the fundamental role of these mental factors in the formation of rlung described in the rGyud bZhi text  may be characterised by both physical and psychological symptoms, as we saw above. One of the ways in which these diverse symptom clusters are explained is that when the wind is “erratic”, it “can send wrong information to the sense organs”  , nutmeg, cloves, asafoetida and/or molasses  alongside questioning of the patient in order to determine the patient’s constitution and the nature of their condition. As with other types of illness described in the rlung disturbance should be high in protein and include what are understood to be “nutritious” foods—for example “oil, butter, mutton with vegetables, soups, porridge, hot milk and a little alcohol” Diagnostic and statistical manual of Disease (DSM)As I mentioned above, a number of Western and Tibetan Sowa Rigpa practitioners and researchers have made attempts to “map” the srog (’dzin) rlung disorder is “maybe like depression”. And, when I discussed mental illness with Tibetans in Darjeeling, it was srog (’dzin) rlung—“life-holding wind disorder”—which was discussed perhaps the most frequently. When I interviewed Dolma (31), a second-generation Tibetan exile fluent in English, she referred to srog rlung in English as “anxiety disease” and the combination English-Tibetan “anxiety na tsha” . Dolma explained that this condition is usually caused by “loneliness”, “too much thinking”, and/or what she referred to as a “competitive mind”. She told me that a friend of hers, Dawa (aged approximately 30), suffered from this, describing how he frequently felt “panic”—“especially in a crowded place, or when he goes in a car or jeep”, with symptoms that come and go. Whilst Dawa was under the care of a biomedical doctor, Dolma explained that in fact he did not take any  medicine for his condition, as his doctor had advised him that it was better to manage without medicine if possible—indeed, she explained that Dawa himself felt that the best treatment for such conditions was “meditation”.Interviewing both lay Tibetans and Sowa Rigpa practitioners in and around Darjeeling, I found many people quite familiar with Western notions of “stress”, “anxiety” and “depression” —particularly those with a good knowledge of English or a significant amount of contact with Westerners. Indeed, a number of interviewees drew comparisons between wind disorders and the broad biomedical categories of “anxiety” or “depression”, sometimes also using the Tibetan and English terms interchangeably. For example, when I interviewed Metok (63), a former nurse who had received her training in the UK many years before, she suggested that srog rlung and anxiety—indeed, a number of Tibetan and non-Tibetan Sowa Rigpa practitioners and researchers have drawn similarities between this diagnosis and biomedical categories of both anxiety and depression. It is clear from the above descriptions of srog rlung and the consequences of its disturbance that some of the symptom clusters certainly suggest such similarities. Discussing srog rlung with Amchi Teinlay Trogawa, director of the CTMI and a practitioner at its clinic in Darjeeling, he described symptoms including: “high and low mood”, “disturbed sleep”, and a “blocked feeling in the chest region”, also suggesting that for some sufferers, perhaps “in a closed room…. they think that they are getting suffocated”. He described physical symptoms too, for example, the “rlung points”—points on the body specifically related to the rlung currents—will likely be “very sensitive and tender”. At the Darjeeling MTK clinic, Amchi Lobsang Thubten explained that a patient with srog rlung will likely display a range of symptoms, such as sadness, restlessness, lack of appetite, inappropriate emotions or unusual aggression. He described how sufferers may also have a fear of being alone or in a crowd and may struggle with concentration and/or memory, perhaps also talking to themselves. Some sufferers, he explained, may even be suicidal. Physical symptoms described by Amchi Lobsang Thubten included heavy breathing, and a desire to stretch and/or yawn.Dolma is not alone in making this equivalence between rlung illness and “biomedical constructions of depression, anxiety and somatization”, suggesting that srog rlung is “most similar” to “major depressive and anxiety disorders” . Thus we have one Tibetan category spanning several biomedical ones. Millard concludes that while “it would be difficult to find Tibetan categories of mental illness which correspond exactly with the categories listed in the psychiatric section of the ICD10”, we can draw comparisons between “the Tibetan nosological category of srog rlung” and symptoms related to certain of its biomedically classified mental illnesses—particularly those in sections F2 , F3 (mood (affective) disorders), and F4   “could represent imbalance of at least four of the five major pranic [appetite , p. 75. sorders) , p. 279—rlung is to any exploration of Tibetan conceptions of the mind and consciousness—and therefore how integral rlung is in Sowa Rigpa approaches to mental health and illness. This “energy” (or “fault”) is only one of the many factors which can be involved in health and illness , but it is the one which is at the forefront of many discussions about mental illness—amongst both Sowa Rigpa practitioners and lay Tibetans. With a number of different wind currents understood to reside in the body, located in different places and related to different functions of the mind and body, lay Tibetans will not necessarily have an in-depth understanding of these. However, all of the Tibetans I interviewed in Darjeeling had at least a general knowledge of the principles of this system, and it is this concept which forms much of Tibetan medicine practitioners’ and lay Tibetans’ explanations of mind and mental health.What I hope has become clear from the discussion here is just how fundamental this notion of rlung is a concept which brings together physical and psychological aspects of the body. As such, it is perhaps not surprising that both physical and psychological factors can lead to a disturbance in its flow, and also that resulting symptoms may be physical and/or psychological, ranging from poor digestion or vomiting to “depression” or “insanity”. As a result, treatment usually takes a several-pronged approach, frequently encompassing herbal medicine, physical therapy, dietary advice, and/or suggested activities to support the person emotionally. Thus the notion of the mind as the root of all  illness which I described at the beginning of this article can be understood in several ways. Not only from a Tibetan Buddhist perspective can we view the mind as the root of all suffering—as Dorjee et al. state, the “clinging nature that ultimately produces as confused mind and thereby all suffering and disease” (rlung. Thus where the mind (or body) is disturbed in some way, the wind will become disturbed as a result, and this wind disturbance can lead to a multitude of psychological and physical symptoms.What should be clear is that disease” , 138—butrlung conditions described above with any biomedical categories of mental illness remains an open question. With the underlying conceptions of anatomy significantly different in these two systems, and the boundaries of these categories drawn in often very different places, it remains rather problematic. However, with clear overlaps between symptomatology of some Sowa Rigpa conditions and some biomedical categories such as depression and anxiety, we might want to draw some comparisons. Moreover, a deeper examination of Tantric notions of rlung can perhaps shed further light on the possible relationships between the system of rlung and some particular Western concepts of anatomy, as Geoffrey Samuel explores in his article in this volume.Whether or not we can equate some of the diverse