Students at the tertiary education level in Australia are at increased risk of experiencing high levels of psychological distress, with international students at particularly high risk for poor adjustment. As mental health and wellbeing strongly correlate with students’ academic performance and general overseas experience, a growing number of studies focus on what universities can do to effectively support students’ wellbeing. However, assumptions are made about what wellbeing is, strategies primarily focus on treating mental ill-health, and treatment approaches fail to account for cultural differences. This study aimed to explore how Chinese international students understand wellbeing, the language used about and for wellbeing, and activities that students believe strengthen their own and others’ wellbeing. Eighty-four Chinese international students completed the online survey, and a subset of 30 students participated in semi-structured interviews. Data were analysed using thematic, phenomenographic, and language analyses. Physical health and mental health appeared as the key components that participants believed defined wellbeing, and intrapersonal activities were perceived as the primary approach used to strengthen wellbeing. Findings help broaden the understanding of wellbeing concept from the population of tertiary students, identify students’ perspectives of activities that strengthen their wellbeing, offer a snapshot of the language used by Chinese students around wellbeing, and provide new data of population health through a wellbeing lens. The coronavirus pandemic of 2019 and 2020 has brought public health into the spotlight, emphasising the extent to which physical health matters. International travel stopped, economies entered deep recessions, millions of workers lost their jobs, and the social fabric of society came to a standstill, all centred around flattening the infection curve and preventing the possibility of overwhelming health care systems and the unnecessary loss of human lives. However, even as the infection curve flattened, awareness began to shift to a second curve: mental illness. Mental health/illness refers to people’s cognitive, emotional and behavioural status, which affects how people think, feel, behave, and interact with others .Even before the pandemic began, the quality of many people’s lives has been questionable. Within any given year, an estimated one out of every five individuals will experience severe mental illness, with some populations at higher risk than others . One of International students are at even greater risk than local tertiary students, as they live away from home, navigate the many challenges of living and studying in a foreign culture, and try to balance the many demands encountered, often with limited support. International students represent a sizeable population; for instance, there were over 600,000 international students studying in Australia in early 2020, with 28% of these students from China . DespiteAccording to Oades and Johnston , wellbeiMental illness has significant impacts on populations worldwide. As of 2017, an estimated 792 million people suffered from mental or neurological disorders , with atIn Australia, the Australian Bureau of Statistics (ABS) found that 4.8 million Australians suffered from a mental health disorder in 2017, with around 45% of Australians having experienced a mental disorder in their lifetime. Over 3000 individuals engaged in self-harm behaviours, and 94.2% of respondents who reported suicidal ideation or attempts has experienced mental disorder within the previous 12 months. Mental illness had an estimated economic impact of $4,000 per person, costing the Australian economy $60 billion in 2016 alone . Importantly, despite the mental health burden, many individuals do not receive proper professional care. Although treatment rates increased steadily from 37% in 2006 to 46% in 2016, over half of the population did not receive treatment. Rates are disproportional; one study found that young people were less likely to seek professional help, and 31% of women versus 13% of men received support and care . Despite large amounts of human resources and financial support invested in this area, there are numerous obstacles that prevent people from receiving care. First, there are challenges in fully identifying those who suffer, with many people being hesitant to report concerns. Mental illness is often first detected through self-reported screening instruments, and yet such measures are prone to people adjusting answers to socially desirable responses, lack of self-insight by respondents, distorted interpretation of the questions, and sampling biases that exclude those who are most at risk for disorder ,21,22. STo address these barriers, numerous policies and practices have been trialled. A primary approach involves public education and awareness campaigns to reduce barriers of stigma and discrimination . Other eAmongst the many populations that could be considered, only limited focus has been given to international students. Given the recent decades of internationalisation and globalisation, a large number of students choose to study and live abroad, with study periods ranging from a few weeks overseas to completing multiple degrees abroad. In 2019, there were more than 950,000 international students who enrolled in higher education, Vocational Education and Training (VET), schools, English Language Intensive Courses for Overseas Students (ELICOS), and non-award sectors in Australia . CompareFor international students, while studying abroad provides an education degree and overseas experience, it also often brings many challenges and difficulties. Compared to domestic students, international students have been identified as a high-risk group for mental health and wellbeing issues, with more numerous/severe transition problems . StudentDespite the widespread availability of counselling services, mental health problems are often unnoticed or overlooked among international students, such that students suffer in silence . For insSecond, stigma remains a major barrier . Stigma Third, international students are challenged by having to negotiate the local health care system, often while lacking awareness and knowledge about the details of health insurance and system procedures . Fourth,As described above, studying overseas provides numerous opportunities for young adults, but also brings a number of challenges. There are persistent gaps between the wellbeing issues faced by international students and the limitations of current mental health supports provided by the education institutions. Simply improving the existing mental health service is not enough to overcome the identified barriers. It is crucial for tertiary educational institutes to develop their awareness/understanding of mental health issues and wellbeing affecting international students, provide accessible wellbeing resources, reduce stigma, and provide professional mental health and wellbeing support.An important question is how to improve international student’s wellbeing in an accessible and effective way. The lack of sufficient care is driven in part by misunderstanding and lack of knowledge around how these students think about and talk about mental health and wellbeing. If we can better understand international students’ language, then we might better be able to meet their needs and improve the mental health of this sizeable population. However, little is known about how university students’ wellbeing is experienced and strengthened, particularly from the students’ perspective. The current study aimed to: (1) explore the language used about and for wellbeing and (2) identify activities that students believe strengthen wellbeing.Qualitative data were collected through on online survey, complemented by in-depth interviews with a subset of respondents. All procedures were approved by the University of Melbourne’s ethics review committee (#1954456.1). Data were collected between September 2019 and February 2020. Chinese International Students Associations and other similar associations/student groups from the eight universities in Melbourne were contacted via email and WeChat, with an invitation to share the study details with eligible students. Students who were interested in the research could go to the online survey, read details about the study, and decide to participate. The online survey began by collecting basic demographic information and screening for mental illness. As the study intended to focus on a normal  population, the survey included the six-item Kessler Distress Scale , which hThe survey then proceeded with a number of quantitative and qualitative questions. Demographic variables included gender, age, English proficiency level , length of stay, education level, and their education status. Gender, age, education level, and education status were assessed on categorial scales. English proficiency levels were assessed in text-entry format question, and English test scores were converted into IELTS scores, based on the equivalent standard set by the university’s admission requirements. Participants were then asked in an open-question format to describe the activities that they engaged in, are engaging in, and plan to engage in to maintain and promote wellbeing, for themselves and for others, and to identify the activities they do to experience wellbeing. At the end of the survey, participants were invited to indicate willingness to be involved in an interview to further explore their experiences. Willing participants were interviewed online using Zoom or WeChat, with interviews lasting 40 to 60 min. Participants could complete the questionnaire and interview in English, Mandarin, or a mix of English and Mandarin. Semi-structured interviews explored how students described and conceptualised wellbeing, and actions taken to support the wellbeing of self and others .To be included in the study, participants had to be a Chinese international student who was (1) studying at a tertiary education institution in Melbourne, Australia, (2) at least 18 years old, and (3) had lived in Melbourne for a minimum of three months and a maximum of four years, to ensure that participants were beyond the immediate transition period and had significant experiences across the Australian and Chinese cultures. Of 233 individuals who showed interest in being a part of the study, 47 were excluded due to not meeting the inclusion criteria, and 32 were excluded due to showing signs of potential severe psychological distress. Of those who met the inclusion criteria, 84 students  completed the online survey. On average, participants were between 21–29 years old. Of the 84 participants, 30 took part in semi-structured interviews. Analyses focused on the free-response questions in the survey and interviews. For the survey data, qualitative content analysis was used, which involved (1) preparation: selecting the unit of analysis and making sense of the data; (2) organising: open coding, coding sheets, grouping, categorisation, and abstraction; and (3) reporting: summarising and sharing categories .Interviews were transcribed and then analysed using a phenomenological approach, aimed at describing, analysing, and understanding Chinese international students’ experiences with and understandings of various wellbeing aspects of their worlds. The interview data are presented based on the phenomenological principle of “to the things themselves” , which wAs most interviews (29/30) were conducted in Mandarin Chinese, analyses were conducted in Chinese, and then translated into English for writing and presenting. A translator with NAATI certification assisted with the translation process to minimise researcher bias and subjective interpretation. All the cited quotations have been verified by the translator, and the phrases with specific cultural meanings have been explained in detail within their particular context by providing the original expression in Chinese. The first aim was to reveal language that Chinese international students use for and about wellbeing. In the interviews, participants were asked: “when you think of wellbeing, what do you think?” and “what does wellbeing mean to you?”. Analyses uncovered five main themes, which further could be classified into 22 subthemes. the first thought of wellbeing is related to physical and mental health”, “without physical and mental illness”, and “it is a positive physical and mental status”. Nine participants mentioned happiness, noting for instance “when I happy every day. if I am not happy, then I am not wellbeing”. Forty percent of participants pointed to a sense of security, especially pointing to financial aspects, while others pointed to a sense of prosperity. One student expressed “wellbeing to me means I can afford all the cost by myself, as I financially depend on my parents currently”. Other students believe that the “financial condition” and “a reasonable income” is the key to living and being well. Relationships were also commonly mentioned, noting for instance, “you have a very good support system to back you up, no matter it’s family, friends, or partner, you need to have it so that you won’t feel insecurity” and another noting the importance of having “a healthy social interaction”.Participants generally viewed wellbeing as being multidimensional in nature. Most commonly, participants pointed to physical and mental aspects, noting for instance that “In the interviews, participants were asked to reflect upon “what words can you think of to communicate or describe wellbeing?” Participants were then asked to “describe a person with high wellbeing level” and “describe a person with low wellbeing level”. “It’s hard because I couldn’t find a suitable word to cover the meaning of wellbeing. I think there are so many things in it. It is difficult to describe and summarize wellbeing in a simple word.”To further explore the role that language plays in understandings of wellbeing, participants were asked to “translate wellbeing into Chinese”. As illustrated in Some participants focused on the components of wellbeing, such as “mental health + physical health”, “happiness + safe + health”, and “life satisfaction”. Others provided literal translations, suggesting that the “well” reflects “happy”, “good”, “positive”, or the “ideal”, and the “being” represents the “status” or “a long-term stage”.too weird in daily conversation”.The struggle to relate their Chinese translation to the word “wellbeing” reflects a blurred conceptualisation of the concept. Seven students noted that wellbeing had the same meaning to them in English and Chinese. Three highlighted that their knowledge of wellbeing came from English-speaking information, which shaped their understanding of the concept and further influenced their Chinese translation. Four participants expressed frustration with the question, two of them mentioned that the context should be taken into consideration, as the meaning of the word could be totally different. Another suggested that the word should only be used in English, as the Chinese translation is “I will think more about the interpersonal relationships, such as friends and family in Chinese. But if I think it in English, I will consider more about myself, like how to manage myself”. Wellbeing was seen as neutral and fundamental in English, versus being positive and ideal in Chinese. For instance, one student noted “when I think it in Chinese, I will think it to be more positive. But if I listen to the word in English, I will think it more neutral, which could possibly include both positive side and negative side”. Finally, wellbeing was seen to be dynamic and long-term in English versus static and short-term in Chinese. As summarised in In the online survey, participants were asked to reflect upon activities that they engage in to support their own wellbeing. Analyses uncovered six main themes, which further could be classified into 21 subthemes. I’m exercising every week to help maintain both mental and physical health. It can make me focus on the moment of sweating and let all the things go with sweat.” Participants also pointed to the importance of continued learning and exploring, noting for example, “I’d love to explore different suburbs in Melbourne on weekends”, “learn new skills”, and “experience new things”. Interestingly, some participants pointed to studying and working hard to achieve goals as a pathway to wellbeing.The main types of activities were cognitive or physical in nature. The most popular activity involved different forms of exercise. For instance, participants noted: “chat with my good friends about unhappy, stressful things to relieve inner anxiety”, “hang out with friends”, “spend more time with family”, and “video-chat with families at home”. Notably, only 2% pointed to seeking professional help. Participants also pointed to the benefit of seeking or providing support to others. Primary forms of support included friends, parents, and teachers. Participants noted that they would “In the survey, participants also reflected upon how they support other people’s wellbeing in the past, at present, and what they might do in the future. Four main themes emerged, which further could be categorised into 12 subthemes, as summarised in ask them how their lives are going”, while 11 students pointed to providing encouragement . Participants noted that they want to “be someone who will answer them”, “ask them how their lives are going”, “encourage others to increase their wellbeing” and “deliver positive energy”. Thirteen responses focused on providing perspective or advice, such as “recommend good books” or “give some advices”. Two responses pointed others to professional help (“suggest them to see a counsellor”), although there was a sense of doubt about whether it is appropriate or not. “Speaking” was the most common subtheme, which included a number of different strategies. Twenty-two responses reflected offering care and comfort, such as “being a listener”, “listen to other’s worries”, and “listening without interrupting”. Some responses pointed to more indirect forms of support. For instance, when others need company, participants might “ask people out for exercise”, “planned activities to engage the person who was low”, and “hanging out with them to create fun experiences”. Participants also expressed their thoughtfulness: “be kind, sensitive and empathy”, “help them while respect their autonomy”, “be sensitive to other’s emotion”, and “stand in other’s shoes”.Responses also pointed to trying to be a good listener, noting “Mental health is increasingly becoming an important public health concern worldwide, with some populations simultaneously at risk for poorer functioning, but less likely to seek and receive proper care than other populations. International students are one of these high-risk populations. While this is caused by a number of factors, these risks may be compounded by the language used both in conveying mental health and wellbeing information and in offering and providing care. Cultural differences can impact upon how words are used and understood , whereas low wellbeing was seen more in what people feel .Although the knowledge of wellbeing has generally been built upon studies from westernised and industrialised nations, a growing number of studies have explored the impacts of culture on wellbeing ,66,67. SThe results support the influence of self-construal processes  and emotNotably, the word “wellbeing” does not directly exist in Chinese and thus is hard to translate, which was reflected by comments and frustrations expressed by participants. According to the English Chinese dictionary, wellbeing has been understood as a combination of happiness, peace, and physical and mental health. Yet participants expressed their confusion and frustration when they considered how to translate wellbeing into Chinese. Further, participants had different conceptions for English and Chinese contexts, with wellbeing in English being more abstract, focused on the self, neutral, and dynamic in nature, versus being more specific, focused on others, positive, and stable in nature in Chinese. Considering “wellbeing” is often used throughout the public health literature, this might suggest that international students may have a very different understanding of the word, which could impact upon cognitions and behaviours. Another example is the Chinese translation of wellbeing as “being good”. Students noted that there is a moral bottom line or standard and to be civilised to achieve the status of being good. This idea mirrors the Confucian value of Wu Chang, in which social norms with virtues regulate behaviours for collective welfare, such as humanity, righteousness, ritual, knowledge and integrity . InsteadParticipants identified a variety of activities that they engage in to support their own wellbeing, as well as pointing to ways that they provide support for others. Students particularly focused on physical and cognitive-based activities. Notably, supporting wellbeing was primarily seen as an intrapersonal activity, rather than something done with others. Others were seen as providing social support or help when needed, rather than as central to caring for wellbeing. This extended into how they supported others’ wellbeing, with the most common activity being providing emotional  forms of support. This suggests that Chinese international students believed it was their own responsibility to maintain and promote wellbeing, rather than being dependent on others. The activities noted support cultural-based stigmas. According to Haslam , four diThis study reveals language that Chinese international students use to understand and talk about wellbeing, as well as strategies that they use to support wellbeing in themselves and others. Mental health and wellbeing are words that are commonly used across the public health literature, but the question becomes the extent to which those words are meaningful to different populations. If words are meaningless, then educational messages, support, services, and approaches to proactively support functioning may be a waste of resources, or only communicate with local populations, fuelling inequities in support and care and further contributing to risk for already vulnerable populations. The visualised language around wellbeing clarifies and informs what words might be useful for communicating about wellbeing with words that everyday people can understand and connect to this concept. The subtle differences in how the wellbeing concept is understood in English and Chinese point to the need for cultural sensitivity when promoting wellbeing in diverse populations. It requires educational institutions and the public health sector to endeavour to increase their cultural and contextual awareness when engaging the public with various translations of this concept.Aligned with the World Health Organization (1948), conceptualisations of health and wellbeing included physical, mental, and social aspects. For Chinese international students, a sense of security and prosperity also mattered. Unfortunately, a sense of security has been undermined for many Chinese internationals, due to discrimination and stigmatisation that occurred through the COVID-19 pandemic . This woThe wellbeing pathways revealed in this study can inform tertiary institutions on what students actually may need to support their wellbeing, which might differ from the typical services that are offered. The services around supporting students’ five components of wellbeing should be taken into consideration, such as offering healthy diet and lifestyle information, promoting mental health and counselling service, providing opportunity for cross-cultural interaction and activities, enhance campus security and non-discrimination environment, and educating students about employability opportunities. Many foreign students struggle to interact with locals and might only develop relationships with other foreign students. In the interviews, participants mentioned the hope for universities to provide opportunities to socially interact with locals and noted interest in workshops that introduce aspects of the local culture, such as slang, local foods, and festivals. They also mentioned that universities could provide more cross-culture activities to enhance the awareness of cultural diversity on campus, as some locals do not want to interact with international students when they been approached. Notably, participants focused more on intrapersonal activities rather than seeking support from others. This suggests that educating students with self-motivated and self-learning skills towards wellbeing is vital, such as highlights the importance of wellbeing during orientation week, offer workshops, training, and compulsory course around wellbeing. The pathways described here might provide a helpful starting point for supporting Chinese International student wellbeing, but most likely are insufficient, and care should be taken in generalising the findings. The data in this study were collected in the latter part of 2019 and early in 2020, before the COVID-19 pandemic impacted upon Australia. As such, the findings point to general experiences by international students, which may shift as the broader socio-political landscape of universities evolve. The pandemic has brought additional challenges to students living and studying abroad. A recent report pointed to problems with how information is disseminated, housing, needs for social inclusion, work, safety, and health . These aWellbeing is a crucial part of public health. Students’ language about and for wellbeing and their ideas on strategies that support wellbeing inform the messages and strategies needed to support Chinese international students well. Findings help broaden the understanding of wellbeing concept from the population of tertiary students, identify students’ perspectives of activities that strengthen their wellbeing, offer a snapshot of the language used by Chinese students around wellbeing, and provide new data of population health through a wellbeing lens.


Utilizing thematic analysis, we identified that hardiness was developed through experiential learning, external support, and the use of specific coping mechanisms. Key to all of these themes was the concept of reflective practice, which was thought to facilitate more meaningful learning from the participants’ experiences and, subsequently, enhance the self-awareness and insight required to augment hardiness and its sub-components. To investigate further the potential relationship between coaches’ reflective practices and their level of hardiness, we conducted a follow-up study. Specifically, a sample of 402 sports coaches completed the Dispositional Resilience Scale-15, the Self-Reflection and Insight Scale, and the Questionnaire for Reflective Thinking. Using latent profile analysis (LPA), we clustered participants into groups based on their reflective profiles . We then examined differences in hardiness between the five latent sub-groups using multinomial regression. Findings revealed that the sub-group of highly engaged, intentionally critical reflective thinkers reported significantly higher levels of all three hardiness sub-components than all other sub-groups; these effect sizes were typically moderate-to-large in magnitude (standardized mean differences = −1.50 to −0.10). Conversely, the profile of highly disengaged, non-reflective, habitual actors reported the lowest level of all three dimensions. Collectively, our findings offer novel insights into the potential factors that may influence a coaches’ level of hardiness. We provide particular support for the importance of reflective practice as a meta-cognitive strategy that helps coaches to develop hardy dispositions through augmenting its attitudinal sub-components. Consequently, our research makes a significant contribution by providing a comprehensive insight into how we might better train and support coaches to demonstrate the adaptive qualities required to thrive in demanding situations.Hardiness has been identified as a key personal characteristic that may moderate the ill-effects of stress on health and performance. However, little is known about how hardiness might be developed, particularly in sport coaches. To systematically address this gap, we present two linked studies. First, interviews were conducted with pre-determined high-hardy, elite coaches ( Sports coaching has become widely recognized as an inherently stressful profession in which individuals encounter a range of organizational, competitive, and personal stressors due to the complex multiplicity of their role . Couple hardiness ; control ; and challenge  we examined pre-determined elite, high-hardy coaches’ perceptions of how they developed their hardy beliefs over time. In Study 2 (quantitative phase), we examined key findings from Study 1 regarding the relationship between developmental factors and augmented hardiness with a large sample of coaches, with the view to quantify the magnitude of these associations. Thus, we sought to improve understanding of how we might better train and support coaches in developing hardy beliefs to protect them from the increasing demands associated with the coaching role. In doing so, we aimed to make a novel and significant contribution to current knowledge in the area.critical realism  is used to generate new conceptual knowledge followed by a quantitative component , which is used to investigate and test that emerging theory (see The research we present in this article (Studies 1 and 2) is underpinned by the perspective of  realism . Critica realism . While t realism , critica realism . Here, ie ground . Therefoe ground . For crieory see . This apThe aim of this study was to explore how pre-determined elite, high-hardy coaches developed their hardy dispositions. Specifically, using a critical incident approach , we inteelite coaches, requiring them to exhibit the personal characteristics associated with effective and adaptive coping  consisted of five senior national  and eight international team sport coaches , who collectively worked across a range of sports . Participants were all classified as high hardy [DRS scores ranging from 108 to 130 ], had been coaching for an average of 8.69 years (SD = 4.1), and had been in their current position for an average of 2.7 years (SD = 1.3) at the time of the study.Twenty five potential participants  were initially contacted through the National Governing Bodies of their respective sports and invited to participate in the pre-screening procedures to check whether they met the sampling criteria. Participants were asked to complete an electronic version of the DRS via an online link, which also contained ethical information about the nature of the study, their rights, and a request to confirm their voluntary consent to participate . Subsequently, only those who scored in the highest DRS quintile were selected to participate in the study itself. The final sample . Third, participants were asked to discuss how their hardy dispositions had impacted on their coaching practice and success. Finally, participants were offered the opportunity to add any further information in relation to their experiences before the interview was concluded with a series of questions concerning the nature of the interview itself .A pilot interview was conducted with a sub-elite, high-hardy, female football (soccer) coach to assess the efficacy of the guide in relation to the study aims and its suitability for facilitating in-depth reflection. Following participant feedback, the interviewer’s reflections and research team discussions, minor modifications were made to the phrasing of questions and additional neutral, non-directional probes were prepared .M = 74; SD = 16.7), were audio-recorded in their entirety, and were subsequently transcribed verbatim.Participants who met the sampling criteria were contacted via email to inform them of the nature of the interview, their rights as participants, the request for voluntary written consent, and subsequently to arrange a suitable time and location for the interview to take place. Once consent had been received and the logistics agreed, each participant was sent an interview preparation booklet, which was designed to: (a) further their understanding of the purpose of the study; (b) prepare them for the nature of the interview by offering definitions of hardiness and its sub-components; and (c) encourage them to consider those incidents that they deemed as most critical in the development of their hardiness so as to aid recall during the interview itself cf. . All intIn accord with our critical realist perspective, the general aim of Study 1 was to generate knowledge  through a process of inductive inquiry. Subsequently, the mechanisms and underlying structures of this emergent knowledge could then be investigated (Study 2) to offer a more thorough examination of factors that may augment hardiness . Followiwork-related demands on hardiness development). Following this, comparative analysis and discussion took place between authors two and five, with author one acting as a critical friend to question any potential bias in the initial coding and facilitate discussion to settle on the final codes  that could be presented in the form of a hierarchical network. Fifth, to address the rigor of the analysis, authors two and five critically discussed the definition of each theme to ensure that it was clear, distinct, and traceable back to the raw data  meeting appropriate ethical standards; (b) selecting an appropriate, information rich  sample; (c) testing the interview guide ; (d) preparing participants by ensuring a clear understanding of hardiness so that this construct could be discussed, rather than potentially discussing related psychological factors; and (e) providing participants the opportunity to comment on the rigor of the interview process cf. .Through the data analysis procedures we identified three higher order themes relating to the development of participants’ hardiness: (a) development through experiential learning; (b) development through external support; and (c) development through the use of coping mechanisms. These, and their lower-order themes, are presented as a hierarchical network . This neThe importance of being exposed to a wide variety of demands, across the different areas of the participants’ lives, for developing hardy dispositions was reported by all participants. Specifically, participants referred to the learning opportunities that such exposure provided them to better understand how they controlled, managed, and/or coped with those demands. For example, one participant stated, “Although the contexts are different, I learned early that all aspects of work and life throw you so many difficult challenges. I knew that if I could cope with them I would be able to cope with anything in sport.” Another indicated:I was studying for a masters; I had about 37 hours of work as a coach and volunteering. I was coaching football at xxx (club), I was also coaching at two football development centers and I was still an elite athlete at that point … being challenged in different ways really helped me to be more robust when I was faced with challenges later on.Other participants referred to specific demands they had experienced that had resulted in a process of experiential learning and thus led to positive adaptations to their hardiness. One participant outlined, “Once you’ve experienced that prickly interview … after a bad game, and you’ve still delivered a good message, you quickly learn to see the media as a test – an opportunity to present yourself as in control.” Similarly, another participant detailed, “Learning to manage with the breakdown of a relationship (divorce) really teaches you how to manage some of the nonsense that happens above you in an organization and the relationships you have with those people (board members).” Such statements represent many of those presented by all participants regarding the necessity of experiencing difficult situations in different contexts for the development of their hardy beliefs.When asked how the exposure to numerous demands contributed to the development of hardiness, one participant suggested, “… you learn to see the issue differently … you learn to see it as a challenge and you make decisions about how you meet the challenge head on, in a positive way.” Other participants indicated, “You begin to understand that you can’t control everything so you need to put your effort and energy into the things that you’ve got some control over” and “It  showed me that I can handle a lot of work and stress and I won’t break down irrespective of the pressure. On reflection, it showed me that I can achieve success and balance and spin plates.” Consequently, it was generally understood that the participants’ exposure to demands was a worthwhile process because of the resultant learning that took place. Thus, the process of experiential learning appeared to influence the participant’s perceptions of the nature of, and control over, future demands, and was therefore noted as being a key contributor to developing hardiness.In addition to being exposed to a range of demands, the participants outlined how learning from adversity had also helped to enhance their hardiness, particularly through the development of its associated attitudinal components. For example, participants suggested, “That situation (adversity) taught me that you can’t predict what’s going to happen to you so you have to focus on the positive things you can do to move forward and commit to them – don’t take a step backwards” and “What I felt at that time wasn’t good, but I still worked – still did what I could. I think I was really brave when I eventually held my hands up and asked for help … that bravery has stuck with me.”dealing with controversy, unexpected career transitions, losing their jobs, and dealing with personal tragedy. For example, participants stated, “I wouldn’t say I’ve experienced many of them (adversities), but getting the sack from xxx (club) was particularly tough. “It taught me to enjoy every moment … to stay focused and stay true to yourself” and “When my dad died I struggled … having time to reflect, it reminded me that he’d taught me so much about everything, so I knew I could cope and move forward. Strangely it probably took that for me to see.” Another participant reported:Participants detailed experiencing a number of adversities, including: On my first day at school, this kid says to me, “Do you want to fight?” … I look back and it was awful but it shaped who I am. I’ve had to battle for everything, whether it was getting into the team or simply surviving the playground.Consequently, the relatively novel nature of the adversity the participants experienced provided unique opportunities to learn about themselves and their personal resources that helped them to manage those situations and, in some instances, demonstrate positive adaptations.Throughout all of the interviews, each participant explained that, while they had learned from situations experienced in all areas of their lives, significant experiences within sport were a key contributor to the development of their high levels of hardiness. Participants indicated that these experiences had, “Shaped who I am as a coach,” “Made me become more resilient,” and “Helped me to understand how to be tough – how to enjoy the challenge.” One participant explained, “I guess the learning from that experience  is really taking stock of the finer details … you’ve got to back yourself and show to the group you work with that you are really are in control.”Participants were clear that learning about the context of sport and performance allowed them to understand how to function effectively, despite the nature of the organizational and environmental conditions in which sport takes place. As a result, some participants felt as though their experiences in sport allowed them to understand the importance of being hardy and how to be successful. For example, “Winning xxx (tournament) took a lot of focus and effort. It’s in those moments, when you think back, that you understand how resilient you are, or hardy as you put it … you don’t get that from other situations” and “I made errors as a player that cost us games, but I bounced-back. At the time you don’t think about it much but when I started coaching I understood what I could do and that’s helped me in this role.”Significant others were identified by participants as those people who had played a key role in their personal and professional development. Eleven of the coaches within this study suggested that significant others  contributed to shaping their knowledge, attitudes, and behaviors during their everyday lives and careers. For example, “My parents did everything possible to give me a chance (in sport). Looking back, it’s humbling really. I think their selflessness, drive and work ethic certainly rubbed off on me. Trying to make them proud has definitely focused me” and “I became really close with xxx (coach). We talked about the things she’d been through and still managed to be successful. That helped me to understand that I could do the same – that I had the mental attributes to thrive.” In developing hardiness, the examples provided by participants indicated how social approaches to learning and development were considered as essential. Indeed, participants implied that such interactions influenced their outlook on life and sport and helped them to gain perspective within their roles, which helped them to function effectively. In summary, “Those personal and professional relationships help you to understand who you are, your strengths and weaknesses … but they also help to shape the way you see things, the way you put the challenges you’re faced with into perspective.” Some participants also outlined how these significant others did not necessarily provide positive influence through their behaviors and attitudes, but such behaviors helped the participants shape their own coaching style. For example, one participant stated, “Having had the coaches that I had … taking all of the worst bits and making sure I wasn’t like that was important … I suppose it gave me a sense of understanding of negative coach behaviors.”significant others in that the support from significant others was generally observed, whereas social support represented the explicit and direct social interactions with others that helped participants cope with, and manage, the demands associated with their professional roles. In doing so, such social support was deemed to have had a particular impact on the development of participants’ hardiness. For example, participants reported, “My parents gave me unconditional support … when those (media) reports were published they were there reminding me of my achievements and stopped me feeling sorry for myself. I suppose that support helped me stay in control of the situation” and “Having someone there to act as a sounding board has been important for me. It’s helped to frame the best approaches to deal with issues and to check in with someone to ensure that you’re giving everything to the cause.” In light of these examples, participants were clear about the contribution that social support played in supporting adaptations to their beliefs concerning control, challenge, and commitment. Specifically, participants indicated that social support helped to alter their perceptions and interpretations of the demands that they experienced and instill an approach to proactively deal with such demands. This sentiment is best summarized by one participant who stated, “Getting honest feedback from those you trust is key because you see the problem differently. It’s no longer something you can’t control but something that you can manage, that will make you better. That’s an attitude you need.”Social support differed from Participants discussed using a number of specific mechanisms throughout their lives that they believed had not simply allowed them to manage stressors, but instead had been transformational in nature , and thus had positively impacted their hardiness.One strategy reported by most participants was that of goal setting, which allowed for the participants’ strength of commitment to flourish, “I had specific end goals in my playing career and in order to achieve those goals no one aspect could derail me … Yes, I think that commitment needed to achieve a goal really builds your hardiness.” Another participant reported how goal setting helped instill a sense of control over, and commitment to, the situation: “Giving myself specific targets really helps me to apply a level of control over my work. They also help to ensure that I stay focused and committed to positive action.” Similarly, the strategy of goal setting also appeared to provide a sense of clarity and focus that influenced the resilient disposition of hardiness: “I knew I always wanted to coach xxx  and I knew what I needed to do. I set targets for my development and I dedicated myself to getting those targets. Staying focused, that’s what makes you tough.” Linked to this, a number of participants discussed the importance of “next action behaviors” in moving on from negative situations  to focus on factors that they could control, “When you’re under the cosh as a team, and as a coach, you can easily get lost. I just set myself little challenges, little goals to keep me moving forward, to stop me from dwelling on the past.”All participants reported the use of both systematic and informal approaches to reflective practice (RP) after demanding events in order to learn and inform future behavior. One participant stated:You experience a situation; you reflect on it and that reflection helps you deal with similar situations in the future. I reflect on everything, I don’t want to go into the theory of the reflective cycle but I think when you do something, you reflect on what went well, what didn’t go so well and how I might make those changes. So, for me reflection is a fundamental part of my coaching and it’s really helped me to be hardier personally.RP was identified as a coping strategy due to the process being associated with “knowledge gains” that helped coaches to deal and cope with the different demands they experienced in their lives and, as a result, instill a great sense of control, commitment, and challenge. For example, “Reflection’s really helped me to understand myself, to become more aware of what works for me and how then I can be positive in difficult situations” and “Using reflective practice has really given me a different perspective on things. It helps me to stay rational, understand what needs to happen, set targets and engage in the right behaviors to achieve those” and “Without reflection I wouldn’t have learned ; it’s the process that draws things together, helps you to realize what you need to do to succeed and, therefore, gives you confidence to take action.” RP was thought to help participants also become more familiar with demanding situations and, as a result, feel more prepared to be proactive in their approaches. Specifically, “(Because of reflection) I know what’s coming up … because of learning about those previous instances before they happen and I like to think I’m pretty tooled-up when they happen.” Other participants acknowledged how engaging in RP emanated from their commitment to improve. For example, “You have to be committed to reflect all the time, on everything, but that comes from that inner drive to improve. I want to get better every day, every experience and so reflection’s a huge part of that journey.”Throughout the discussions with all participants a number of problem-focused approaches to managing demands were discussed, including: “placing focus onto those factors that could be controlled”; “seeing the issue differently, as a positive challenge” ; and “making calculated, informed decisions rather than reacting rashly.” Specifically, one participant stated:Having 90–95% control and only having to react to 10% will definitely help you as a coach. Having structures and a contingency plan, dealing with the “what if” scenarios, so when they happen in the game you have anticipated them and are prepared.These approaches were reported to influence the perception of control that the participants had in different situations and, therefore, helped them to feel better prepared for the difficulties they encountered. One participant reported, “When xxx (family member) passed away I couldn’t control that; there was nothing I could do, but focusing on what I could do to support my mum and the rest of my family helped to make sure I acted as positively as I could.” Participants detailed that many of these approaches and attitudes had developed over time through learning from their experiences rather than through formal education. For example, “I flew off the handle with (player), it made me feel better at the time but it didn’t really help. Reflecting back, I knew I had to be more managed, controlled … you don’t get taught that” and “I’m pretty good at seeing things for what they are rather than through emotion that distorts them. I think that’s something I’ve developed over time, through experience of tough situations.”hardiness  and situational  factors thought to contribute to increases in hardiness. Of particular relevance was how participants engaged in a process of experiential learning following demanding situations, which resulted in a higher propensity to manage future stressful episodes. These findings offer novel empirical support for recent literature in which researchers have argued for the potentially adaptive role of stress e.g., . Indeed,Perhaps fundamental to the participants’ hardiness development in this study was their engagement in RP as a process to facilitate meaningful learning from their experiences. Participants recognized RP as both a coping strategy and as the key process in supporting greater self-awareness and insight , both of which are thought to be intrinsically linked with the sub-components of hardiness . ParticiImportantly, the participants in the current study demonstrated a commitment to RP in which they largely considered their engagement in the process as systematic and deliberate. Historically, it has been argued that RP can occur at different levels of insight, from technical  to critical  allowing us to examine how different profiles may influence each of the sub-components of hardiness.n = 355) and individual (n = 47) sport coaches. The participants worked at the youth (n = 228), senior (n = 92), or both youth and senior (n = 82) levels of their respective sports, and covered a range of performance levels, including: grassroots (n = 34); local/regional clubs (n = 149); national clubs (n = 109); national representative teams (n = 36); international (n = 44); and other (n = 30). The participants ranged in age from 18 to 68 years  and in coaching experience from 1 to 28 years .Participants were recruited through National Governing Bodies, social media, and snowball sampling procedures under the premise that they were in a coaching role at the time of data collection. The final sample consisted of 402  multi-national , team  and insight (SRIS-IN). Self-reflection is also split into two related components, engagement in self-reflection (SRIS-SRE) and need for self-reflection (SRIS-SRN), and measures the recognition of the need for and the process of engaging in reflection. Insight assesses the “clarity of understanding one’s thoughts, feelings, and behaviors”  and understanding  assess non-reflective actions. Two sub-scales, reflection  and critical reflection  assess reflective actions. The QRT utilizes a 5-point Likert response scale (1 = definitely disagree to 5 = definitely agree), with sub-scale scores ranging from 4 to 20. The QRT has acceptable internal consistency  and construct validity has been supported through confirmatory factor analysis  of participants’ RP, the Questionnaire for Reflective Thinking QRT;  was adopanalysis .All three measures (and instructions for completion) were uploaded to Online Surveys together with participant information, consent details, and a request for demographic information . From this, an electronic link  was created to allow the questionnaire pack to be widely distributed as well as provide potential participants the opportunity to take part at a time and location of their choosing. A number of National Governing Bodies agreed to distribute the link to their coach networks, and a request was made for participants across a range of social media platforms. Potential participants were instructed that they needed to complete the entire pack in one sitting, but that the link would remain open for a period of 2 months. Given that all questions were made compulsory, participants not wishing to answer a question or complete the entire battery of measures were informed that they could cease their participation at any time. As a result, only complete cases were recorded and stored on Online Surveys, meaning that there was no missing data.reflection variables obtained from a correlated seven-factor measurement model as indicators of the LPA to control partially for measurement error . Lower values on the relative fit indexes, a statistically significant ratio test, and entropy values that are closest to one and larger in comparison to other profile structures provide evidence for a better fitting model  encompassed individuals who reported average levels across all seven reflection indicators. We labeled these coaches moderately engaged, surface-level reflective thinkers. The second largest profile  represented individuals who reported low-to-moderately high levels of all seven reflection indictors, with the exception of insight and habitual understanding, where they assessed themselves as relatively average. We labeled these coaches engaged reflective thinkers. The third largest profile  included individuals who reported moderately low levels of all seven reflection indictors. We labeled these coaches disengaged, non-reflective thinkers. The second smallest profile  was characterized by individuals who reported moderate-to-large low levels of all seven reflection indictors, with the exception of insight and habitual understanding, where they assessed themselves as relatively average. We labeled these coaches highly disengaged, non-reflective, habitual actors. The smallest profile  captured individuals who reported high levels of all seven reflection indicators, with the exception of habitual understanding, where they reported moderately low levels. We labeled these coaches highly engaged, intentionally critical reflective thinkers.In terms of standardized factor scores see , the larhighly engaged, intentionally critical reflective thinkers (profile 5) reported the highest level of all three hardiness facets, whereas the highly disengaged, non-reflective, habitual actors (profile 1) reported the lowest level of all three dimensions. Hardiness scores for the other three profile groups were largely similar in magnitude and situated between the extremes of profiles 1 and 5. The inferential tests supported the adaptive nature of profile 5, such that participants in this profile reported statistically higher levels of all three hardiness dimensions than all other subgroups. In contrast, the highly disengaged, non-reflective, habitual actors (profile 1) reported statistically lower levels of control than all other profiles, though the comparisons were mixed for commitment and challenge. The moderately engaged reflective thinkers (profile 4) also reported generally higher levels of all three hardiness dimensions relative to the other subgroups. Collectively, these findings indicate that the most meaningful differences between profiles with regard to hardiness scores are observed when individuals reported low or moderate-to-high levels of most reflection dimensions.To understand the nature of profile membership, we examined differences on hardiness between the five latent subgroups see . A visuaThrough the two studies presented in this manuscript, we aimed to examine how sports coaches might develop and optimize hardiness, a form of dispositional resilience that is thought to be influential to the way individuals manage demanding situations . In the critical sporting incidents, as these experiences were thought to help them better understand the demands and what was required to manage them on a daily basis in their work lives. Similarly, engaged reflective thinkers (profile 4) demonstrated significantly lower levels of hardiness than the sub-group of highly engaged, intentionally critical reflective thinkers (profile 5), but higher overall hardiness than the other profiles . As a result of this finding, we suggest that engagement in RP is necessary, yet an individual’s ability to engage in higher-order reflective thinking is potentially most important in relation to the development of hardiness.The findings of our second study support the potential importance of RP as a meta-cognitive strategy that can optimize hardiness in coaches. However, these findings also detail the key role that the level of an individual’s RP plays in their experience of hardiness and its sub-components. For example, higher levels of hardiness were found in those participants who reported a highly engaged and critically reflective profile than in those who reported disengaged, non-reflective profiles. There has been considerable debate in the RP literature concerning the nature and importance of critical levels of reflection e.g., . The autmoderately engaged, surface level reflective thinkers, and engaged reflective thinkers respectively, with the smallest sub-group of participants being the highly engaged, intentionally critical reflective thinkers. These sub-groups also indicated higher levels of overall hardiness than the two non-reflective sub-groups. These findings suggest two things: (a) a large proportion of our sample reported a need to reflect and at least some engagement in RP; and (b) only a small proportion of the sample reflect at the critical levels required to achieve greater developmental adaptations to hardiness and its sub-components. In support of this, researchers have argued that critical RP is difficult to attain, requiring a specific mindset and commitment to the process , we cannot presume that sub- or non-elite coaches would not also demonstrate high levels of hardiness and, therefore, provide very different insights into the development of hardy dispositions. In Study 2, however, we did sample coaches working at all levels of their respective sports, identifying participants across those levels who profiled into each of the sub-groups. Given that the majority of the sport coaching workforce operate at sub-elite levels, researchers may wish to explore potential comparisons between elite and non-elite coach hardiness, as well as investigate whether RP profiles differ across coaches working at various levels of performance. Indeed, researchers have detailed how coaches operating at all levels experience considerable, yet varying demands e.g., . Such fuBy adopting a critical incident approach in Study 1, we focused on three key experiences thought to have influenced participants’ hardiness. While the semi-structured nature of the interviews afforded us the opportunity to explore beyond these experiences, we appreciate that other frameworks have been developed to guide temporal enquiry . Accordingly, our research was conducted in compliance with the principles of the Declaration of Helsinki and written informed consent to participate was provided by all participants in both studies.BC, LB, SH, and RN were involved in the conceptualization of the research question and study design. LB was responsible for data collection in study one. LB and AM conducted the study one data analysis and construction of the findings . DG conducted the study two data analysis and preparation of findings. BC, LB, RN, and TW prepared the manuscript in its entirety with SH and DG responsible for manuscript editing. All authors were involved in data collection for study two.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The dynamical evolution of a system of interacting elements can be predicted in terms of its elementary constituents and their interactions, or in terms of the system’s global state transitions. For this reason, systems with equivalent global dynamics are often taken to be equivalent for all relevant purposes. Nevertheless, such systems may still vary in their causal composition—the way mechanisms within the system specify causes and effects over different subsets of system elements. We demonstrate this point based on a set of small discrete dynamical systems with reversible dynamics that cycle through all their possible states. Our analysis elucidates the role of composition within the formal framework of integrated information theory. We show that the global dynamical and information-theoretic capacities of reversible systems can be maximal even though they may differ, quantitatively and qualitatively, in the information that their various subsets specify about each other (intrinsic information). This can be the case even for a system and its time-reversed equivalent. Due to differences in their causal composition, two systems with equivalent global dynamics may still differ in their capacity for autonomy, agency, and phenomenology. Traditionally, how well we can predict the behavior of a system is taken as a measure of how well we are able to model, and thus “understand”, the system  but see. PredictOn the other hand, characterizing the functional role of particular parts of a system and the way in which they interact has always been a main line of inquiry in the sciences dealing with complex systems, such as biology and, most prominently, neuroscience ,6,7. In compositional: the various subsets within a system may specify irreducible information about each other.Originally conceived as a theory of consciousness ,25,26, iautonomy and agency, with respect to which, measures that are primarily aimed at predicting a system’s dynamical evolution in holistic or reductionist terms generally fall short. This includes questions regarding actual causation (“what caused what?”) ,37S of tM, for example, implements a majority function, turning on (‘1’) whenever at least two elements of Here we are interested in the intrinsic information that a system in its current state specifies about its intrinsic causes (its prior state) and effects (its next state). Intrinsicality: From an extrinsic perspective, the entropy H of a system is also a lower bound on the expected number of “yes/no” questions needed to determine the system’s state . AS constrains its potential next states according to its state transition probabilities effect repertoire of By being in state Equation , assumincausal marginalization ..31].t. The random sample of 10,000 random probabilistic systems was generated by filling each entry in the state-by-node TPM =n bit , which dDefinition 2.A reversible system S with state space S, still differ for all unique ER systems. From a holistic perspective, however, all ER systems are dynamically identical, as they each follow a single periodic cycle through The observed, stationary probability distribution S)=n bit  for all Equation , which dhttps://github.com/grahamfindlay/pyphi.git . To compute All quantities evaluated in this article were computed using custom-made python scripts (available upon request) based on PyPhi, the IIT python software package . The par


Menopause before the age of 40 years is known as primary ovarian insufficiency (POI). Besides physical effects, being diagnosed with this disorder adversely affects the psychological health and quality of life (QOL). The present study aimed at shedding light on the factors affecting the QOL of women with POI.The present study is a qualitative one. The data were collected using semi-structured in-depth interviews with 16 women having POI, selected purposively. Data rigor was ensured using Lincoln and Guba’s criteria. The recorded data were transcribed verbatim and then analyzed constantly at the same time as gathering the data using conventional content analysis.Three themes emerged regarding the QOL of women with POI, i.e. disease effect , distorted self-concept (threatened identity and disease stigma), and hormone replacement therapy effect .Due to the profound effects of the disease on different aspects of the biopsychosocial health of women with POI, a multifaceted health care approach is recommended to improve their QOL. Menopause before the age of 40 is called POI, mentioned as a premature ovarian failure or premature menopause, identified by oligo/amenorrhea for at least 4 months, and an elevated FSH level > 25 IU/I on two occasions 4 weeks apart , 2. In aPOI occurs either spontaneously or as a result of medical interventions, including chemotherapy or bilateral oophorectomy . SymptomSpontaneous POI exposes women to an accelerated risk of chronic sequelae such as osteoporosis and fractures, overall cardiovascular disease, stroke, Type 2 diabetes, and total mortality , 9.Besides physical effects, being diagnosed with POI adversely affects the psychological health and QOL of women , 10. WomAlthough the QOL plays a vital role in women’s health, to the knowledge of the authors, no qualitative studies have been carried out throughout the world focusing on the QOL of women with POI.There is a direct relationship between health and the QOL, hence there is a strong need to assess how a patient perceives the QOL affecting, as a subjective entity, her well-being which, according to recent studies, will in turn influence morbidity and mortality as an objective one . MoreoveThe present study is the qualitative phase of a sequential qualitative-quantitative exploratory study on the QOL experiences of POI women.The study population was women with POI referred to the gynecology clinic of the Research Institute of Endocrine Sciences of Shahid Beheshti University of Medical Sciences, Tehran, Iran, who met the inclusion criteria.The inclusion criteria were women with spontaneous POI based on the diagnostic criteria, disorder duration of at least 1 year, being oriented and alert, being of Iranian nationality and Farsi speaking, and not having a history of psychological or disabling chronic diseases. The POI diagnosis criteria included: experiencing amenorrhea lasting at least 4 months before the age of 40 accompanied with two FSH serum levels of more than 25 mIU/ml, and tested with at least a one-month interval .In-depth semi-structured interviews were used to collect the data. First, the participants were asked about their personal information including education, occupation, menarche age, duration of the disease, marital status, family history of POI, having children, and type of pregnancy. Afterward, general and open-ended questions were asked using the interview guide which was designed based on pilot interviews with 3 participants and used after being reviewed by the research team. The interview guide developed for this study is provided as the Additional File Ethical approval to conduct this study (IR.SBMU.PHNM.1395.529) was granted by the Ethics Committee of the School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Prior to the interviews, the purpose of the research was explained to the participants, they were informed that the interviews would be recorded, and they were also assured of the confidentiality of their personal information. Informed consent was obtained from all individual participants included in the study.The gathered data were analyzed using the content analysis method with a conventional approach . ImmediaThe data analysis was performed in six stages : (1) getRigor and conformability of the data were ensured using the four criteria proposed by Lincoln and Guba . The creConformability was ensured using an external check. To confirm dependability, in addition to creating an audit trail, the researcher recoded the same interview transcriptions with an interval of a few days and compared the outcomes. Also, the transcriptions of the initial interviews were recoded by two colleagues with Ph.D.s in reproductive health. Ultimately, a 95% consensus was achieved through an external check, peer-check, and dependability items.In this study, 16 women with POI, aged between 28 and 47 years, and a POI duration of 2–15 years were interviewed. The demographic characteristics of the participants are summarized in Table After content analysis of the interviews with a focus on the factors influencing the QOL of women with POI, three themes emerged , explained as follows .The very first complaints of POI in these women were menstrual disorders including menstrual irregularities, oligomenorrhea, and in some cases, metrorrhagia, occurring 6 months to 6 years prior to the final diagnosis. Two of them had primary amenorrhea. Many of the women with POI complained about vasomotor disorders such as hot flushes, night sweats, and heat intolerance.Fertility disorders were also caused by POI. The women inclined to have a baby complained about infertility. Those resorting to assisted reproductive technology (ART) mentioned donor egg pregnancy, abortion, and in-vitro-fertilization (IVF) as factors reducing their QOL and putting a long-lasting strain on them.“I have osteoporosis and severe joint pain. I feel pain deep in my bones. I can’t take long walks” .As for bone complications, two of the most commonly experienced issues were joint pain and osteoporosis. Also, a few of the women complained about post-menopausal tooth pain and sensitivity.“Dryness and itchiness drive me crazy. Sometimes I scratch myself to bleeding. You wouldn’t want to know how awful it is when at work, it hurts so much that I like to chop it off.” The mucocutaneous complications were reported by almost all participants as occurring in the form of vaginal or skin dryness; vaginal itchiness and tightness; and reported by a few, there were falling hair and wrinkled skin.“The disease has affected my sex life. I don’t feel like having sex at all. Last time I had sex, it was so, so painful and hurt a lot. I just tried to cope up with it and make as if it wasn’t there but I could never have an orgasm.” Despite these disorders, most women expressed that their frequency of having sex remained unchanged.“Now that I am disabled and not a perfect woman anymore, I want to manage it and have a kind of normal sex life. I don’t want my husband to feel deprived. I would like him to have a normal sex life.” .The afflicted women would mainly experience sexual function disorders due to ovarian hypofunction. They experienced dyspareunia, reduced sex drive, and anorgasmia.“I feel as if I had become heavier … when you don’t get period, you’re down … you’re not that agile anymore. You’re bored and not fresh.” .Many women were in good health, however, some of them reported conditions like weariness, loss of physical strength, and sleep disorders.“It came to me like a blow. I felt awful. I was shocked and frustrated. I was in shock for some time.” .According to a majority of the participants, being diagnosed with the disease was shocking and unbelievable:“I am so disappointed. Everyone dreams of having a baby. I cry when I’m alone and think of it … , that I cannot experience it naturally. When others are talking about children or I see a little child, I get even more disappointed” .The women experienced grief for quite a long time after being diagnosed with the disease. They were concerned about the complications of the disease , and couldn’t easily talk or even think about it:“Before receiving the treatments, I experienced all those changes of temperaments, you know, you suddenly get happy and then, for no reason you start to cry. I was beginning to feel helpless because it hurt so much.” There were many cases of becoming aggressive, agitated and losing control over anger associated with POI, reported by the interviewees. The conditions associated with fits of moodiness in these women included rage, mood swings, impatience, and, as reported by some of them, introversion.“I am anxious; I very much like to read a book but I just can’t seem to be able to finish it because of all the anxiety I have. I am trying to tell you that I lack concentration.” Also, there was a large number of these women complaining about stress-related problems such as anxiety, tension, and lack of concentration while before having POI, they never had such an experience at this level.“I’m worried about getting married. I’m afraid there will be no Mr. Right accepting me as a girl getting to menopause at an early age who cannot give him a baby”. Subsequent to POI-induced infertility as well as menopausal complications, many women experienced negative feelings including hopelessness, emptiness, being cursed, and unhappiness:“I feel empty for being infertile. I can’t enjoy real happiness … why should I be that unlucky? My peers get periods and are healthier than me.” The leading causes of POI women’s anxiety were as follows: losing health, having children, and getting married. Other causes had roots in physical effects of the disease, its economic burden, fear of future incidence of the possible related complications, and its turning into a chronic disease:The analysis of the experiences of women with POI yielded factors such as threatened identity and disease stigma, distorting their self-concept and adversely affecting their QOL.“I feel disabled; I am not an all-around woman anymore. Compared to normal women, I lack something. It’s as if I’m weaker than other women. I feel I am sterilized.” Femininity was threatened by amenorrhea and followingly, infertility; as a consequence, women would experience feelings like deficiency, losing self-confidence, femininity defect, being different from other women, and embarrassment. Some women even resisted entering a relationship with the opposite sex:“I accepted the donor egg to save my marriage, but there are some things to worry about. What if the child leaves me because I am not his/her genetic mother? What if the egg donor shows up and claims the baby one day or another?” The identity, and as a result, the maternal role of POI women who wanted to have children were threatened since they couldn’t have the natural experience of a genetic mother. Their main concerns turned out to be: forced acceptance of a donor egg, the donor egg child’s lack of resemblance to them, not being accepted as a mother by the child, and the egg donor claiming the baby.“A woman with POI is like a flower withered before blooming. I feel so old; it is as if I am too old for my age. I’m not youthful anymore, I’m withered.” .POI had caused an undesirable self-image in women making them feel aged, ‘withered’, disabled during intercourse, and with deteriorated self-confidence as a result of breast sagging and poor fitness. One of the women explains:“I feel like old women when I have to take calcium pills at this age to maintain strong bones.” Another interviewee states that:“One of the problems I have with the diseases is that I have to hide it because I don’t like anyone to find out about it. You need to make believe that you are fine while having it with you.” Most of the participants resorted to concealment due to the disease stigma. The afflicted women and the donor egg receivers intended to hide the disease and the donor egg from others. Also, some women reported feelings of isolation after having POI.“I kind of feel like it’s becoming a drawback for me and my husband is using it against me. The moment something comes up, he brings it up and then it’s me with egg on my face.” The interviewees reported that they suffered consequences of the disease stigma such as being judged, being labeled, being blamed, looking pathetic, people’s scornful look, and the bad reputation of the disease.As a symptomatic therapy influencing the QOL, hormone replacement therapy (HRT) was administered to POI women. Two main categories emerged out of the participants’ experiences, i.e. positive or desirable effects, and negative or undesirable ones.“I take medicine to regulate my menstruation. My period is regular now and I have no hot flushes. I don’t think of how it affects my health” “I have gained lots of weight since I took the medicines. Now, I have stopped using them by myself. I couldn’t swallow the pills. I was fed up with them.” The present study adopted a qualitative approach to the analysis of the QOL experiences of Iranian women with POI. The results showed that several interrelated factors could affect women’s QOL.Here, the “disease effect” is taken as the understanding and experience women have of the physical and psychological effects of POI on their QOL. The decrease in ovarian hormones triggers a set of symptoms capable of affecting the women’s QOL. Studies have shown that menopause was accompanied by a reduction in the QOL of women due to its physical and psychological effects , 19.The interviewees mentioned menstrual irregularities as the earliest symptom that engaged them for months before the cycles stopped permanently. Similarly, Alzubaidi et al. reported menstrual irregularities as the most common early symptom among women with POI, lasting 3 to 5 months from the appearance of the symptoms to the final diagnosis . HoweverIn line with the results of other studies , 22, ourIn the current study, the sexual disorder of the majority of the interviewees led to reducing the quality of their sexual life. Sexual dysfunction in women could negatively affect QOL . In lineLosing fertility could negatively affect the POI women’s interest in having sex to the extent that they regarded it as useless . HoweverOsteoporosis and joint pain were also among experiences putting restrictions on women’s activities in the current study; although a long-term side effect of POI, the two were not correlated with the disease duration. This could be related to race, nutrition, physical activity, and lifestyle differences . A studyIn accordance with other studies , 24, 25,Losing fertility came as a great shock to the women in the study. Furthermore, they experienced a set of psychological symptoms due to being subject to health risks or hormone disorders following POI. Other studies have reported common feelings of shock, confusion, rage, sorrow, loss, depression, excitability, anxiety, and emptiness among women with POI , 24, 28.In the present study, “distorted self-concept” included threatened identity and disease stigma. It has been shown that self-concept and QOL are directly related . PasqualLosing fertility made women feel deficient and older than their peers. Part of Iranian women’s identity is their maternal role and childbearing, giving them power both in the family and society. So, losing fertility affects all the elements of a woman’s identity  . In OrshWomen in the present study were grappling with POI-induced stigmas so that hiding the disease became a major obsession to them. The bad reputation of the disease and lack of knowledge and understanding on the part of others comparing them to old women made the participants conceal the disease and opt for isolation.From society’s view and even in the medical discourse, menopause is synonymous with oldness . InfertiIn line with findings of the present work, the results of other studies on lived experiences of infertile Iranian women showed that due to the negative reactions, they intended to terminate their relations with their spouse’s relatives or hide their problem , 32. SimIn the present study, “HRT effect” included physical and psychological advantages, despite some minor negative effects experienced by the participants. Induction and regulation of menstrual cycles were of prime importance to the participants and they found it solacing to feel like their non-menopausal peers. However, these women complained about being tired of long-term consumption of medicine and weight gain. In Singer et al.’s study, the long-term consumption of the medicine was reported to be a source of problem to the POI women . In OrshSome studies have shown that HRT could lead to the improvement of QOL in menopausal women . HRT risThe limitations of the study were that participant selection was done purposively and from large urban areas; moreover, only the experiences of patients who consented to participate were included. These might hamper the generalizability of the results. However, this qualitative study contributes greatly to the existing literature since it’s the first qualitative research carried out on the QOL of POI women around the world. Further studies will aid in the elaboration of the QOL of these women in other parts of the world.It is concluded that POI affects different aspects of a woman’s life as well as her health and in addition to exerting physical and psychological effects, it distorts women’s self-concept. Also, it was revealed that HRT affects POI women’s QOL both positively and negatively. Due to the profound effects of the disease on different biopsychosocial aspects of women, its hidden complications require ample attention on the part of health providers to enhance their QOL through multifaceted health services. The findings of the present study could serve as a stepping stone to the development of a POI women’s QOL questionnaire.Additional file 1.