Most research on multidimensional frailty focuses on deficits and risks of adverse outcomes. However, although some frail older people report a low quality of life (QoL), others still report a relatively high QoL. More knowledge about these discrepancies might give new insight into developing frailty prevention strategies. Therefore, this mixed-method study aimed (a) to identify characteristics related to QoL among frail older people; and (b) to explain discrepancies between higher and lower levels of QoL, with a specific interest in identifying strengths frail older people with a higher QoL still have.n = 16) and lower levels of QoL (n = 18). Frailty was assessed with the Comprehensive Frailty Assessment Instrument, which measures environmental, physical, psychological, and social frailty. Other quantitative measures included socio-demographic characteristics, overall QoL, meaning in life, and mastery. The qualitative part focused on the meaning and maintenance of QoL (among other factors), despite being frail. Possible explanations for discrepancies in QoL were explored.Semi-structured interviews were held with community-dwelling, frail older people with higher  contains supplementary material, which is available to authorized users. Although frailty is often described as merely a physical construct , there iCurrent approaches on frailty seem to be dominated by a “deficit approach.” They mainly focus on things people cannot do any longer and the risks of adverse outcomes , 6, or dAs frail older people still can have a good perceived quality of life (QoL), this might be an important entry for such a strengths-based approach. For example, previous research has shown that nearly 50% of the participants who were frail at least on the physical domain still reported a good to excellent QoL . In anotThe aim of this mixed-methods study was twofold: (1) to identify characteristics of community-dwelling, frail older people with higher and lower levels of QoL, respectively; and (2) to explain discrepancies in self-reported QoL, with a specific interest in identifying strengths that community-dwelling, frail older people with a higher QoL still have. Herewith, the focus was not on investigating associations between frailty and QoL, but on investigating which factors might explain differences in QoL among frail older people, as it seems particularly important to make (strength-based) interventions more tailored in this vulnerable population. While some studies assess multiple domains of QoL, this study focuses on overall QoL, which is defined as ‘an individual’s overall satisfaction with life and general sense of well-being’ , and forhttp://www.d-scope.be), which was conducted between November, 2015 and April, 2016. The D-SCOPE project aims at early detection and prevention of multidimensional frailty to enable ageing in place, focusing on deficits as well as strengths older people have. Participants needed to be 60 years and over, and living in the community. Exclusion criteria were as follows: hospitalization, institutionalization, and not being able to answer simple questions. In total, 121 community-dwelling people aged 60 years and over were recruited. Purposeful sampling was used to oversample community-dwelling older people at risk for frailty .” Regarding their living environment, some participants needed adaptations , or had difficulties walking the stairs. Negative aspects about the home environment were lack of shops in the neighborhood, not having as much contact with neighbors as preferred, new neighbors who were less likely to help, or losing interactions. For example: “The first generation of people to live here were all friends. We’d go to concerts together, we did things with one another. The second generation, they were friendly folks, but they weren’t really friends like before. And now there are a few older people living here, who don’t get around as well as they used to, and who are pretty isolated too, actually. Plus a number of young people, a bunch of foreigners who don’t even say ‘good morning’ when you see them... time was, you wouldn’t dream of not doing that” . Some participants reported (being confronted with) memory problems, while others feared developing cognitive problems. In addition, trouble keeping up in today’s society was mentioned a couple of times in both subgroups.The majority of participants in both subgroups did not identify themselves as frail. However, most reported physical health problems, and difficulties in at least one of the following domains: social relations, psychological functioning, the home environment, and cognition. Some examples of physical problems were loss of strength, mobility problems, and limited vision or hearing. Consequences of limited physical abilities were mentioned as well, such as losing confidence due to previous falls. A male participant (aged > 75) mentioned: A few discrepancies regarding multidimensional frailty between both QoL subgroups were observed. Some participants in the high QoL subgroup mentioned positive stories about their social relations. For example, a male participant (aged > 85) never felt lonely because he always had dinner together with his children. However, in contrast to the high QoL subgroup, participants in the low QoL subgroup mentioned a couple of times that they did not have enough financial resources to be able to perform desired activities.In both QoL subgroups, participants mentioned the following aspects as important for their QoL: activities ; autonomy/independence; sufficient financial resources;  health; optimism; pets; social contacts with their partner, family members, neighbors, and/or friends; and traveling.I have to say, no matter how low you’re feeling, when you do that  and they give you that look... It just makes your whole day, doesn’t it? It’s amazing how that works” . In contrast, in the low QoL subgroup, “unmet needs” were revealed. Participants mentioned feelings of loneliness, insufficient contact with family members, or inability to perform the activities they would like to do. In addition, a female participant (aged > 65) told: “Um, to have a good quality of life and to live with purpose, it’s primarily important to have good health. So you need to be healthy, and to have financial resources as well. You need those, too—because when you can’t afford the things you want...,” while she also said: “That’s something else I find exhausting. I mean, because I’m constantly having to pinch pennies.”By comparing both subgroups, it appeared that only participants in the high QoL subgroup mentioned that having something in prospect and being of value to and/or helping others was important for their QoL. For example: ““If the children weren’t around any longer, I wouldn’t care a thing about living. Not a thing. Then I might as well just come right out and say I want to die, in that case. That’s something that I’m quite satisfied with, something that keeps me busy. Ah, yes, of course. Today I’m going to make soup.”Regarding meaning in life, the following was mentioned to be important in both subgroups: aging in place, family bonds, going out, pets, having social contacts, and being of meaning to others. For example, a male participant (aged > 85) told: When comparing both subgroups, having something to look forward to  was mainly mentioned in the high QoL subgroup. Once again, unmet needs were mentioned in the low QoL subgroup. For example, a female participant (aged > 65) told that her children and grandchildren, who were important to her meaning in life, lived abroad. As a consequence she had not much to look forward to.Participants in both subgroups mentioned acceptance, active problem-solving, expressing emotions/feelings, optimism, religion, seeking distraction  and comparing themselves with those in a worse situation as important factors to deal with problems. Examples of active problem-solving were memory training and remaining physically active despite limitations.“I used to still be able to go for bike rides, now I visit comrades, friends and family”; man, aged > 80), and actively sought social support from friends and family members, which was less pronounced in the low QoL subgroup. In addition, participants with higher levels of QoL tried not to dwell in the past or on things they were no longer able to do. Instead, they focused on positive aspects , or tried to change the situation they were in. Furthermore, they seemed more convincing in how they dealt with problems. For example, a male participant (aged > 80) responded as follows to the question, “And you tried to solve the problem?”: “I didn’t try to – that’s what I did.” In contrast, strategies to deal with problems applied by participants with lower levels of QoL, such as optimism, did not always seem to be effective and long-lasting. For example, a female participant (aged > 80) responded to the question, “What do you think an older person should do in order to preserve their quality of life?” with: “Stay optimistic. Keep being an optimist. ... That gets harder as you go on. Then you ask yourself: ‘What’s left for me?’ I’m pretty much left to my own devices ... Why am I still here?” Additionally, passive reacting was mentioned in the low QoL subgroup, although this did not always seem to be effective. For example, a female participant (aged > 65) told: “And that I’m coming here alone, too. And then the emptiness, the loneliness especially. And then I just watch TV, whatever’s on, and kind of zone out. And then it’s exactly like my brain has been numbed, just a little.” Moreover, she passively waited until her friends called her, even during times when she needed social contact.However, some strategies to deal with problems seemed more prevalent in the high QoL subgroup. For example, participants replaced activities  was emotionally attached to her house because her deceased husband had built everything). No noticeable discrepancies were observed when comparing the high and low QoL subgroup.“I’m happy whenever I see her. Because I see her as—I’d never say, ‘the hired help.’ No, no—I always say ‘my friend.’” Negative aspects about receiving help included being confronted with things they could not do any longer, as well as (the fear of) becoming dependent: “I’d really like to be able to dine out from time to time. But I can’t do that by myself. I always have to have someone else go with me. I went [to a restaurant] once with the carer, but then she has to ask for permission from her, uh, company and also, well, I can’t pay for her meal all the time. So you see, that’s gone too.” . In addition, some participants preferred to arrange things themselves. For instance, a male participant (aged > 80) stated: “We do everything ourselves, because I was sick of it. No, no, no... The children think they can do a better job than we can. No, we can take care of it on our own.” Lastly, some negative experiences with formal care were mentioned, such as feeling treated like a number.The majority of participants in both subgroups received informal care from family members, neighbors, and one participant even from her former son-in-law . Most participants were positive about the help they received. Regarding formal care, participants mentioned the importance of social support , and that it was reassuring to have someone to rely on, more than the actual care they received. A female participant (aged > 80) told: “And when the weather’s fair I can walk to my fence and back 10 times in an afternoon, with my little rolly-car [rollator], and that makes me feel good. Someone’s bound to walk by so you can have a bit of chit chat.” In addition, participants in the high QoL subgroup were more involved in activities offered by welfare organizations, which gave them something to look forward to. Regarding social support, positive stories were mentioned more often in the high QoL subgroup compared to the low QoL subgroup. For example, having social contacts with and feeling supported by others really helped participants, and provided comfort: “Sometimes just getting a hold of someone by phone, or that I just finished talking with somebody and I think, ‘So, I feel worlds better’.” . Although less often, a few participants in the low QoL subgroup explicitly mentioned positive aspects about social contacts as well: “That’s a real comfort to me, getting out of the house and sitting at a table with those guys and drinking coffee and such.” .Some discrepancies appeared between both subgroups. In the high QoL subgroup, more participants used assisting aids compared to the low QoL subgroup, and this actually enabled them to do the things they wanted. For example, a female participant (aged > 85) told: “It feels as though I’m stronger and healthier, like I used to be, because of those children [birth of grandchildren]. Like I won the lottery” . In the low QoL subgroup, changes in living situation were mentioned, which were positive in most cases, sometimes due to a higher comfort level. However, the house of a female participant (aged > 80) burnt down, which caused her to lose tangible memories: “And then the house having burnt down. That’s my lot in life, I can’t do anything to fix that misfortune. Those are all my memories and what have you, and they’re all gone. And yes... I still miss that. That’s over now. It can’t be brought back. No. I fully understand that.” Lastly, a female participant (aged > 75) in the low QoL subgroup recently lost her job due to illness, and as a consequence also lost social contacts.Participants in both subgroups mainly experienced negative life events, such as changes in their  health, losses of people around them, or troubles within their families. For example, a female participant (aged > 85) recently lost her youngest brother, who was like a son to her because she raised him. However, some positive life events were mentioned as well, such as an improvement of health after stopping smoking and the birth of great-grandchildren: No clear discrepancies were observed between the two subgroups.Some participants still had really specific dreams, such as going out for dinner once again, winning the lottery, swimming with dolphins, remaining independent, or going back to their place of birth.What am I still doing here?” , or even feared the future. In response to the question, “Do you think your life might change within a year?” a male participant (aged > 80) replied, “I hope not, but I worry it will. I might get more of the shakes .”When comparing both subgroups, it appeared that wishes regarding the future were more often pronounced in the high QoL subgroup. In contrast, in the low QoL subgroup it was more common that participants did not dare to dream or did not have any expectations, and they said things like: “This mixed-methods study is the first aimed at identifying discrepancies between community-dwelling, frail older people with higher and lower levels of self-reported, overall QoL, focusing on potential strengths frail older people with higher levels of QoL still have. Despite similarities regarding perceived frailty or vulnerabilities according to the qualitative data, the quantitative data showed that people in the high QoL subgroup had lower levels of psychological frailty. In addition, higher age, higher levels of meaning in life (both quantitative data), having things in prospect, being of value/meaning to others, being able to cope with or adapt to difficulties, performing activities, and satisfaction with social network appeared to be factors that can distinguish frail older people with a higher QoL from those with a lower QoL. In addition, in the low QoL subgroup more unmet needs were experienced regarding factors important for QoL and meaning in life.Participants in the high QoL subgroup seemed to have more effective ways of coping with and/or adapting to difficulties. For example, they focused on things they still were able to do, or replaced activities they were no longer able to perform. Indeed, previous research has shown that being able to cope with difficulties was important for life satisfaction in people aged 80 years and over who were assessed during and after rehabilitation . In addiAlthough no clear differences were found in the qualitative interviews regarding the experienced level of frailty, while exploring the other quantitative findings, lower levels of psychological frailty were observed in the high QoL subgroup. Indeed, previous research has shown that feeling down, which is an important aspect of psychological frailty, is associated with lower levels of environmental, social, physical, and psychological QoL . In addiRegarding QoL itself, previous research has already shown that psychological well-being, social contacts, and being able to perform activities are important aspects of QoL in older people . Indeed,An unexpected finding might be that the majority of participants in both subgroups received (in) formal care as previous research has shown that support from informal caregivers enabled frail older people to maintain their well-being . We therThis study has several strengths. First of all, we adopted a mixed-methods design, and with the qualitative part we were able to explore experiences of frail older people more in-depth, taking a lot of different individual perspectives into account. Second, to reduce the risk of bias in personal interpretation, all interviews were coded independently by two researchers with different educational backgrounds, and group analyses were performed independently by two researchers as well. While author AvdV was involved in conducting the interviews and analyzing them in the first stage, author RV was an independent researcher who did not conduct any interviews nor was involved in the research project, to enable the trustworthiness of the findings. Lastly, by providing quotes in the results section, readers are enabled to interpret findings themselves.However, this study has several limitations as well. First, the small sample size might have influenced quantitative findings, as the statistical power was relatively low. Second, only five participants in the low QoL subgroup (≤ 6) scored 5 or lower on QoL, and none below 4, whereas five participants in the high QoL subgroup (≥ 8) scored a 10. Therefore, the contrast between subgroups might be not as large as needed to distinguish substantial differences in people with lower and higher QoL levels. Third, QoL might fluctuate from day to day , which wFrail older people with a higher QoL seem to have better and more effective ways to cope with and/or adapt to difficulties. In addition, they report higher levels of meaning in life, seem to have more things in prospect, are older, have lower levels of psychological frailty, perform more activities, and are more satisfied with their social relationships compared to frail older people with a lower QoL. On the contrary, frail older people with lower levels of QoL report more unmet needs regarding their QoL and meaning in life.While this study aimed to identify individual perspectives and therefore was explorative, by means of a quantitative study approach it will be possible to examine whether for example coping strategies, having something in prospect, and meaning in life actually contribute to QoL in frailty on a larger scale. Hereby, a longitudinal study with repeated measures might be needed as QoL might change over time. Furthermore, future research should explicitly ask whether or not participants feel frail. Previous research has shown that older people who were classified as frail do not always perceive themselves as frail , and “exWhile current clinical practice in frailty mainly focuses on the prevention of negative outcomes, such as delaying functional decline  or insti


According to Antonovsky's  sense of coherence (SOC) model, persons with a high SOC have the ability to benefit from their general defense mechanisms in order to overcome stressful situations. In a health-disease continuum, this leads to the development towards health. However, Antonovsky's global hypothesis that the strength of the SOC may influence the physical health status of a person could not be proven.psychological health. These authors introduced the idea of applying a shortened version of the original 29-item SOC questionnaire, but have not yet developed or tested the shortened questionnaire. Backed by their important findings, it appears to be promising to consider the use of the SOC questionnaire as standardized by Antonovsky, but cleared of the items regarding “predictability”, i.e., Flensborg-Madsen et al. suggested that the items on “predictability” be excluded from the SOC scale when a correlation to physical health is to be investigated. Further investigations in this area of research will be of high impact, not only for health sciences, but also for medical practice.Flensborg-Madsen et al. from Copenhagen were able to provide a new access regarding SOC and health. They investigated the mixture of emotional aspects and mental constructions as a possible cause for fairly low correlation between SOC and physical health. Thus, in an empirical way, they described “emotional coherence” in relation to physical health, while “mental coherence” was linked to


Primary orthostatic tremor is a rare disorder that is still under-diagnosed or misdiagnosed. Motor symptoms are fairly characteristics but the real impact on the patient’s every day life and quality of life is under-estimated. The ”how my patients taught me” format describes the impact on the patients’ every day life with their own words, which is rarely done.A 46 year old lady was diagnosed primary orthostatic tremor (POT) based on the cardinal symptoms: feelings of instability, leg tremor and fear of falling in the standing position, improvement with walking and disappearance while sitting, frequency of Tremor in the 13–18Hz range, normal neurological examination. She gives illustrative examples of her disability in every day life activity . She reports how she felt stigmatized by her “invisible disorder”. As a consequence, she developed anxiety depression and social phobia. All these troubles are unknown or under recognized by doctors and family.We review the clinical signs of POT that may help to increase the awareness of doctors and improve the diagnosis accuracy, based on the motor symptoms and description of the every day life disability, as reported by the patient. Non-motor symptoms  should be better considered in POT as they have a major impact on quality of life. Pharmacological treatments  may be helpful but have a limited effect over the years as the patients experience a worsening of their condition. On the long term follow-up, there are still unmet needs in POT, and new therapeutic avenues may be based on the pathophysiology by modulating the cerebello-thalamo-cortical network.The online version of this article (doi:10.1186/s40734-016-0048-5) contains supplementary material, which is available to authorized users. Feelings of instability and fear of falling are frequent complaints in elderly subjects and have a strong impact on quality of life. Although these features are fairly typical of primary orthostatic tremor (POT) , this raNevertheless, this condition is relatively easy to diagnose when you listen carefully to your patients, as they often report the main clinical features: lower body tremor activated upon standing (with feelings of unsteadiness and decreased time immobile in the upright position) which is improved by walking and absent when sitting or lying down. The unique electrophysiological signature characteristic of primary orthostatic tremor is a 13–18 Hz tremor in the lower limb muscles (and sometimes the trunk) in the standing position .A 46-year-old lady was diagnosed with “primary orthostatic tremor” after 10 years of undiagnosed symptoms: she complained of fatigue, stiffness of the legs, fear of falling and feelings of instability. Her first symptoms occurred when she had to stand still for an unusually long time (she was a singer in an amateur choir). Over time, three general practitioners examined her, and the proposed diagnoses were depression, chronic fatigue syndrome, and functional disorders, for which she was prescribed antidepressant therapy without any beneficial effect. Eventually, based on the description of her clinical symptoms, a neurologist suspected the diagnosis of POT when she mentioned that the symptoms occurred in the standing position. Neurological examination was normal, however, in a prolonged standing position, the neurologist observed fast trembling of the hem of her skirt, revealing her leg and thigh orthostatic tremor. Electrophysiological assessment confirmed the diagnosis of POT (frequency: 17Hz) Gabapentin (up to 300 mg/day) was not well tolerated. Clonazepam (3 mg/day) was prescribed with a partial benefit  and was increased up to 4 mg/day according to the patient’s needs.Although the patient further increased the dose of clonazepam up to 4.5 mg/day (higher doses were not tolerated due to drowsiness), she reported that the duration of standing position without support decreased progressively over the following 5 years, with an important impact on her every day life. Here is the description of everyday life with POT by the patient: “Each morning presented numerous obstacles: I have to sit to take a shower and wash my hair; I could not use the hairdryer standing in front of the mirror and I hastily brush my teeth and put on her makeup; I have to put on my trousers while seated. Cooking breakfast was not without its challenges either: I constantly have to lean on the surroundings while washing the dishes, and I am afraid to use a stool to put away her dishes in a high cupboard. Then, I race to the metro. One particular morning, I felt very uncomfortable standing in a compact crowd and asked a fellow passenger for a seat. The passenger looked very annoyed and muttered “you are not disabled!”, and I felt ashamed. My work environment is also full of uncomfortable moments in which standing is hard to avoid, such as taking the elevator, making copies at the copy machine, and long lines in the cafeteria. I would deliberately avoid friends to skip long conversations in the standing position, which elicited quizzical looks: “maybe she isn’t in a good mood?”, they would think. When I went back to my desk, I felt exhausted although it was only mid-day. In the evening, shopping at the grocery was a nightmare, especially standing in line at the cashier. I would skip chorale rehearsal, as it was too tiring to remain standing. Moreover, my family did not understand why I was so sad, depressed, anxious, and “phobic” about many activities, such as going out, visiting exhibitions, etc. I feel stigmatized by an invisible disease, and I have progressively lost my self-esteem; I had the impression of being misunderstood and that people were not taking my troubles seriously. The diagnosis was a relief. At last, I could explain my troubles in simple words. Eventually, I have joined the patient’s association in order to increase the awareness of people and doctors.What I have learned from this patient and many others is that the impact on daily life is under-estimated, as doctors often do not realize how many activities may become restricted or impossible with POT. As illustrated by this observation, the detailed description of limitations in everyday life activities, with special attention to those while standing, corresponds to the (mainly motor) key diagnosis features –4 of POTAdditional file 1: Video S1. The “hem sign”: fast trembling of the hem of the skirt, revealing legs and thighs orthostatic tremor. (MP4 507 kb)Overall, the recent cases series on large number of patients –4 reportPOT mostly appears as an isolated disorder as up to 85% of the cases never evolved towards another condition , 4. ThosOverall, careful clinical history and clinical examination, may helpneurologists and non neurologists to detect patients with POT, who were misdiagnosed and did not receive adequate treatments and attention.


Purpose: Understanding how transgender people, who committed criminal offenses and are detained in prison, produce a narrative representation of self within different prison contexts. More specifically, this study has been based on two sub-aims: On a paradigmatic level, it has been aimed at critically investigating how the discursive positioning among the Self and the Other might promote the internalization of positive and/or negative attitudes toward the self. On a pragmatic level, it intends to offer some suggestions for goals and strategies of psychological counseling with these inmates inside such highly institutionalized contexts.Method and Materials: In total, 23 in-depth interviews were conducted with transgender women detained in either female or male prison contexts in Italy and Brazil. The lexical, semantic, and semiotic structure of the transcribed interviews has been investigated by adopting the quali-quantitative software Iramuteq for performing statistical text-mining analysis. Frequency, correspondences, and distribution of the most representative utterances across the corpus of data have been accessed and critically analyzed.Results: The findings showed that transgender inmates in Brazil made repeated use of the adverb “not,” while the verb “exist” became the most representative word for the Italian sample. In Brazil, indeed, transgender women assumed masculine-driven behavior due to a common imprisonment with cis-gender men. On the contrary, transgender women in Italy are detained in protected sections, where they are allowed to wear female clothing and continue hormonal treatments. Surprisingly, transgender inmates in Italy suffered more violence in a female sector when compared to exclusively male jails.Conclusions: Transgender people represent a challenge for prison administration because it is not clear in which penitentiary context they should be detained. They should receive special attentions in order to face their special needs, which are radically different when compared to other typologies of inmates. Within penitentiary contexts, psychological counseling with transgender women should pay a special attention to the several psycho-social dimensions of this existential condition. In particular, psychological counselors should consider its inner complex articulation within different social, cultural and normative contexts. Transgenderism refers to people who have a gender identity not fully aligned with the gender assigned at birth  to macro (culture and society), allows on a pragmatic level, moreover, to identify coping strategies to be implemented in healthcare policies and clinical intervention programs, specifically addressed to transgender people in jail. As shown by several studies focused on this topic  transgendered individuals often use contragender-negative reinforcement to conceal their transgender feelings (…) or may exhibit hypermasculine behaviors that serve as a facade to conceal his internal feminine feelings. He may make commitments in his male gender role that are difficult to alter at a later time in his life, when making changes toward a female gender role may appear more desirable Samons, : 143.This quotation clearly shows the way transgender people are imprisoned, rather than in jail, within a sexualized, deterministic ontology, making it very difficult for these people to claim their right to intimate citizenship. The continued references to “male to female” transition, “treatment,” “gender identity disorder,” and above all, the use of terms such as “he” and “male toward female gender roles,” along with improper semantics like “his feminine feelings,” even considered as “more desirable” Samons, : 143, arsystem of meanings and symbols—and the rules, privileges, and punishments pertaining to their use—for power and sexuality: masculinity and femininity, strength and vulnerability, action and passivity, dominance and weakness. One can see in it the outlines of something that links misogyny, homophobia, transphobia, and the restricted way we raise our youth  or for other inmates . Also, mothers with babies up to 6 months receive special attention and are kept apart from the remaining female population. However, only a few prisons in Brazil predispose special sections for homosexual or transgender prisoners. Their detention exclusively depends on the discretional decision of each prison's directors, because no national legislation is available. In the second federal prison of Brasília (PDF II), belonging to the Until today, indeed, it has not been clear how to solve a situation where symbolic constraints do not manage a gender claim, in contrast to the heteronormative hegemony of prisons' organizational logic. Even regarding the Italian context, where special attention to transgender people's detainment has been paid since the 1980s, little has been done  but also between cultures  and races (black and white).Due to the observed lack of studies on transgender people in jail, moreover, this study aims to show that different situations, within the same context, shape different representations of the self, demonstrating that identity is circumscribed by situated practices of interaction and positioning. The wired interrelation among context (prison), situated positioning (everyday interactions in jail), and norms (penitentiary system) has, therefore, been analyzed in order to understand if (trans)gender identities, though being reified by a dominant sexual binary, could be considered in an intersectional perspective, as strictly associated with specific ethnic groups and social classes.Finally, the current research presents the first direct and participant observation of a reality of extreme psychological, sociological, cultural as well as normative relevance and of great topicality, along with the intersectional importance of gender and social policies—that of transgender people detained in different penitentiary contexts—to whom no integrated and unitary workspace has been devoted until today in Italy and Brazil.Drawing on the theoretical basis previously expressed with regard to the on-going development of personal identity and, specifically, on the idea of a narrative construction of personal identity, a quali-quantitative approach of text-mining analysis was adopted. It is noteworthy that different qualitative researches have been already carried out in recent years because they have been proved to be effective in critically analyzing discursively reified patterns of identity such as the gender transition paths investigated in the current research Vitelli, . In totaBrazil: Seven interviews were conducted in the second penitentiary unit of the federal male prison “A Papuda” in Brasília, Brazil. This number corresponds to the entire transgender population that has been detained during the data collection.For a detailed description of each interviewee's information, see Table 2. Italy: A total of 16 interviews were conducted in three Italian prisons:- The male prison “Villa Baldenich” in Belluno, where all four transgender women, detained during data collection, were interviewed. Three were from Brazil and one from Italy.- The male prison “Poggioreale” in Naples, where all seven transgender women, detained during data collection, were interviewed. One was from Brazil, one from Algeria, while all others were from Italy.- The new penitentiary complex of Florence-Sollicciano, where five Brazilian inmates out of 18, detained at that moment in a separate section of the prison's female ward, were interviewed.For a detailed description of each interviewee's information, see Table This study was carried out in accordance with the recommendations of 'name of guidelines, name of committee' with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. In particular, all participants took part voluntarily in the present study, and informed consent forms explaining the detailed goals of the research were distributed to all subjects before being interviewed. Sampling, methods, and analytical procedures were in full compliance with the ethical guidelines established by the National Board of Italian Psychologists ] and hosts a total of nearly 6,500 inmates  was instituted in 1933 and is classified as a low-access male prison (“carcere a bassa soglia”). The overall number of inmates, indeed, was just 93 people during data collection, out of whom four have been identified as transgender women and have, therefore, been detained in a separate wing of the institution . All interviews were conducted inside a multi-purpose room of the transgender wing, normally used for lessons and other leisure activities, with a few desks and chairs, and a series of posters and geographical maps all along the partitions. The language used for the interviews was mainly Italian, though those conducted with the Brazilian inmates (three out of four) contained various Lusophonic inflections.This enormous prison complex in southern Italy is one of the most ancient (instituted in 1905) and largest  in the whole country. As underlined by the Committee on Civil Liberties, Justice and Home Affairs of the European Parliament (2014), this penitentiary context is a very complex institution. Today, it counts more than 2,000 inmates, distributed in eight sub-wings. The number of transgender people at the moment of data collection (July–September 2016) was seven, and all are detained in a protected section of the “Torino” sub-wing. The prison is located in a central, densely inhabited region of Naples, quite near the train station. As in Belluno, also in the parthenopaeus jail, all transgender inmates have individual cells with their own bathroom. Transgender women are usually allowed to freely circulate inside their section, without closing the doors of their cells. Like in Villa Baldenich, as in Poggioreale, they are allowed to wear female clothes, use make-up, and continue with their hormonal treatments.The interviews were all conducted in the multi-purpose room of this small section. The room was quite empty with a few chairs and some equipment for fitness activities.The third Italian penitentiary complex is the prison  of Florence-Sollicciano . The NCP is situated in a recently constructed, densely populated suburb on the western hills of Tuscany's capital. Completed in 1982, according to a national reform of penitentiary legislation (Law 663), its architecture was inspired by the coat of arms  of Florence, as an explicit symbolic reference to the historical and cultural context, and moreover, to the institutional power. NCP's overall structure consists of a male and female wing, each one divided in several sub-wards and sections. During the data collection between February and April 2012, 1,021 inmates were detained in the institution, though the regular capacity was conceived for only 447 prisoners , but recently it was moved to the female section.generalized or the significant other.As the corpus of data consists of the transcriptions of 23 in-depth, audiotaped interviews, a quali-quantitative analysis of the implicit and explicit contents, respectively, was performed throughout the methodological lens of a socio-cognitive approach devoted to a critical understanding of the production of discursive processes  along with specific rhetorical strategies, have been considered for demonstrating how such connections could be responsible for the (re)production of stereotypes, prejudices, ideological orientations, etc. Different studies focused on the narratives of transgender people, already used computer-assisted programs for performing text-mining analysis, in order to bring forth statistically significant correlations between some occurrences and specific lexical classes  of lexical classes Reinert, A word cloud analysis (WCA) of lexical frequency and distribution  across the overall corpus of data and across specific lexical (stable) classes, individuated by the program ex-ante according the intertextual affinities of certain vocabularies, which are associated with an integrated dictionary . This method reduces single textual segments into specific morphological key-terms, classified by the programs either regarding its relevance or its frequency.The WCA, in addition, aggregates the occurrences regarding specific lexical means by visualizing them graphically according to their frequency and intertextual relevance. It consists of a basic lexicographic analysis, while offering a well-structured output, particularly useful for the critical understanding of statistical procedures applied to qualitative, textual data.The size of the two corpuses of data, N1  and N2 (7 Brazilian interviews), respectively, was determined by the sum of all absolute frequencies (occurrences) that constituted the lexical database. Regarding the pre-processed lexical corpus, the overall size counted 68,424 occurrences. From this pre-processed textual repertoire, all irrelevant lexical expressions were previously removed. Specifically, the following occurrences were not considered for the analytical procedures: demonstrative, indefinite, possessive, and additional adjectives; adverbs; articles; digits; conjunctions; onomatopoeia; pronouns; prepositions.The set of different occurrences (forms) defined the vocabulary contained in the corpus of the transcribed interviews. The number of identified forms V was 2,222 for the Brazilian (Portuguese language) sample and 5,136 for the Italian  one, which was calculated by summing the number of different forms in the lexical corpus:The lexical extension has been determined by type-token ratio (TTR) as a percentage ratio between the vocabulary size (V) and the size of the corpus (N). Such procedures show the lexical richness of the textual repertoire. The computed value for the analyzed text was 84.47% for the Italian data and 78.50 for the Brazilian one.The hapax referred to those occurrences that appeared only once in the corpus; the percentage of hapax in the overall textual repertoire was 19.94 for the Italian sample and 20.88 for the Brazilian one.The frequency class consisted of a set of words that showed the same number of occurrences throughout the overall corpus. For calculating the frequency classes, all words must be sorted according the number of occurrences in descending order. The most frequent word is associated with rank “one.” Moreover, the keywords refer to uncommon terms that appear with higher frequency across the overall corpus.The algorithm that underlies the lexicometric analysis is based on a series of bi-partitions, due to a correspondence analysis conducted on a binary table (absence/presence) that crossed the textual units. Each bi-partition was carried out in three steps:- A correspondence factor analysis (CFA) was conducted on the table. For all possible partitions along the first factor of the CFA, the inter-class inertia was calculated. An initial cutoff was performed on the partition for maximizing the inter-class inertia.- Each unit of the table was initially switched from one class to another, and the inter-class inertia was recalculated afterwards. Whether the calculated values resulted in being higher than the previous inter-class inertia, the permutation has been retained. This part of the algorithm looped back around, until no permutation increased the inter-class inertia.The principal aim of the algorithm was isolating those lexical forms that maximized inter-class inertia. In this context, the coordinates of lexical units on the first two axes were reported in relation to the percentage of cumulative variance explained by the mean of all four factors, namely 66.93 for the Italian sample and 68.68 for the Brazilian one.The results section has been split into three subparagraphs, each one concerning one of the different analytical procedures that were performed.In the first paragraph the findings of the HDC will be presented, while in the second one, the results of the WCA will be shown. Finally, a total of four significant extracts (one for each institute) were selected out of the interviews, to show how the two main key-terms (not and exist)—which emerged from the lexicographic analysis—appear within talk-in-interactions .The most frequent occurrences contained in class one are: “persona – person,” “vita – life,” “essere – to be (exist),” “amico – friend,” “rapport – relationship,” “compagno–boyfriend,” “accettare – accept,” and “vicino – close.” Such words allude to an intimate and private representation of the self by emphasizing the primary status of a subjective personality, rather than that of a prisoner and/or a transgender, generally assigned by the common sense of a heteronormative-based, middle-class community. The desire to be considered and treated as a human being, and not just as an abnormal criminal, shows how transgender people must fight daily for their right to be recognized and for social inclusion. The affective value of interaction, instead, links to the most individual dimensions of one's existence, and surely, the most authentic representation of oneself and significant others. As class one is the most representative of the whole Italian sample, the words contained in this class certainly dominate the overall discursive structure. This shows that emotions, relations, and effects become the cardinal coordinates, circumscribing a person's central representation of oneself, consistently with the findings of former studies focused on this issue , what becomes one of the most crucial aspects of a transgender person's existence regards all treatments that are carried out to complete the sexual transition. Such treatments consist, indeed, in all those daily routines that a transgender woman must do for the continuity of her gender claiming, as clearly shown by words like “hospital,” “ intervention,” “physician,” and the estrogenic integrator “diane.” The substantive “cigarette,” finally, becomes an object of pleasure on one hand for attenuating the extreme stress factors of detention, while on the other, it is a pastime that prevents the idleness of prison life. In addition, a cigarette, such as other drugs, becomes an interactive and negotiation medium, often useful for empowering positive attachment styles with the other inmates. In general, drugs often become part of the living experiences of transgender people who have to face a transition between and across the gender antipodes, especially of those who belong to poor socio-economic classes, such as Black people  but also between countries , because out of 16 transwomen interviewed in the Italian jails, nine were from Brazil and migrated to Italy, where some of them lived without a proper visa – “permesso di soggiorno.” Other words contained in this class, are “strada – street,” referring to street working activities  and ages, like “diciasette – seventeen,” and “quattordici – fourteen,” which indicate the moment of becoming conscious about their own gender identity. Interesting is the use of the Portuguese inflection “não – no”, which is be the second most frequent occurrence inside this class. The “no,” indeed, becomes a global negation of oneself in many aspects of their lives.Class 4, instead, contains mostly terms focused on their (trans)gender identity and sexual orientation, like the nouns “gay”, “uomo – man”, “donna – woman”, “trans”, “transessuale – transsexual”, the adjectives “femminile – feminine” and “maschile – masculine,” and the verbs “diventare – to become” and “effeminare – to feminize.” The words actually demonstrate the difficult challenge transgender people have to face when they try to claim their identity and sexual choices. The correlation between “gay” and “trans,” indeed, shows how common sense already associates gender identity with sexual orientation, consequently classifying transgender women as homosexual, cis-gender men.The class with the lowest percentage is class 3, containing lexical forms linked to the daily practices in prison and to their general juridical situation. The most frequent words, indeed, are the nouns “avvocato – lawyer,” “instituto – institute,” “reato – crime,” “domiciliare – house arrest,” and “arrestare – to be arrested” and the names of important penitentiary institutions in Italy, like “San Vittore” in Milan or “Poggioreale” in Naples, where many transgender people have been detained before being transferred to other jails. Surprisingly, this last class, though containing words that are directly linked to the prison context where the all interviewed people must spend considerable time, results in being the least significant one. Such an apparent contradiction is due to the situational frame of a prison, which becomes for inmates an everyday context—where to interact and live. As shown in previous studies , contains words linked to daily habits before being arrested. This class mainly contains lexemes, referring to the conditions that contributed to committing the crime. Examples of such occurrences, are the nouns “Mato Grosso ” and “carro – car”, which refer to the way inmate 6 was arrested, namely the alteration of the car's registration number in this region. Accordingly, other terms contained in this class are “cadeia – jail,” “juiz – sentence,” and “audiência – judicial hearing,” which certainly refer to the antecedents, promoting their experience of detention.Class 1 (20.2%) is the class containing those lexemes that refer to the contextual elements of the prison where the interviewed people are experiencing their period of detention. The most frequent terms, indeed, are “ala – wing,” “espaço – space,” and “cela – cell,” confirming that the restriction of one's physical agency has a considerable impact on their own representation of themselves, as also shown by previous studies born” as a woman.Occurrences contained in class 2, finally, allude to their desire (“desejado”) to be recognized as a woman and human being. Such words, indeed, are the noun “mulher – woman”, the verbs “gosto” and “gostar – I like, to like”, “igual – equal”, and “felicidade – happiness” in order to “sentir bem – feel fine”.The graphical output of this lexicometric procedure is based on a simplified factor analysis, according the most relevant occurrences across the overall corpus of data. Contrary to the HDC, based on an inter-class inertia, this kind of analysis brings forth the centrality of certain key terms. In the case of the current study, such words are “essere – to be/to exist” for the Italian sample and “não – no/not” for the Brazilian one.The central term of the Italian sample consists of the word “exists,” showing the relevance of such a semantic (and semiotic) construct of one's representation of self  spent in jail, a representation of their selves as a human being. They The central concept of the Italian sample, accordingly, alludes to a perception of oneself linked to subjectivity and, consequently, agency.Something quite different emerged from the Brazilian sample. The occurrence appearing most frequently across the overall corpus of data is the word “não – not/no”  on one hand nor as men (“homem”). Furthermore, they are even excluded from the LGB universe, because they do not match with social representations linked to homosexuals . These last ones, though suffering several forms of symbolic and physical violence within the heteronormative domain, are more likely associated with culturally legitimated and historically anchored categories of social means, i.e., gay and lesbian people. Transgender women in the Brazilian prison, consequently, seem to denounce a multiple exclusion; they are banned in society as criminals, banned in culture as queers (“viado”), and banned in the LGB community as transgender. Such individuals, therefore, feel as if they are something different, which the generalized other does not even consider as people (“gente”). Finally, they have no voice in public life “não falar”  and, consequently they have no perspectives (“querer – to desire/wish”) for their private (“família”) or professional  life.talk-in-interaction  associated with the lexicometric procedures of the Iramuteq software within small portions of textual content, how the two main key terms of the WCA (“não” and “essere”) interact within so-called contexts of situated The first extract, is from the interview with one Brazilian inmate out of the four inmates , detained during data collection in the aforementioned prison. This talk-in-interaction refers to the description about her self-representation as a gendered agent.Extract 1essere molto bene. So quello che sono, so quello che voglio.Io vivo il mio I'm feeling fine with my way ofbeing. I know who Iam, I know what I want.In line with the results of the WCA, the representation of self across the Italian sample has been linked to the central concept “essere – to be.” The perception of self, accordingly, in this small and familiar prison context in the Dolomite Alps, is mostly positive. Like in the current extract, all inmates detained in this jail claim a egosintonic representation of their gender identity, which is not felt as something socially banned, but rather as an authentic expression of one's own way of being, thinking, feeling, and interacting. The interlocutor actually knows about her inner and deep aspirations concerning her life choices. Her transgender being, accordingly, shows a positive attachment style, either with herself, or with the significant and generalized other.The following extract is taken from an interview with one Brazilian inmate, out of a total of 18  inmates, detained during data collection in this prison. As in the previous case, the following extracts regard her representation of the self as a gendered agent.Extract 2essere me.Io non volevo assolutamente I didn't absolutely want tobemyself.This short talk-in-interaction shows an opposed representation when compared to the former extract. The interlocutor, indeed, declared not feeling comfortable with her identity as a transgender woman. This denial of oneself, certainly, became a redline of nearly all transgender inmates interviewed in the prison of Florence. Within this particular jail, transgender women are detained in a special section inside the female wing of the prison. Contrary to the initial hypothesis, which pretended to empower transpeople's agency in claiming a female-driven representation of the self within a feminine context, these inmates suffered more violence inside this section, if compared to those transgender women who are detained in special sections inside ordinary male prisons. As shown by previous studies , detained during data collection in this prison. The following talk-in-interaction, refers to the description about her self-representation as a gendered agent.Extract 3sono completamente donna; offende pure il mio essere donna.Ma non è corretto che io possa fare la doccia (…) con le donne, perché non It would not be correct, however, to take a shower together with women, because Iamnot completely a woman; this even violates my ownbeinga woman.Such an apparent contradiction also emerged in recent studies about transgender women detained in prison . In different situations, we must behave ourselves in a manner, which doesnotmake me feel fine; even during daily small-talk, the other (masculine) inmates donotlike us. I cannotstay in the way I like to be, making the others believe that I am a perverse person or something similar.The adverb “não” within this short extract has been repeated four times, underlining the continuous struggle among one's right to undo gender in prison and the duty to adapt oneself to the constraints of a strongly hetero-normalized context. As the interlocutor, and all other transgender inmates of the Papuda prison stressed, being a transgender person in jail becomes a hidden and even clandestine condition. Neither the other inmates nor the surveilling agents, indeed, have any idea about what it means to face a transition among gender identities. Consequently, to avoid violence, excessive discrimination, and transphobia, these inmates must behave themselves as much as possible, in line with an inter- and extra-personal representation of a hetero-normalized masculinity. As underlined by Amodeo et al. , such neRefusal of oneself, by adopting an etio-pathogenetic explanation: “I am wrong.”Representation of oneself as a cis-gender gay man: “My sexuality is different, but my sex is right.”In the current study the discursive processes of transgender people detained in Italian and Brazilian have been critically analyzed. The main goal of the study, accordingly, was to show how a (trans)gendered identity depends on the intersection among different social, cultural, relational, and normative dimensions. From the analysis, indeed, two main discursive positions emerged:- A negation of self for the Brazilian sample, expressed through the Portuguese occurrence of “não.”- An affirmation of self for the Italian sample, expressed through the Italian occurrence of “essere.”The situation observed in Brazil, actually, reflects the general condition of detainment of transgender people in other countries, especially the USA Samons, , where sBy comparing different practices of detainment  in two different countries, it was possible to shed light on how the identity of a person changes either according the situation of a certain context or according to wider systems of symbolic means and normative power.In particular, Brazilian transgender people in Italian prisons show a more authentic and egosintonic representation of their gendered self, while those detained in Brazilian jails, though the cultural origin and the skin color (black) is the same, often negate their feeling as a transwoman, and instead, represent themselves as cis-gender, homosexual men. Something similar has also been observed in many US prisons Sultan, , confirmAs most Brazilian transgender people, mainly those detained in the prisons of Belluno and Florence, migrated to Italy  to improve their own living conditions, their ambition of self-realization was, therefore, much higher than those incarcerated in the Papuda prison.Generally, the situation in the Brazilian prison is much more dramatic and precarious when compared to the Italian institutions. In Italian prisons, although transgender inmates are detained in protected sectors, apart from the common, mostly male and heteronormative prison population, the incarceration process itself is quite different. In Italy, indeed, several reforms, above all from the 1980s onwards  results in twice the regular capacity of the institutions .- Self-harm and suicide are common aspects in nearly all jails of both countries.Finally, also regarding the specific detainment condition of transwomen, some recurrences could be found out for both countries:- Most transgender prisoners, not only in Brazil, but also in the whole Italian penitentiary system, are from South America; in the specific case of the current study, out of 16 interviewed inmates, nine were from Brazil, one from Algeria, and only six were from Italy .- All Brazilian transgender inmates, as most of the general prison population (see above), in both countries are black.- Nearly all transwomen of both countries referred to rejection and refusal of their gender choice in their family context.- All transwomen in both countries had sex-work experiences.- All transwomen in both countries suffered extreme psychological, social as well as physical violence.- The most common crimes committed by transwomen in both countries are drug-dealing and sex-work exploitation.The situation observed in both countries, accordingly, showed the emergence of two different ways to face the detention of transgender people in prison. In Italy, where since 1980 special attention has been paid to the incarceration of transpeople, such inmates live their detention in a more harmonious manner compared with the Brazilian sample.Furthermore, as mentioned by some Brazilian prisoners, a last variable problematizes even more their life in jail: being black. The skin color in those countries, which has an economic system based on the exploitation of black people exported from Africa (slavery), such as Brazil or the USA, nowadays is a delicate, struggling, and complex challenge to be faced. The social and cultural discrimination of black people in the USA and in Brazil (among other countries worldwide), causes a vicious cycle among exclusion and denial, promoting a ghettoization of black people within social, cultural, and economic poverty. Such a condition, as has been shown by various studies conducted in both countries  In Italy there are different practices of detention for transgender inmates: separated sectors in small male prisons—so-called “low threshold jails (“carceri a bassa soglia”)”—like the prison of Belluno; separated sectors in huge male penitentiary complexes, like in Naples; and finally, separated sectors in female prison contexts, such as in Florence.Because in Brazil, transgender inmates are co-located in common jails with cis-gender heterosexual men, it was not necessary to compare different institutions with different forms of detention, such as in the Italian jails. (2) In Brazil, transgender inmates are classified as men; therefore, it is quite difficult to get an approximate overview of how many transwomen are incarcerated and in which institutions they are detained. In Brazil, there is also a complete lack of scientific literature that focuses on this reality. To the best of our knowledge, no study, before the current one, has ever been published about transgender women in Brazilian jails.Another limitation regards the choice of the investigation instrument. As the main goal of the current study consisted of a lexicometric analysis of the textual data (the interviews with the transgender inmates), this survey has principally focused on the discursive dimension of interaction on a syntactic and semantic level. The limitation of a quali-quantitative investigation tool, indeed, does not allow a deeper analysis on a semiotic, symbolic level. Future research should, therefore, conduct a critical analysis of the discursive processes for catching the implicit means “between the lines.”Finally, due to the intercultural, comparative aims of the present survey, the two national specific samples were interviewed by using two different languages: Italian and Portuguese. The overall textual material, therefore, was split into two archieves, which must be processed separately in the Iramuteq software. Such a methodological limit allowed for only the interdiscursivity, but not the intradiscursivity to emerge, from the overall corpus of textual data.The current study highlighted the discursive processes, which underlie the narrative construction of self of transgender women detained in Italian and Brazilian jails. This survey is the first interdisciplinary and international research project about the incarceration of transgender inmates in both countries. What principally emerged out of the findings was a radically different discursive positioning between the two national samples. While the world cloud analysis for the Italian data showed that the most frequent occurrence was the verb “essere – to be/exist,” the Brazilian data showed the adverb “não – no/not” to represent the most significant term within the discursive production of the inmates in the Papuda prison. There are two main reasons for such a discrepancy in the discursive representation of self: transpeople in Italian jails are classified as such; therefore, it is possible to get an overview of how many transgender inmates exist in the Italian penitentiary system. Furthermore, transwomen in Italian jails are detained in protected sectors, and prison workers receive a special training to interact appropriately with these inmates. Transgender people in Italian jails, accordingly, are visible; indeed, they exist (“essere”). However, in Brazil, transwomen are detained together with cis-gender heterosexual men and, moreover, they are not recognized for their own authentic gender claim, but, instead, they are classified as men. Their identity in prison is, therefore, negated; their self becomes invisible and, consequently, they do not (“não”) exist.Transgender people represent a complex challenge for prison administration, because it is not clear in which penitentiary context they might receive more recognition. Certainly, transgender women should not be detained in ordinary sections together with cis-gender men, like in Brazil, and feel free in (un)doing gender in jail, such as in Italy.Finally, transgender people in prison should receive special attentions in order to face their special needs, which are radically different, whether compared to other typologies of inmates. Until adequate, multi-professional support to raise collective and individual awareness, either inside or outside the prison-walls, of the complex condition of transgender inmates is implemented throughout the healthcare system and clinical policies, neither effective nor enduring benefits could be expected from intervention programs to prevent (trans)gender based violence in jail. Especially within penitentiary contexts, psychological counseling with transgender women should pay a special attention to the several psycho-social dimensions of such a harsh and extreme existential condition. Such a paradigmatic and at the same time pragmatic view made emerge its inner complex articulation within different social, cultural and normative contexts.The all authors AH, VF, PV, and RV contributed to the drafting phases of substantial contributions to the conception or design of the work and interpretation of data for the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All data were personally collected and transcribed verbatim by AH in both countries; only in the prison of Naples the interviews were conducted together with an Italian transgender activist, who also transcribed them verbatim.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.


Hospital usage and service demand during an Infectious Disease (ID) outbreak can tax the health system in different ways. Herein we conceptualize hospital surge elements, and lessons learnt from such events, to help build appropriately matched responses to future ID surge threats.n = 35) were conducted with governance and public health specialists; hospital based staff; and General Practitioners. Key policy literature in tandem with the interview data were used to iteratively generate a Hospital ID Surge framework. We anchored our narrative account within this framework, which is used to structure our analysis.We used the Interpretive Descriptive qualitative approach. Interviews  and capability (for treatment complexity) demands were identified. Starting with the Lack of a shared definition and decision making of surge threats had rendered the procedures somewhat duplicative. This burden was paradoxically exacerbated by a health system that highly prizes planning and forward thinking, but worked largely in silo until an ID crisis hit. Many such lessons can be put into play to further strengthen our current hospital governance and adapted to more diverse settings. Increase in trade and travel, as well as ecological and climate changes have made pockets of the world more vulnerable to health system surges caused by Infectious Disease  (ID). SiSince the aftermath of SARS (2003), the first major pandemic of 21st century, it is anticipated that many countries still do not have adequate advance emergency planning to deal with outbreaks, including threats of H5N1, H1N1 influenza –8. Some We have undertaken a qualitative study using the Interpretive Description (IntD) approach –12, baseIdentify the basic conceptual elements of hospital ID surges, combining constructs from the literature –15, 17 wDescribe a typology of ID hospital surge threat scenarios primarily in relation to virulent air/droplet borne diseases - contrasting with vector borne scenarios - and link this to levels of alert for hospital planning and response;Collate lessons learnt from past air/droplet borne ID outbreaks and catalogue these into incident management strategies related to: staffing, space, supplies (or ‘stuff’ sic)  and systTherefore, we aim to produce an evidenced-based set of tools to improve incident management systems informed by narrating accounts of ID outbreaks in Singapore from 1999 onwards (since the Nipah outbreak) . Our objBasic elements of hospital surge events were extracted from literature captured in a systematic review on this topic , 15. Then = 35), conducting interviews with largely tertiary and policy sector health care professionals, as well as primary care physicians, Table We used a multiple stakeholder qualitative design . These included both air and droplet borne, and vector borne diseases.Related topics structuring the reminder of the interview included: current state of resources; historical opportunities for improvements; decision-making processes. The topic guide was piloted and revisions incorporated, see Supplementary file for a copy of this tool. Given we followed the Interpretive Descriptive theoretical approach, we prompted narrative with very open questions to start but also helped to co-construct the focus of the discussion, anchoring it towards the elements of hospital surging known to be of interest.n = 5), Board Members (n = 4), Clinicians (n = 8), Nurses (n = 7), Operations Managers (n = 3), and General Practitioners . TTSH is the major ID hospital in Singapore, thus 53% of interviews were carried out with participants based at this hospital.Sampling was purposive, seeking maximum variation of healthcare professionals with significant experience managing ID surges; emphasis was on recruiting reputed specialists in the ID field to start with. Most re-structured hospital representatives gave permission for their staff to be approached; Singapore General Hospital (SGH) refused to participate. This included clinical staff working in the Infectious disease, Emergency Medicine and Microbiology department from regional institutions . Participants comprised Public Health Specialists . We found the concept and understanding of a Hospital Nipah virus in 1999. However, for this outbreak it emerged that its impact wasn’t felt much due to the small number of cases, non-complexity of treatment, and early containment  because. I remember that the peak period of H1N1 we were screening about 600 cases every day. Yah, so the surge was the challenge then… It was the turnaround time for the screening results to be out. So that took about between 6 to 12 hours. And imagine having a few hundred people in front of you for 6 to 12 hours and they getting fidgety and some of them were called from airport and brought here, yah’ - N1.During the Dengue  outbreaks were described as having the lowest impact. Some GPs reported extra loads, but generally hospital staff said they system was able to cope well, since this flow of patients tended to be expected and not much over the norm, for instance: ‘Actually, I didn't feel that much, you know, day in day out we just work. Of course, there are a number of dengue patients coming in… I don't feel stress because of the dengue patients’- N2.Despite this extreme patient load, the H1N1 surge was described in far less dramatic terms compared to SARS. Some of the clinicians mentioned that the containment policy for H1N1 initially was an overreaction and other nations had a better response to surge by not initiating mass screening policies. Correspondingly, Chikungunya outbreak (2008) was described in comparable terms, also a vector borne disease, for which the transmission tended to be slower due to prevention at source. These IDs were related by our respondents to seasonal flu: which is easily transmittable in theory yet in practice does not cause volumes of cases because of early preventative measures, vaccines and self-containment. Plus, these IDs were described as easily managed once diagnosed: ‘Dengue, you know, and because of during the flu season when we have more cases of pneumonia, respiratory diseases coming in. So that I think we experience it regularly.’ - OM3. We observed a system highly adapted to capacity threats.The The types of functional vs. threat ID surge scenarios in our context are summarised in Fig. ‘Hospital bed occupancy rates are usually in the red zone, somewhere around 85-95% on a daily basis, so very little capacity’- C7.Our participants talked about ‘Peacetime scenario’ Fig.  which waEveryday fluctuations, or endemic diseases, we don’t actually consider it as a surge’ – C3. Therefore, the Singapore system has become highly resilient in terms of adapting to lack of space and crowding. As long as hospital demand spikes were related to well-known IDs and prevented from exploding at source, they were viewed as manageable.It was interesting that Endemic or seasonal scenarios Fig.  like Den‘The number of patients coming to the hospital forms this space, alright [holds hands wide apart]. The number of patients that really are at risk is this big [shows a smaller space]. And then it goes up, it goes up, and finally there at the top are the patients that are infected [shows very small space]’ – BM4. The size of the Pyramid tiers was seen to also inform the decision to refer for screening in the first place, and contact tracing policies, which can themselves be either overblown or not stringent enough.Threats were experienced when the ID need for screening spread beyond adapted, resilient capacity. The H1N1 outbreak was described thus. This outbreak takes the shape of a Pyramid crowding scenario Fig. , shrinkiIt is not business as usual. [although] In fact, during SARS, the hospital is actually quite empty’ - BM4. Despite little crowding it was this service surge demand that caused the most fear, disruption, casualties and confusion in our setting.Most mentions of capability came from narratives on SARS, which can be described as a Fig.  Reverse-‘What happens if you exceed that [past predicted capacity and capability], and I think that is Spanish Flu revisited type of scenario, which is classically a Black scenario, which everybody knows if it happens, you know, life ends as it extends.’ - BM3. Spanish flu (1918) , with a very considered view ofwhat exactly is a threat[emphasis our own]; so, when I was overseeing the initial Ebola requirements for the hospitals, there were a lot of barriers that were primarily driven by conventional [and implicitly inaccurate] definitions [of threats].’ - BM3.Yet there is no alert system, providing definitions of surge threats for hospitals, their staff and governors. Another senior participant described this gap thus: The current alert system used in Singapore is called: ‘Disease Outbreak Response System Condition’ ‘DORSCON’ , which iMapping lessons learnt to surge threats to improve coordination.Staffing: Manpower management and willingness to work;Space: Institutional roles and national level policy;Supplies: Equipment and stockpiling;Systems: Financing for innovation, communication, monitoring and surveillance, as well as logistics and operations.The lessons learnt are anchored onto the recognised incident management domains. In this set of analyses, we elaborate the sub-categories for each of these areas, as listed in Fig. In Fig. Staffing is a challenge during any surge threat, since both sufficient and adequately trained staffs need to be mobilised. After SARS, ID physicians in Singapore tripled in numbers  we are not needed any additional medical manpower. It is only the nursing manpower… So, we just have to supplement whatever we need if there is any infectious disease outbreak basically’ - OM3. numbers  but stilOn the other hand, (S2) specialist clinical staff were see as needing redeploying the advent of a Reverse-Pyramid or Black scenario. Senior participants mentioned that during ID outbreaks they can seek to recruit staff from other hospitals, less specialized in ID hospitals or redeploy nurses within the same hospital to supplement a Pyramid load. But this came with problems, given that it took some time to settle in staff into a new environment and/or role and for them to become efficient. Thus, (S3) drilling all existing staff in Infection Control policies before bringing in extra support was seen as important; this included setting up leadership roles and accountable training leads to coach new recruits effectively was one way to improve capability.We did have a meeting and many people volunteered, PhD people volunteered…but we decided not to go with that and just employ our own people and use our own people.’ - M1. But the consensus was that the people with the right CVs for the post were needed, and it was better to build up a contacts list for these, or redeploy within, than stretch people’s capability.Similarly, thinking ahead about recruitment during peacetime was important. For example, it was suggested that (S4) CVs of short-listed clinical, nursing and lab applicants should be kept after recruitment drives, with permission, so that these candidates can be called on during surge events. There was discussion of using volunteers: ‘willingness to work, and to work well, of healthcare professionals during these turbulent times. Related strategies are particularly important when facing virulent and deadly pathogens such as SARS or Ebola. Good leadership, (S5) motivating by example, was perceived to the most important factor keeping staff turning up and doing their best. During SARS the leaders volunteered to do the risky procedures and praised their staff to the media  Singapore, you know, infectious diseases is not our number one disease burden, so a lot of way our infrastructure is structured might not actually cater for that [ID outbreak].’ - OM3. Space has always been an issue in ID surge events where isolation measures pose an additional burden on the existing space crunch. Currently in Singapore there are few isolation rooms in the hospitals built before SARS and hence patients already exposed to each other (family) were cohorted in the same isolation room by partition. It was explained that it is part of the Institutional role to back the initiatives that (S10) counter this outdated historical legacy.cannot plan…you cannot build a white elephant’, just on the off chance of it being needed. It has also been acknowledged that maybe it is not really needed, since alongside an ID surge there is a reduction in electives that free up bed capacity, also: ‘Of course if it is a ID surge, the general public will avoid us. So, then there will possibly be more room to reallocate our spaces and all that’ - C5. Nevertheless, (S11) facing the ‘white elephant’ appeared to be underway, and staggered to make it manageable.One solution has been to plan a new ID Centre, the National Centre for Infectious Disease (NCID), planned to be in operation by 2018 . This buNational policy level initiatives to (S12) improve these set-ups include scouting better locations, as well as structures with capacity for greater distancing of patients, temporary ventilation systems and basic amenities.For example, senior administrators and clinicians discussed lobbying for more single occupancy isolation rooms, Microbiologists for enough space for their large equipment to process screening, and state-of-the-art equipment. In the meantime, the system has adapted by using temporary structures, such as setting up laboratories in general Intensive Care Unit (ICU) rooms (Ebola preparations). Alternate Treatment Sites (ATS) were built by hospitals as an emergency tented areas during H1N1. Such spaces are necessary to planning in a space constrained setting. Because if you get admitted, you goes under Medisave, you know so if you get a full blood count every day, cost 30 dollars a day, and you know you get your….whatever, 40 bucks a day, times five days you know pay by Medisave. But if you went to a GP, charged you 40 bucks a day, you will pay out of your pocket’ - PH01.Another solution to minimize congestion is to (S13) restructure insurance plans and primary care capacity to address overuse of hospitals for ID, instead moving screening and basic treatments to primary care clinics. In the long run this will create more hospital capacity without having to build it. It is a phenomenon particular to Singapore Health insurance Medisave policy , that itSo from a ward that is 30-35 bedder, suddenly you are dealing with ward with seven beds. Because there were only seven cubicles [and only one bed can be occupied in it at a time] and same number of staff.’- BM2.Another national level policy concern relates to much toing and froing on whether to have a designated hospital to house all patients during a nationwide outbreak or whether each hospital ‘keeps’ its own patients without referring them onwards. This question is not easy to address. During SARS one hospital - Tan Tock Seng Hospital (TTSH) - was designated. From a capability perspective, it appears more efficient to centre the bulk of resources in one place; yet we were reminded by our participants that this comes with risks (contagion during transportation and transfer), and requires planning of transport and investment in logistics. It is nevertheless underway (S14) that a state-of-the-art ID hospital is being built. Largely, it appears, to be able to deal with a Reverse-Pyramid hospital surge scenario. This new facility should particularly cater adequate isolation wards, unlike wards during SARS: ‘It was notable however that: ‘Making an acute hospital another pandemic hospital was not a viable idea... because as you know by now most of Singapore’s hospitals function at close to maximum capacity… And shutting down a hospital has tremendous inextricable impacts on the healthcare system’ - C4. A huge Pyramid or Black scenario surge would require reserve (S15) ‘sister’ hospitals and centres to manage overspill. Some participants mentioned that collaboration with private hospitals could be helpful, and something that was not yet leveraged. Under-utilized primary care centres and smaller public sister tertiary centres can be set up to function as a centralised hub during a mass outbreak. During H1N1 overspills were naturally managed with sister-like facilities, adopted opportunistically as the need arose.It was felt that the selection of appropriately regionally distributed centres and coordination of planning and response during Peacetime would minimise disruption to on-going services during an outbreak. Nevertheless, there are known drawbacks with using a designated ID hospital, not least its likelihood to become stigmatised for use during peacetime, the potential shutdown of multiple large hospitals was not viable. It was however notable to us that the biggest drain on the system appeared to be the lack of confirmed decision on this policy - which resulted in stockpiling and planning for a ‘what if we have to cope with this alone’ scenarios, which can be seen as siloed, duplicative and ultimately wasteful strategies.supplies, we were told about improvements in ID surge preparedness Equipment and stockpiling since SARS, during which a shortage of everyday supplies for patient management  was felt. When H1N1 pandemic hit, the access to resources were described as ready and available. Current policy in many hospitals was to (S16) independently stock PPE’s, drugs for at least 3 days, in order to allow time to reorder in case of a surge event. In addition, (S17) transparent listing of reserve supplies on a centralized system is important for coordinated planning. For example, to know availability of surplus medical supplies and planning for ID outbreak equipment will help operations managers assess shortfalls, particularly if they are designated a sister centre during a mass Pyramid or potentially Black outbreak. (S18) Operations managers spoke of valuing good relations with international suppliers.As for Financing for innovation, in particular (S19) investing in automated devices to facilitate the monitoring of patients for clinical management: ‘In terms of equipment we know that it will be much better with using more automated devices, instead of manually measuring’- BM2. Regarding systems investments, paradoxically, OMs tended to feel their budgets were realistic, even generous: ‘I am glad to say, and this can go on record, that MoH is very generous with the budget and especially when it comes to an outbreak.’ – OM1. Whereas medics expressed reservations along the lines (S20) that there was too much emphasis on frugality, or basic care delivery, above innovation and effectiveness: ‘The tagline is Singapore healthcare, the most cost effective. [but] The emphasis is oncost[emphasis their own] effective. Not effectiveness. So it is bang for buck’ - M3. Placing effectiveness above short term cost-saving would improve capability in the face of any surge threat.Certain hospitals have also reported Systems were built on generally sound communication, emphatic consideration of logistics and operations and some efforts toward monitoring and surveillance. With respect to Communication it was relayed that Singapore higher management (S21) valued principles of transparency. During SARS ‘The management was actually brutally honest’- C1 [on SARS]. One poignant example was shared during H1N1, when the only available Tamiflu was recorded as past ‘best date’. Rather than try and cover this up the management checked the efficacy of the drug and was upfront about the issue: ‘basically we went on TV say you know this stuff is perfectly good, we’ve seen the test, someone saying ‘I would take it and give it to my kids’.’PH1. This open dialogue with the public built trust as well as transparency into the system.In contrast, within institutional structure the flow of communication has been very top-down with members assigned an authoritative person to take instructions from. It was noted that the system might benefit from (S22) a flatter and wider structure. It was shared that with fast moving issues on the ground, top-down instructions may not be applicable; some system to feed how to adapt upwards was required. Immediate notification was issued to senior staff, especially to doctors via email. Nurses didn’t have any institutional email were communicated only by roll calls at the start of each of the three shifts in a day. One way to improve this was suggested via SMS notification that could send alert and procedural notifications direct to mobile phones.‘[MoH] are in an ivory tower… the layer between them is the hospital administrators, of course…’-C6. As for boarding of communication channels - it was noted that professionals were quick to come together in a crisis - but it was emphasized that inter-agency communication needs to also happen in Peacetime, and share information. Relatedly, Monitoring and surveillance would also be helped by (S23) recording bottom up bottlenecks, preferably in real time. Surveillance in Singapore as an island nation has otherwise been actioned toward uniformity, through liaison with ministries. During major outbreaks Singapore is notable as one of the few countries to issue daily surveillance report against the standard one-week reports in other pandemic affected countries.A response inbox could be set up for staff to upload notifications of difficulties on the ground, addressing the general malaise that the decision makers: Yet S24) apart from prevalence data, other more meaningful datasets and collaborative efforts to inform future outbreak modelling appeared scarce and reluctant to surface. Participants also mentioned the hierarchical nature of system as a deterrent in vocalizing their thoughts and working together in research areas. There were also (S25) concerns regarding the detection of an unusual cases or outbreak as there has been no formal system set up to do this, or generalizable tools to guide what to do in response; each outbreak was seen to require its own disease-specific protocol, intuitively and implicitly using lessons learnt – this highlights the need for the DECIDE tool proposed herein  and to a lesser extent complex disease management were at the centre of these systems.Such planning tended to boil down to capacity or (S26) ‘upsizing’ to address IC by increasing staff ratios because of lengthy, time consuming, strict infection control practices; or to deal with travellers brought for screening and isolation at the hospitals straight from airport; added paperwork, liaison with the embassies. But there were also the months of capability assurance and training. Learning about equipment and treatment protocols, running PPE usage drills, practicing patient transport routes. Transferring of suspected and probable cases across hospitals remains a major area of concern. Contact tracing of taxi drivers and passengers once SARS was known may well have saved Singapore from a Black scenario. Standardizing these processes, including mortuary procedures and sewage cleaning, and limiting a bulk of resources to designated and sister hospitals can save procedural waste.‘You know in Singapore, we work things out from first principles, we will already have some certain level of knowledge as to what will work and what will not work.’- OM2. The efficacy of ministries was respected. Targeted involvement from health professionals in the formulation of policies during surges was also seen to be an important exercise. The worry was also the institutional memories were getting lost: ‘And I think immediately after SARS, the awareness was there for everyone but there been turnover and everything. So, people have actually, you know, kind of like forgotten you know, so that is one thing’ - OM3.Regards decision-making we noted that leaders of Singapore are very principle driven; and expect policies to be based on fundamentals of science; but science in context, relying on institutional memories, as one operations manager put it: ‘I am putting it to you that a surge response is an engineering challenge. It is not a science challenge. It is not an admin challenge. It is not a microbiology or lab challenge. It is an engineering challenge.’ –M2. Like all engineering challenges the apt response depends on the soundness and extent of understanding of the problem, finding a mapped solution, communicating and sharing it accurately and adapting it when needed.As such we propose to formalise institutional memories, using them systematically toward better decision-making. Systems function rests ultimately on good coordination, which is not an exact science, takes account of logistical realities while using institutional memory. This is but likened to an engineering challenge: Detecting, and linking to surge threat scenarios, as defined in Fig. Evolving, by linking your threat to strategies, Fig. Communicating your approach to your various stakeholders; Implementation planning through an appropriately representative committee ; Delivering your intervention by adapting it to unexpected bottlenecks; and again – since nothing ever fully goes to plan - Evaluating it, by recording new lessons learnt and updating your list of strategies as you go.To preserve, advance institutional memories, and ensure new ones are captured we propose the DECIDE steps. The six steps in DECIDE, are detailed in Fig. Some institutional memories will be instantly clear and can be brought to immediate systems benefit. Others, may require time - professional, disciplinary and cultural distancing to come into focus. It is these memories and experiences, which this research sought to record. One such notable conclusion is that the existing constraints on the Singapore hospital systems, operating at maximum capacity itself appears to have rendered it buoyant to shocks, rather than more vulnerable to them. People, departments, agencies have had to learn to adapt every day to never lessening demands. This itself seems to have rendered the system better able to absorb and bounce back from shocks. Shocks such as H1N1 could have utterly collapsed a health system with existing space crunches.It was a surprising finding that Dengue or other endemic and seasonal surges were absorbed by a system so close to the brink, in such a normalised fashion. It is nevertheless both paradoxical yet somehow evident that a system which is so clearly burdened at the outset in terms of capability is able to respond so well to it in a time of crisis. Capacity is a systems’ issue that Singapore is conquering; perhaps issues such as space and manpower influxes are simply easier to solve in the interim than capability related ones. These, in turn, are evidenced to be enabled by flatter, more explicit structures and leveraging of more integrated services and ways of working.Conceptualization of ID hospital surges will help toward better, practical, pre-emption of problem areas , 15. It Hospitals and social institutes serve as amplifiers of ID spread ; during Complete shutdown of mainstream hospitals, as was the case during SARS in our setting and others, has shown difficulty in recovering  and to rDeveloping a robust technology in preventing infection control mishaps and e-health helping in detecting patterns will help deal better with nosocomial infections and intervening early , 36 ThisOur Framework for ID hospital surge planning & response builds on known elements and supplements this existing work with primary, targeted, qualitative analysis. Although many evaluations of surge management will have documented disparate strategies, in specific contexts, to our knowledge the conceptually mapping, making use of historical data and institutional memory has not yet been undertaken.While all the 26 strategies that we identified as useful in the Singapore context may not be generalizable to all countries, the conceptual elements grouping them and identified typology threat scenarios are adaptable to different settings. We contend that the steps in the DECIDE model are transferable and offer a useful process to map hospital ID surge planning and response in any context.We were limited by recruitment largely in one main hospital (TTSH), because this is the hub of ID specialism in Singapore, although remaining structures in Singapore comprised nearly half of our interviewees. Singapore General Hospital (SGH) refused to participate.In sum, the current analyses are intended to help us learn about the specific to inform the general. Our Peacetime scenarios (inclusive of manageable endemic outbreaks), Pyramid, Reverse Pyramid, and Black scenarios will be catalysed by different IDs in different settings. For example, in settings that cannot prevent vector outbreaks at source so well, endemic outbreaks - e.g. Malaria during the rainy seasons - may not be manageable, and will instead be typified as a pyramid scenario. Likely with more admissions than was the case with H1N1 in our setting due to higher transmissibility, thus a wider middle tier and admissions peak. And not all Peacetime settings will be predisposed to capacity limitations from the start. The current study fills in the shapes of what is ‘known’ to help plan for ‘unknowns’  during I