Since the 1970s, Singapore has turned into one of the major receiving countries of foreign workers in Southeast Asia. Over the years, challenges surrounding access to healthcare by Chinese migrant workers have surfaced globally. This study aims to explore the experiences of Chinese migrants accessing primary and secondary/tertiary healthcare in Singapore, and the opportunities for overcoming these barriers.We conducted 25 in-depth interviews of 20 Chinese migrants and five staff from HealthServe, a non-governmental organization serving Chinese migrants in Singapore from October 2015 to January 2016. Interviews were transcribed and analysed inductively adopting thematic analysis.Chinese migrants in Singapore who were interviewed are mainly middle-aged breadwinners with multiple dependents. Their concept of health is encapsulated in a Chinese proverb “健康是本钱”, meaning “health is my capital”. Health is defined by them as a personal asset, needed to provide for their families. From their health-seeking behaviors, six pathways were identified, highlighting different routes chosen and resulting outcomes depending on whether their illness was perceived as major or minor, and if they sought help from the private or public sector private or public sector. Key barriers were identified relating to vulnerabilities during the migration process, during their illness, when consulting with healthcare providers, and during repatriation. A transactional doctor-patient culture in China contrasts with the trust migrants place in Singaporean’s public health system, perceived as equitable and personable. However, challenges remain for injured migrants who sought help from the private sector and those with chronic diseases.Policy recommendations to increase patient autonomy enabling choice of healthcare provider and provide for non-work related illnesses are suggested. Partnerships between migrant advocacy organizations and various stakeholders such as hospitals, government agencies and employers can be strengthened. Since the 1970s, Singapore has turned into one of the major receiving countries of foreign workers in Southeast Asia . SingapoOver the years, challenges surrounding access to healthcare of Chinese migrant workers have surfaced globally –7. Like Nonetheless, studies and the media in Singapore have demonstrated the challenges faced by migrant workers, in spite of these laws , 18. ForA qualitative study design was chosen. In-depth interviews were conducted with 20 Chinese migrants and five full-time staff or part-time volunteers at HealthServe from October 2015 to January 2016. HealthServe was selected as the study site as it is a non-governmental organization (NGO) providing support for vulnerable migrant workers from China, Bangladesh, India, Myanmar, Thailand and Sri Lanka  They have a lot of authority and decide how much you are paid. […] We’re all on tenterhooks. We are powerless before our supervisors here.Interviewer: How do you overcome your challenges?Migrant: Just persist and let it pass. (M002)One consistent theme reported by migrants was feeling oppressed in a new work culture, which was vastly different from home, even though their “In China, we have a saying, “健康是本钱” . With health, I can work. Without it, I cannot do anything. (M009)When asked what “health” meant to them, many migrants used a Chinese proverb “健康是本钱”, referring to health as a form of capital to earn money for their families:Work will not be the same with my injury. I will earn less with lighter work.” (M010) Nonetheless, this seemingly materialistic view belies the perspective of most migrants, who believe that money is secondary to health and family.Health is of utmost importance as without it I cannot earn money for a better life for my family. (M007)Most migrants shared that health implied the ability to earn money. An injured migrant described how the lack of health affected his ability to make a living, “Health is supreme because my family needs me to support them. If I am unwell and my family needs to support me instead, I would be a sinner.” (M013)Such strong familial ties were common among nearly all migrants. The intensity of this breadwinning responsibility which most migrants feel is well-expressed as such, “Interviewer: Why is health important to you?Migrant: I can still see the world, I’m lucky to be alive.Interviewer: Is this a new perspective after your injury?Migrant: Yes. Before I got injured, health was just being able to earn lots of money. (M015)However, a minority of migrants who suffered disproportionately severe injuries had a renewed perspective of health. One migrant with a skull fracture and five operations in total reported a change in perspective before and after his injury. This was one of a few exceptions:Health is important like kinship, money is secondary. It does not matter how much I earn, health is more important. […] Because with health I can be with my family and be happy. (M005)Another migrant who fell from an eight-metre height shared how health transcended monetary value:In summary, health was perceived as a form of capital and asset, to enable them to work hard to better the lives of their family. However, in the face of unusually severe injuries, participants tended to view health more poignantly, as an opportunity to spend time with their families and savour life.Healthcare access by Chinese migrants in Singapore can be divided into six major pathways, and depends on whether the illness was perceived as minor or major, and whether self-medication, returning to China for treatment, the private or public health sector was chosen Fig. . The thiFor minor illnesses, there were three possible routes: the majority would first self-medicate. If self-medication was unhelpful, they would visit private clinics in or outside their worksite. A minority who heard of HealthServe would visit its clinic. For major illnesses, five routes could be identified. For chronic illness or major non-work related injuries, most participants preferred to return to China. Several interviewees, however, reported being comfortable seeking help from HealthServe.Work-related injuries and diseases can be covered by the Work Injury Compensation Act (WICA), which allows employees to claim for medical leave wages for the days that the employee was issued with medical leave due to the work injury or disease, medical expenses, and lump sum compensation for permanent incapacity or death . Howevercunyi”s (village doctors). In contrast, acquiring medication in Singapore was “more troublesome”. Many migrants reported cultural barriers such as inconvenience in finding a clinic, not being able to buy medicines without a doctor’s consultation, and not being able to understand English. Nearly all participants reported that cost was an important consideration, as migrants who take a day off work without producing a Medical Certificate (MC) from a doctor do not receive the day’s wage  If it is a more serious illness and you don’t have money, the company will send a guarantor’s letter so that you can stay in the hospital first. (M013)Only one migrant from an exceptionally established company expressed gratitude to the generous insurance provided, “Interviewer: Is your friend with kidney stones cured?Migrant: Yes. The boss asked him to go back to China and get treated. But he came back again after getting cured because the pay is higher here. (M010)One staff reported the challenges of uninsured non-work injuries such as cancer:There is no provision for illnesses like cancer for which insurance will pay. But for ‘humane medicine’, there needs to be provision for such situations. (S021)All migrants stated a medical examination was necessary before qualifying for work in Singapore. Hence, most did not know anyone with serious chronic diseases. Because the medical insurance for migrants does not cover non-work related illnesses, those with chronic diseases reported their preference to return to China, as treatment would be more affordable. One migrant shared about his friend’s situation:The doctors think of the interests of the bosses because the bosses are paying them. Bosses usually have their selected hospitals and will not let you go to the public hospitals. (M014)Migrants who suffered work injuries had mixed experiences. Many were funnelled directly to private practitioners by their employers. They described negative experiences, such as suspected collusion between their employers and doctors, language barriers, and difficulties obtaining medical documents and having their work injuries reported. They shared observations of conflict of interest in the doctor-patient relationships at private hospitals, resulting of mistrust of their doctors:Staff: The reason for giving two days MC is because if you have three days MC or more, you have to report the incident to MOM. Then the employers will get a penalty.Most HealthServe staff members reported the potential conflict of interest to patients when privatized doctors are contracted by employers, as they may be under pressure to issue less MC by employers .Staff: I should have seen the doctors at the big (public) hospital from the start as it is easier to get my documents there. […] They would report your case after you get your MC. The boss has no authority over them. At the small hospital, I could not even see my MC. (M019)Public hospitals were generally perceived to be more equitable and trustworthy. Such information is spread by word-of-mouth among migrants. In Mandarin, they are described as “big hospitals”, paralleling the trust migrants place in bigger city hospitals in China. This is in contrast to the mistrust they have in private hospitals, which are described as “small hospitals”, corresponding to the less advanced, smaller facilities in China. One migrant shared his difficulties in reporting his work injury:The public hospitals are fairer. They do not rely on “guanxi” (private ties) with employers, unlike private doctors. (M015)One injured migrant who was sent to a private hospital was unable to obtain any medical documents and thus took his friends’ advice to transfer himself to a public hospital, where he could obtain his MCs. This was recounted by a few participants:General Practitioners are cheaper than A&E (Accident & Emergency). Often migrants prefer to pay from their own pocket so they can continue to work without their bosses knowing. (S023)Nonetheless, one staff highlighted that migrants may prefer to present to General Practitioners over the Emergency Department of public hospitals:baoxibubaoyou”, which refers to their culture of reporting only good news and hiding bad news. Surprisingly, several migrants, all of whom had suffered work injuries, expressed their desire to return to Singapore to work again:Although I sustained work injury here, I would still come again if I can. The laws here are good and the government will help you if the company does not pay. (M004)One common challenge reported by most participants was the long wait from the point of injury to being repatriated back home. During this time, they usually suffered a loss of income. The mental stress of waiting for compensation is compounded by most participants’ unwillingness to share news of their injury with their family. Many explained why using the Chinese proverb “Those who were seriously injured can’t work when they return home and their families suffer more problems. […] Whenever we visit China, we meet with the family and share what the migrant went through. Through this, we salvaged a few marriages. (S024)HealthServe staff with experience of visiting repatriated migrants in their villages in China explained the challenges of injured migrants assimilating back home:The story of one of the migrants illustratesthe points of vulnerability in a migrant’s journey Fig. , and thechiku” (eat bitterness). As time passed, his salary increased from USD$1100 to USD$1500 a month. Bing shared his challenges of working in an unfamiliar country, “We do not have time to find out where to see a doctor as we work most of the time. It is only when we fall sick that we start sourcing for information.”Bing is a 53-year old farmer migrant from Jiangsu, China. Being the sole breadwinner of his family with elderly parents and two sons, his motivation for migrating was to earn more money for his family. Upon persuasion by his friends and agent, he chose Singapore for its reputation of good security. When he first arrived, his expectations were challenged. He stayed in a container with 16 people. The long working hours and pay were different from the rosy picture his agent had painted to him. However, having paid high agent fees of USD$5000, he decided to “, “When we are injured, we don’t have the power to choose our healthcare provider. When you’re in pain, you’re under the control of your boss. After I went to the public hospital, my relationship with my employer turned sour. My supervisors told me I should not have gone to the public hospital as I did not have their permission.”During work, he fell through a scaffold while carrying 25 kilograms worth of cement and suffered a left knee fracture. His supervisor advised him to rest, but due to persistent pain, he walked to a nearby private clinic. The doctor advised him to seek help from a public hospital if the pain persisted. A few days later, on his way to a public hospital nearby, Bing’s manager stopped him and took him to a private hospital situated further away. Bing was unable to choose his healthcare provider of choice and explains this vulnerability that many migrants face, “I understood when the private doctor and the safety officer spoke in Mandarin but then they switched to English. The doctor said that I needed 4 months rest before I could do light work. Yet he wrote the notice for light duty for my boss instead. He said and did different things. […] I think they “chuantong” (colluded).”During the healthcare consultation, Bing faced language barriers in communicating with the doctor at the private hospital, who spoke directly to his employer. He describes his challenges, “They had me discharged on the day I had my operation. […] The safety officer said that I was the one who insisted on discharging. My employers had all my MCs so I could not report my work injury. They did not give me my salary for 2 months. I asked the safety officer if mine was considered a work injury but he said no because I was not hospitalized.”Bing underwent an operation and was not allowed to keep any medical documents. Bing explains the challenges he facedMigrant: The public hospitals are more “gongping” (fair). Their service is good.Interviewer: Are there barriers between the doctors and you?Migrant: No barrier. I trust the doctors at the public hospital.Interviewer: But the barrier exists with the private doctors?Migrant: Yes, whatever documents are issued is given to the boss only.Bing suffered a loss of income. Without any medical documents, he could not report his work injury or receive his fair compensation. During this time, he suffered much mental stress. Thus, Bing heeded his friends’ advice and presented at the Emergency Department of a public hospital. For the first time, he received his copy of MC which he finally used to report his work injury. Bing shares his sentiments about his private and public sector healthcare experiences:xiangjiarenyiyang”, which means the staff was like family. At the point that this paper was written, Bing was still awaiting part of his compensation from his company, 10 months after his injury. He mentioned he was looking forward to returning to China to start a small business.A year ago, Bing had suffered a skin allergy to cement. When self-medication proved ineffective, he visited a private clinic which cost USD$40. He paid for himself. His friend then recommended him to HealthServe. After his work injury, Bing returned to HealthServe, which provided him with free housing, food, medicine, emotional and spiritual support. When asked to describe his experience at HealthServe, he used a phrase which was commonly used by other migrants, “This study contributes to the perspectives of mainland Chinese migrants and non-governmental staff and volunteers serving them, on their access to primary, secondary and tertiary care in Singapore. Most Chinese migrants interviewed reported feeling culturally and socially accepted in Singapore, where many speak Mandarin. This is in contrast to the social exclusion reported by mainland Chinese migrants in Hong Kong, which has an intense political rivalry with China .Health was perceived by participants as an asset and an important form of capital, needed to work, earn and contribute to improving the lives of their families. This is supported by another local cross-sectional study of 525 migrant workers from Bangladeshi or Myanmar nationality exploring health-seeking behaviours, where the majority of those who saw a doctor did so because they felt medical care would enable them to work better . The ChiModels have been constructed to explain how health capital differs from other forms of human capital, as one’s stock of health uniquely determines the total time one spends on producing monetary earnings and commodities , 28. Leechiku” (eat suffering).One of the four basic premises which underlie the theory of the demand for health is reflected among the perspectives of migrants interviewed- that health is desirable but not valued above all else . When prDue to limited understanding of the healthcare landscape in an unfamiliar environment and the strict hierarchical work culture on worksites, most migrants interviewed faced challenges in choosing their preferred healthcare provider. Negative experiences reported while attending the private sector included perceived collusion between doctors and employers, withholding of medical documentation, insufficient hospitalization or medical leave, and lack of discharge care. Difficulties with reporting work injury resulted in a loss of medical leave wages, an unduly long wait to receiving fair medical assessment and compensation, and the mental stress of waiting to be repatriated. The significance of mental stress should not be underestimated, as findings of a study of Chinese migrant workers within China itself suggested that migrant residents had a higher prevalence of depression and less utilization of healthcare services and self-medication .Nonetheless, migrants interviewed often displayed great resourcefulness to tap on their interconnected networks, to look for alternative sources of help such as HealthServe, through word-of-mouth from their friends. This form of social capital can be succinctly described by Coleman as “the value of social norms of reciprocity, social networks, and mutual trust”, which also affects health . In facthabitus, fields, and capital. Habitus has been used widely to refer to a system of dispositions through which we perceive, judge and act in the world [Within this context the work of Bourdieu is called upon, particularly his concepts of he world . Fields he world . For exahe world , 36. ThiIn this context, their ability to navigate the different fields also depends on their particular endowment with capital . BourdieWith regards to primary care for minor illnesses and other non-work related illnesses or chronic diseases, most of the migrants interviewed indicated they would self-medicate, pay on their own to see a private doctor, or return to China for long-term treatment. This response is supported by Lee’s study, which shows that nearly half of the interview subjects would self-medicate, and in those who saw a doctor, private general practitioners and workplace doctors were the most visited, followed by government clinics and hospitals, and the HealthServe clinic . Nearly Some findings of this study were, however, inconsistent with those of Lee’s and team, who found that migrants who earned lower salaries were significantly more likely to believe they would have to pay for their own healthcare or be uncertain about who would pay . Our fin“Health is my capital” well encapsulates the sense of ownership and resourcefulness of the migrants interviewed, in their access to healthcare in a foreign land. A study suggests that migration results in new ways of mobilizing, enacting, and validating cultural capital which builds on the power relations and resources of the country of origin and country of migration . This caInevitably, this study has some limitations. The study was conducted at a single NGO site in Singapore, at HealthServe. Thus, experiences could have been skewed as those with injuries and compensation issues tended to present there. This group is likely a vulnerable group who may report more negative experiences. Experiences of migrants presenting at other NGOs or even directly at their place of work could differ. For example, this data excludes the healthcare perspectives and experiences of migrants who fail to present at all to any healthcare providers.The study’s strengths include access to Chinese migrants who faced challenges accessing primary, secondary and tertiary care in Singapore. In 2014, HealthServe had 3424 consultations, 216 work injury cases and 226 non-injury cases . Using HWhile policies and guidelines such as the Employment Act exist in Singapore to protect migrant workers, gaps emerge in the background of a constant flux of change . The magMost migrants reported a lack of power to choose their healthcare providers, and a sense of helplessness when their healthcare outcomes were determined by their employers, whom they perceived to collude with their doctors. Disengaging the private sector from employers by designating appointed public hospitals to attend to migrant workers or availing opportunities for migrants to choose their healthcare providers could be potential solutions. Regular audits of medical records of migrant worker patients to survey the severity of injuries and corresponding MC and work injury compensation outcomes could help, especially in the private sector, given potential manpower constraints at public hospitals.Strengthening partnerships between HealthServe and various stakeholders would facilitate communication between different government and private, medical and non-medical agencies involved in migrant care. To deliver culturally-competent care to migrant patients, training among medical students could include a component on migrant issues. Efforts to nurture an inclusive society for all can be made through the development of culturally-sensitive healthcare policies, such as health services which ensure continuity of care after repatriation. In countries like Britain, attention has been drawn to policymakers to develop culturally-sensitive health services for Chinese immigrants, acknowledging their heterogeneous backgrounds and diverse migration experiences .Migrants are a vulnerable group in Singapore. While they are able to access healthcare, improvements by multiple stakeholders through enforcement, adjustment and refinement of guidelines are needed to overcome their challenges in a dynamic migration landscape. A concerted effort for open communication between employers, MOM, migrant workers, private and public healthcare sectors and migrant NGOs is needed. Medical staff should adopt culturally-competent relational skills, while employers should adhere to governmental guidelines to protect migrant workers. Additionally, policymakers should examine how migrant workers can gain access to healthcare providers of their choice without pressure from their employers. The evidence provided in this paper suggests that further legislation is needed to protect this vulnerable population, to strengthen their access to healthcare and to help them maximize their health capital for meaningful gains.


Adequate self-management is the cornerstone of preventing type 1 diabetes mellitus (T1DM) complications. However, T1DM self-management is challenging for young people, who often struggle during the transition from childhood to adulthood. The mobile health  app Young with Diabetes (YWD) was developed in collaboration with young people to enhance their T1DM self-management during this transition.The purpose of this study was to explore the influence of YWD on young people’s self-management during a 12-month period.A qualitative explorative approach was used, comprising a purposive sample of 20 young people  from 3 pediatric and 3 adult departments. Participants were interviewed individually using a semistructured interview guide. Data were collected from January to March 2017 and analyzed using thematic analysis.A total of 5 themes were identified: (1) not feeling alone anymore (“we are in this together”); (2) gaining competence by sharing experiences and practical knowledge ; (3) feeling safer (“it’s just a click away”); (4) breaking the ice by starting to share thoughts and feelings and asking for help (“it is an outstretched hand”); and (5) lack of motivating factors (“done with the app”). Young people reported that YWD promoted self-management by peer-to-peer social support, exchanging messages with health care providers, and sharing YWD with parents. Participants recommended YWD as a supplement to self-management for newly diagnosed young people with T1DM and suggested improvements in app content and functionality.The mHealth app YWD has the potential to support self-management. In particular, peer-to-peer support reduced feelings of loneliness and helped young people to gain knowledge and skills for managing T1DM. A need exists for alternative ways to train health care providers in using YWD and to support collaboration between young people and their parents to further improve young people’s self-management of T1DM. Type 1 diabetes mellitus (T1DM) is a demanding disease for young people, who struggle to learn to self-manage their condition during the transition from childhood to adulthood . As younMobile health  apps seem to be suitable tools for engaging young people in self-management by providing information and optimizing interaction with health care providers and parents -19. HoweThe Young with Diabetes (YWD) mHealth app was developed in a mixed-methods design based on a participatory and iterative approach  in collaYWD is based on a family-centered approach  as recomYWD comprises 8 main functions : (1) My Young people, their parents, and health care providers received the same version of YWD, except the Chat Room that was only available for young people. Anonymity in the Chat Room was encouraged with the use of nicknames.The aim of this study was to explore YWD’s influence on young people’s self-management during a 12-month period.A qualitative exploratory interview study was embedded in a 12-month randomized controlled trial (RCT) testing the effect of YWD on young people’s self-management skills. A purposive sample  of youngYoung people and their parents were randomized to the intervention group  or control group (n=75), and participants in the YWD group downloaded the app on their mobile phone or tablet. PC-S provided an initial 10 min introduction of the app to the participant in person or by telephone. Participants were encouraged to use YWD between clinical visits and in collaboration with parents and health care providers. No prompts or reminders triggered app use. All young people had a mobile phone.Health care providers were encouraged to use the app in the outpatient clinic. YWD-trained diabetes team members, including physicians, nurses, and dieticians (n=39) with at least 1 year of diabetes outpatient clinic experience, provided the YWD intervention as part of usual practice. Monthly face-to-face sessions were offered to refresh the use of YWD, and a telephone hotline was available in case of technical issues.Individual interviews were conducted between January and March 2017 from 1 to 3 weeks after the RCT was completed. The interviews were conducted by GRH . GRH interviewed participants independently of their parents in their homes (n=19) or at school (n=1), using a semistructured interview guide  that inc1c (HbA1c) levels (primary outcome) and scores on 3 psychometric scales (secondary outcome): Perceived Competence in Diabetes (PCD) ...but it [YWD] has helped me to do some of the daily work.20-year-old female, ID17This was identified through 5 themes: (1) not feeling alone anymore (“we are in this together”); (2) gaining competence by sharing experiences and practical knowledge ; (3) feeling safer (“it’s just a click away”); (4) breaking the ice by starting to share thoughts and feelings and asking for help (“it is an outstretched hand”); and (5) lack of motivating factors (“done with the app”). In the following section, the findings are detailed.The Chat Room proved to be the most important function of YWD. Finding peers who faced the same challenges in T1DM self-management was enlightening for all interview participants; they felt that:...we are in this together.20-year-old female, ID1Feelings of loneliness were relieved when young people became aware that their struggles were familiar issues among their peers. The possibility of contact with peers made their current challenges and worries easier to bear, as did knowing that they were not alone in having these burdens. Some participants had never met other young people living with T1DM, as illustrated here by a male:I have gained a slightly better understanding, because before I had the app it was a little difficult to realize how others my age felt because there is no one at my school...that has diabetes...I think it is good to know that I am not the only one that has these problems or thinks about the same things, like the future with diabetes and all that.18-year-old male, ID15The possibility of participating in chats or simply observing chat comments helped young people acknowledge that it was not always easy to self-manage T1DM. They realized that peers were familiar with their concerns, frustrations, and challenges, which helped reduce feelings of loneliness, as expressed by a female:[I]t is good to know that you are not the only one with it...of course you have the support from your family and your friends, who say that you will get through it...but hearing it from someone who also has it and knows what you are going through and...to have others you can talk to, that is very, very nice.18-year-old female, ID14Feeling like everyone else and “being normal”  occurred when young people were in the Chat Room. By reflecting on their peers’ ways of living, young people experienced normalization of T1DM into everyday life. This contrasted with the feeling of being different that often arose when spending time with friends without T1DM:[O]ften you feel that you are walking around in your own little world, because you are surrounded by people that don’t have diabetes.18-year-old female, ID14The Chat Room provided a safe, closed space where a spirit of companionship arose even though the young people did not know each other. A female described the experience:[O]ften when you are at school, you are reminded that you have diabetes...But when you are in that diabetes chat room, then you are among others, and it is like the diabetes things are something that you have in common with the others.18-year-old female, ID14. They became aware of the difference between advice and information they received at outpatient clinic visits and the insights and real-life knowledge they received in the Chat Room:Young people shared T1DM experiences in the Chat Room, which helped them gain new knowledge and skills for managing their disease ...they know what they are talking about.22-year-old male, ID3They experienced health care providers as being unable to provide the person-specific information they sought. On the contrary, health care providers often discussed T1DM in general ways, for example, by looking at blood sugar curves trying to figure out the cause of fluctuations. The young people found that sharing experiences with peers provided valuable and reliable person-specific information, such as how to manage hypoglycemia or deal with challenges when traveling. This knowledge improved their self-management competencies, as described by a male:[O]ne way is that a physician tells you how to do it, another thing is when the ones that have [T1DM], tell what they do to make their blood sugar levels drop or what they do when they travel, so that has helped me quite a lot.18-year-old male, ID15Young people became confident about trying out new ways of handling T1DM. They exchanged tips and tricks, such as precautions for driving, how to regulate blood sugar in relation to sports, and how to use the different functions of the insulin pump around meals to avoid fluctuating blood sugars.There are people who have solutions to problems that you might not be able to find yourself.16-year-old male, ID13Easy access to the Chat Room provided young people with opportunities to immediately change self-care practices. As a female described:There was one person who wrote that she used the basal [rate] in the pump...and I didn’t know that you could turn up the basal, then she wrote how to do it...that has helped me a lot, now it [the blood sugar level] doesn’t fluctuate as much.19-year-old female, ID6Young people gained practical knowledge that supported their participation in social life, such as going out with friends, while still feeling confident about taking care of their T1DM. Exchanging experiences in the Chat Room provided them with real-life scenarios of risky situations, such as drinking alcohol. They did not receive this type of information from their health care providers. From their peers, they received concrete instructions about how to act and cope, as described by a female:...it has also helped me a lot with what to do if things go wrong when I drink and am at a party...18-year-old female, ID14Most young people had not used the Information about...section, often because they felt they knew everything about T1DM after having been diagnosed years previously:Maybe sometimes it is just the words, “Information About,” where I think I don’t need to read that.20-year-old female, ID17Therefore, they did not consider the informational part of the app as an option for obtaining advice about how to self-manage different situations in real-life contexts. However, they were convinced that the information function of YWD would be very useful for young people newly diagnosed with T1DM. As a male put it:...The category “Information About” would be real smart for new diabetics who don’t have any idea as to how the different things affect your body.17-year-old male, ID18Young people felt safer living with T1DM knowing that all the information they needed about their disease was available in YWD. This gave them a sense of freedom and peace:It has been a relief for me that all my diabetes things are gathered in one location.18-year-old female, ID14Before using the app, they had often had difficulty maintaining an overall perspective on their T1DM while taking care of school, work, and youth life. Ready access to information and knowledge made self-management easier:It’s just a click away.20-year-old female, ID5. YWD functioned as a kind of “back up”  in almost all aspects of life with T1DM from minor concerns to acute issues. Young people viewed the app as a lifeline and felt safe just having it, as described by a female:For instance, some young people used links in the app to figure out how to count carbohydrates, some gained new perspectives by watching video self-portraits, and some reached out to peers or health care providers ...then it is more reassuring with the app...let us say you have a situation, and then you can quickly...sit and look it up.20-year-old female, ID1parking lot for speculation and worry, helping ease their minds. As a female explained:A few young people benefited from writing personal notes in the My Page function to organize their life with T1DM. Before using the app, they had expended a great deal of energy figuring out how their blood sugar responded to activities and food intake. By making notes about their reactions during different activities and in various circumstances, they gradually developed a personal guide to rely on in similar situations. This app function provided a I have gotten a better perspective on it, so I don’t have so many different thoughts...and I have gotten it all gathered so I can access it directly and see, that is what I did the last time and create my own guides to what I need to do, so that has helped me a lot.18-year-old female, ID14Young people appreciated that the app’s informational sections were easy to understand and focused on the most important aspects of T1DM. They had greater confidence in the information presented by YWD than in information they had previously located online. This gave them a sense of safety, as expressed by a male:Information about...,” that is professionals that have written that, it is not someone off some Google home page...so that makes it a lot more reassuring to have this app.17-year-old male, ID13For some young people, YWD became a way to break the ice with their health care providers and parents. It supported them in sharing thoughts and feelings about their challenges of living with T1DM and asking for help.Young people found that contacting health care providers through YWD was very informal, which facilitated writing messages:I communicate with my nurse in a completely different way—I can be much more honest.20-year-old female, ID17Young people primarily wrote about practical things such as scheduling appointments or new prescriptions. They emphasized that health care providers did not introduce YWD during outpatient clinic visits or only referred to it superficially, such as by asking whether they had used the app. Young people had the impression that the app was not meant for collaboration. However, YWD made a profound difference in the few instances in which young people used it in collaboration with health care providers. For example, they used it to ask for help to lose weight or help to manage an eating disorder, topics that had not been discussed during clinic visits. A female described it this way:I have had difficulties with my eating disorder, and that has not been something I have told my practitioners, so the app gave me an opportunity...to write them, because it was hard for me to say, either over the phone or face-to-face.23-year-old female, ID10Other young people used the “Unfinished sentences” in the My Page function as a way to break the ice and address unspoken difficulties in living with T1DM. They felt that doing so made it possible to talk openly about their thoughts and feelings:The thing that I am worst at, regarding my diabetes...” that is a very accurate sentence, because it is like taboo.20-year-old female, ID17By sharing their thoughts and feelings with health care providers, young people suddenly experienced more continuity in those relationships. This promoted sharing successes and failures and receiving ongoing support, which not had been possible before.It motivated young people to improve their self-management because health care providers immediately responded to their actions. A female explained it this way:The thing about how many blood sugar levels I have measured in so and so many days, that I would never have told her, but she sees the progress and tells me about it and praises me for it and that would not have happened without the app.20-year-old female, ID17YWD also became a way for young people to break the ice and start to share thoughts and feelings about the challenges of living with T1DM with their parents and to ask for help when needed. Some young people and their parents looked at the video self-portraits or at posts in the Chat Room, competed in the Carbohydrate Counting Quiz, or looked at the information sections separately or together. They then began to talk about topics that previously had been difficult to discuss openly, as in the example of a male who had talked about sex with his father for the first time while looking at the app together:[M]e and my dad, we talked about the issue of having sex with diabetes...that is probably not something I would have thought about normally—if there is a difference there...so because of the app we actually talked about some stuff.17-year-old male, ID18Young people described their parents as gaining a deeper and more nuanced perspective on the difficulties they faced in trying to self-manage T1DM. This changed the way parents and young people interacted about their self-management. Young people described their parents as seeming more eager to provide appropriate autonomy support, rather than admonishing or comforting them. As a girl describes:We talk about it in a different way, because they are informed about it, and they have asked... “Have you had it like that...?” and I have said “I think, like all the others, that it is a shitty thing to have” ...then they have said: “If there is something we can do [as opposed to everything will be all right], we would like to help.” They somehow better understand how it works in our minds...how we feel about our diabetes.18-year-old female, ID14Young people felt that their parents started to show greater confidence in them, and they had the impression that their parents suddenly took their situation and frustrations more seriously. In some cases, this led to changes in their parents’ point of view, including relaxing rules as they became more confident that the young person could handle, for instance, alcohol. A boy stated the following:Here in the beginning of last year, my parents wouldn’t allow me to drink, and now I have just gotten permission since we looked at the app together, there was a chat concerning alcohol and that has helped us a lot.15-year-old male, ID20Despite the fact that young people appreciated YWD, some also expressed being “done with the app” after the first few months because no new information, quizzes, or video self-portraits were added during the trial. A male said:It would be nice if it [YWD] was updated...it’s like Wikipedia, when you have read it, then you have read it, new knowledge won’t suddenly appear.17-year-old male, ID18Moreover, they noticed decreased activity in the Chat Room, which reduced their motivation for keeping the app. A male described the lack of motivating factors:There aren’t enough who write, so it is kind of like...it is hard to see where the app is supposed to take us, when there aren’t enough who use it to answer and write.22-year-old male, ID3However, young people wanted to keep YWD, except for 3 male participants, aged 20 to 22 years, who no longer wanted it due to the static content. All participants had many suggestions for improvements to content and functionality to ensure more activity and make YWD more useful .This qualitative study provides insight into the mHealth app YWD as a motivating factor and a supplemental tool to self-manage T1DM. In particular, young people experienced interactions in the Chat Room, exchanging messages with health care providers, and looking at the YWD with parents as useful features. Our findings show the importance of helping young people communicate with like-minded peers to share feelings, practical knowledge, and experiences. In addition, the findings indicate that YWD is a promising supportive tool to change communication patterns between young people and health care providers during and between outpatient clinic visits and between young people and their parents. Finally, YWD could be a tool for health care providers to address sensitive topics in outpatient clinic visits. However, improvements are also needed to maintain young people’s motivation for self-management.The Chat Room was found to be the most important part of the app, providing an online community for young people struggling with the same feelings, thoughts, and practical issues related to T1DM self-management. Young people felt they received support for self-managing specific diabetes situations and experienced diminished feelings of loneliness. Previous research has identified this kind of interaction as diabetes-specific social support , which iIn addition, untreated loneliness is known to contribute to diabetes distress ,42. DiabIt is well known that health care providers play a significant role in supporting young people’s self-management . HoweverHealth care providers’ training in how to use YWD was very brief, lasting a single hour. This may not have been sufficient to help them feel confident in using the app in collaboration with young people and their parents . AdaptioInterestingly, we found that YWD use often changed interaction patterns between young people and their parents. The app created a platform for young people and parents to approach each other in a more constructive way and enable them to talk about sensitive topics by sharing video self-portraits or posts in the Chat Room or looking at the To Parents section. Parents often face challenges when trying to support their child in achieving self-management ,49. New The findings highlight the importance of addressing communication about illness in any patients with long-term conditions by focusing on improving peer-to-peer support as well as supporting the digital communication with health care providers. However, there is a need to focus on health care providers’ competence at using mHealth apps. Given the many available mHealth apps, it may be worthwhile to introduce a course during health education programs, such as in medical and nursing schools, focusing on how to use technology collaboratively with patients. This is supported by a recent study  in whichIn addition, YWD may be a valuable tool for people with newly diagnosed T1DM as recommended by participants in the study. The informational functions of the app may be most useful at an early stage of the disease. We intend to incorporate young people’s feedback and suggestions for improvements in content and functionality  before tYWD may have the potential to provide a generic model for supporting young people with other chronic conditions and their parents and helping health care providers to engage with young people in ways that provide ongoing support. Despite disease-specific differences, young people with chronic conditions and their parents share many commonalities .One of the strengths of our study is the recruitment of participants with a variety of app use, age, gender, T1DM duration, affiliation with diabetes departments, and outcome measures. We consider this population as representative of the entire study group. In addition, patient-centered methods were used to assess YWD. Furthermore, the study used a rigorous qualitative methodology , as described by Braun and Clarke , to provThe YWD app appeared to be a motivating factor in young people’s self-management of T1DM. In particular, peer-to-peer support, exchanging messages with health care providers, and looking at the YWD with parents were useful in supporting self-management. YWD changed communication patterns between young people, health care providers, and parents and provided young people with ongoing support. YWD is not effective as a stand-alone intervention, but it seems to have the potential to help young people, parents, and health care providers optimize T1DM self-management. A need exists to refine YWD according to users’ suggestions, to optimize and standardize health care providers’ use of YWD, and to further investigate how the app can be used collaboratively by young people, their parents, and health care providers.


Faculty development as knowledge mobilization offers a particularly fruitful and novel avenue for exploring the research-practice interface in health professions education. We use this ‘eye opener’ to build off this assertion to envision faculty development as an enterprise that provides a formal, recognized space for the sharing of research and practical knowledge among health professions educators. Faculty development’s knowledge mobilizing strategies and outcomes, which draw upon varied sources of knowledge, make it a potentially effective knowledge mobilization vehicle.First, we explain our choice of the term knowledge mobilization over translation, in an attempt to resist the false dichotomy of ‘knowledge user’ and ‘knowledge creator’. Second, we leverage the documented strengths of faculty development against the documented critiques of knowledge mobilization in the hopes of avoiding some of the pitfalls that have befallen previous attempts at closing knowing-doing gaps.Through faculty development, faculty are indeed educated, in the traditional sense, to acquire new knowledge and skill, but they are also socialized to go on to form the systems and structures of their workplaces, as leaders and workers. Therefore, faculty development can not only mobilize knowledge, but also create knowledge mobilizers. Achieving this vision of faculty development as knowledge mobilization requires an acceptance of multiple sources of knowledge, including practice-based knowledge, and of multiple purposes for education and faculty development, including professional socialization. Many scholars in health professions education (HPE) have debated the relationship between education research and education practice, typically aiming to improve how education science is used in education practice –4. As a as knowledge mobilization offers a particularly fruitful and novel avenue for the exploration of the research-practice interface in HPE. While we are not the first to make this suggestion,[We argue that positioning faculty development ggestion, we have ggestion, and envimobilization over translation, in an attempt to resist the false dichotomy of ‘knowledge user’ and ‘knowledge creator’ that knowledge translation sets up. Second, we hope to avoid some of the pitfalls that have befallen previous attempts at closing knowing-doing gaps, by leveraging the documented strengths of faculty development against the documented critiques of knowledge mobilization. These arguments are meant to present a positive and novel view of the age-old research-practice gap, and to situate this view within HPE.To substantiate this assertion, first we explain our choice of the term knowledge We are specifically choosing the terminology of knowledge mobilization because it foregrounds a conception of fluid movement rather than hierarchical transmission of knowledge from research to practice. In making this linguistic choice, we were informed by critiques of knowledge translation that challenge its limited definition of knowledge as deriving from research alone. Such definitions are evidenced by commonly overheard conflations of ‘knowledge’ and ‘evidence’ in everyday conversation. ‘How can we move this knowledge into practice’, people ask, referring to a research-derived best practice as ‘the knowledge’.integrated knowledge translation (IKT),[users is an assumption that the process of knowledge translation is ultimately still about moving research knowledge, as the ‘real’ knowledge, into use in practice by practitioners as knowledge users [Yet education practitioners interact with many complex social processes and systems, and thus develop and draw upon many sources of knowledge. These various conceptions of knowledge can (and should) inform practice, such as: knowledge that remains largely tacit, knowledge that derives from workplace learning, knowledge that derives from social relationships and communities, knowledge that derives from practical and ethical reasoning, and knowledge that derives from social constructions, such as learning normative ways of acting within particular cultures and contexts –11. Focuon (IKT), in the cge users . In contThis step alone – choosing knowledge mobilization as HPE’s preferred terminology – will not in and of itself instil a collaborative relationship between research and practice. So we suggest that another step toward bridging research and practice in HPE is to leverage faculty development as a form of knowledge mobilization.and organizational goals,[Faculty development is a form of higher education, and one well-positioned to mobilize a plurality of knowledge sources in HPE. Faculty development is often defined as a process by which faculty, including preceptors teaching in the clinical setting, work to enhance their practice in education, leadership, scholarship, personal development, and professional development. Faculty development activities should align with and support both personal al goals, since inWhile the ‘content knowledge’ being shared through faculty development programming should be up-to-date and based upon research evidence, just as importantly, faculty development programs aim to value and build upon faculty’s experiential, personal, and contextual knowledge , 13. Theimportant, pedagogically [through practice and informal mechanisms like their networks, but research knowledge tends not to flow through these mechanisms and networks [To make our point and illustrate opportunities, we have presented faculty development as idealized, and knowledge mobilization as over-simplified. But to be fair, we recognize that there are many ready critiques of current faculty development approaches . For exaogically . These fnetworks , 18–20. narrowly defined is indeed insufficient for large-scale change, but that education can be conceptualized as far more than providing learners with knowledge and skill [Faculty development as a knowledge mobilizing enterprise re-frames this form of higher education as transformative education. In this framing, faculty development still includes the sharing of research-based and experiential knowledge on topics of interest , and also adds explicit attention to professional socialization of faculty as knowledge mobilizers and change agents . By posind skill . Throughnd skill , 25. Earnd skill . More exsocializes faculty to take on particular roles. Both faculty development and knowledge mobilization have room to grow and we suggest they may do so best, in the field of HPE, together.Faculty development creates relational spaces for educators’ practice-based knowledge to interact with education research knowledge. Thus faculty development can be conceptualized as a form of knowledge mobilization where faculty development activities and programs bridge research and practice, and the outcomes of this bridging include faculty becoming knowledge mobilizers themselves. As knowledge mobilizers, faculty become change agents in the system. Faculty development, in this image, can build cadres of change agents who bridge research- and practice-based knowledge about education in their everyday work and leadership. We suggest that this vision of faculty development as knowledge mobilization responds to critiques of traditional knowledge translation efforts. Achieving this vision of faculty development as knowledge mobilization requires an acceptance of multiple sources of knowledge, including practice-based knowledge, in an interactional, non-hierarchical relationship. It also requires a broadened understanding of education as more than knowledge and skill acquisition; faculty development, as an educational, knowledge mobilizing enterprise, also


When the task is reading nonwords aloud, skilled adult readers are very variable in the responses they produce: a nonword can evoke as many as 24 different responses in a group of such readers. Why is nonword reading so variable? We analysed a large database of reading responses to nonwords, which documented that two factors contribute to this variability. The first factor is variability in graphemic parsing (the parsing of a letter string into its constituent graphemes): the same nonword can be graphemically parsed in different ways by different readers. The second factor is phoneme assignment: even when all subjects produce the same graphemic parsing of a nonword, they vary in what phonemes they assign to the resulting set of graphemes. We consider the implications of these results for the computational modelling of reading, for the assessment of impairments of nonword reading, and for the study of reading aloud in other alphabetically written languages and in nonalphabetic writing systems. Amongst the reading-related abilities possessed by adult skilled readers of alphabetically written languages is the ability to read aloud a letter string which the reader has never encountered before: a pronounceable nonword, for example. Nonword reading is of importance for theories of reading for a number of reasons.One reason is that the ability to read nonwords—to ‘sound out’—is widely regarded as very important for learning to read. Young children who are in the process of learning to read will already have an auditory vocabulary of 10,000 words or more  but onlyAnother reason for the theoretical importance of nonword reading is that this ability responds selectively to brain damage suffered by previously literate people. In some such people, nonword reading is selectively impaired relative to word reading: this is ‘phonological dyslexia’ see . In otheAny theory of reading therefore needs to include an account of how nonword reading is accomplished. This is particularly true of computational models of reading, which originally had great difficulty in simulating nonword reading see , p. 57.Any attempt to account for how nonword reading is accomplished will need to confront the fact that nonword reading is very variable in adult skilled readers. For example, almost all of the 412 nonwords used in the nonword reading-aloud study by This response variability in responses to nonwords in a reading-aloud task is not a new finding.How might such variability in nonword reading be explained? This what we sought to investigate.tik is about as sensible as asking what its meaning is. What you are saying is this: If tik were an English word, how would it be pronounced? Since this is a counterfactual, it is logically no different from the question: If tik were an English word, what meaning would it have? Obviously a much better guess could be made about “the” pronunciation than the meaning. But it is just a guess nevertheless. Letter sequences “have” a pronunciation only if they spell words.’ Here Forster, perhaps at least partly with tongue in cheek, is challenging the common assessment practice of considering that a nonword has only one correct reading-aloud response (a point we return to in the ‘Discussion’) by proposing that a nonword has no correct reading-aloud response.There are various possibilities. One relatively uninteresting possibility is that the variability is largely unsystematic. Since there is no objective criterion for classifying a reading-aloud response to a nonword as correct or incorrect, it might be that what subjects do when attempting to perform this task is largely unconstrained and noisy, and little that is systematic will be discovered if such responses are scrutinised. A view of this kind has been proposed by is a systematicity in the way people read nonwords. If there were such systematicity, then what is it that varies systematically? A different possibility is that there It appears that these three processing components are distinct because each can be selectively impaired in patients with acquired dyslexia , as follThe acquired dyslexic patient MS  had a spnaming was almost perfect.The acquired dyslexic patient WB  had a spThe acquired dyslexic patient CB  had a spThe relevance to our paper of these results from acquired dyslexia is that they support the model shown in Differences in graphemic parsing (do subjects differ in how they parse a particular nonword?).Differences in phoneme assignment (do subjects differ with respect to what pronunciations they assign to particular graphemes?). This is the possibility that Differences in blending (do subjects differ with respect to how they blend the phonemes of a nonword?).We might expect three subject-based variables to be relevant here:Differences in graphemic parsing (do nonwords differ with respect to how variably they are parsed?).Differences in phoneme assignment (do nonwords differ with respect to how variably phonemes are assigned to their graphemes?).Differences in blending (do nonwords differ with respect to how variably they are blended?).The three subject-specific variables mentioned above might explain some of the variability on response made when nonwords are being read aloud, but there might also be item-specific variables influencing this variability. In Our goal in this paper is to explore the degree to which variability in reading-aloud responses to nonwords is influenced by each variable.Our analyses are based on existing data that were collected in the study by https://www.researchgate.net/publication/257938878_111020NonwordReading.There were 412 of these 1,475 phonologically and orthographically legal nonwords for which the two models produced different responses. These are the informative nonwords here, since for each of them one can determine which (if either) model response corresponds to the response adult skilled readers make. That allows an assessment of which model’s nonword reading procedure most resembles the nonword reading procedure used by adult skilled readers. Hence these 412 nonwords were given to 45 undergraduate university students to read aloud. The nonwords were presented in uppercase. There was no time pressure to respond. Each response was phonetically transcribed by two judges, one of them a trained phonetician. The set of 412 nonwords, and reading responses to them, is available at We pursued our aims by analysing the responses of the subjects in this nonword reading study. Out of 18,540 potential responses (45 subjects by 412 nonwords) in the database from this study, 422 (2.3%) were unavailable for analysis . Hence we had 18,118 responses to analyse.1A grapheme is the written representation of a phoneme. So a word with three phonemes must have three graphemes, regardless of how many letters it has cf. ., the number of graphemes into which a nonword is parsed should equal the number of phonemes in that nonword’s pronunciation. Given this, one would expect subjects to produce parsings where the number of graphemes in the stimulus equals the number of phonemes in the response. However, subjects might not always do this. If sometimes they do not, then different subjects would be producing different parsings, and therefore different reading-aloud responses, with the same nonword. We refer to parsings which violate the constraint that number of graphemes is equal to number of phonemes as ‘nonstandard parsings.’By the definition of ‘grapheme’Response /sprʌŋk/ indicating a parsing into the graphemes <S> <P> <R> <U> <N> <K>: here a new grapheme N has been inserted.Response /spɔːk/ indicating a parsing into the graphemes <S> <P> <K>: here an existing grapheme R has been omitted.Response /spraʊ/ indicating a parsing into the graphemes <S> <P> <R> <AU>: here an existing grapheme K has been omittedExamples of such nonstandard parsings from our dataset using the example nonword SPRAUK, whose standard parsing is to the graphemes <S> <P> <R> <K>, are:The number of nonstandard parsings in the set of 18,118 analysable responses was 2,199 (12.1%). Thus nonstandard graphemic parsing is not an uncommon occurrence when nonwords are read aloud.For the 15,919 reading-aloud responses which elicited standard parsings , each grapheme in the stimulus is unambiguously associated with one phoneme in the response, and vice versa. Such responses can be analysed to determine the extent to which a given subject always assigns the same phoneme to a given grapheme. They can also be analysed to determine the extent to which in any given nonword all subjects assign the same phonemes to that nonword’s graphemes.We only considered graphemes that occur in every subject’s set of responses at least four times, so as to make sure a grapheme has a reasonable chance of being read in different ways by different subjects. There were 36 such graphemes: GE, A, AU, B, C, CH, D, E, E.E, F, G, H, I, I.E, K, L, LL, M, N, O, O. E, OO, OW, O, P, PH, R, S, SH, T, TH, U, U.E, V, W, Y, Z  are different graphemes). The maximum frequency of occurrence of a grapheme in a subject’s set of responses was 114 (this was the grapheme L in many subjects’ sets of responses).On average, a grapheme from our target set of 36 graphemes occurred 30 times in subjects’ responses (from four to 114 times). If each subject produced standard parsings for all nonwords containing any one of the 36 graphemes, we would have 1,216 analysable Grapheme-Phoneme Correspondences (GPCs) per subject . This would render 54,720 data points in total as there are 45 subjects. However, not every subject parsed every one of the 36 graphemes out on every occasion . This left us with 48,269 grapheme–phoneme assignments to analyse.We define ‘standard phoneme assignment’ for any grapheme as the phoneme that occurs most often for that grapheme in the monosyllabic words of English, taking context and position into account. Subjects did not always use standard phoneme assignments. For example, the most common phoneme for the grapheme AU is /ɔː/, but other phonemes  were also assigned to this grapheme.Of the 48,269 grapheme–phoneme assignments we analysed, 4,230 (8.8%) were nonstandard assignments. Thus nonstandard phoneme assignment is not an uncommon occurrence when nonwords are read aloud.We mentioned above that differences at the blending stage might contribute to individual variability in response to nonword. However, we did not observe this. No subject ever failed to blend individual phonemes into an integrated syllable when reading aloud a nonword. Hence, variables 3 and 6 are not contributing to variability in nonword reading, and so we will not consider these variables further.Does the incidence of nonstandard graphemic parsings vary from subject to subject? The answer is Yes: Hence, we have established that one variable that contributes to variability in nonword reading is a difference between subjects in graphemic parsing (variable 1).Does the incidence of nonstandard phoneme assignments vary from subject to subject? The answer is Yes: Hence, we have established that another variable that contributes to variability in nonword reading is a difference between subjects in phoneme assignment (variable 2).how many different phonemes a particular subject assigns to a particular grapheme. We assessed this kind of variability by measuring entropy (H).Another variable that can be considered here is ip is the proportion of participants assigning the grapheme a particular phoneme. An H value of 0 denotes that participants were unanimous when assigning a phoneme to a particular grapheme, whereas high H values indicate high variability across subjects in what phoneme was assigned to that grapheme.To measure how variable the pronunciations given to graphemes are across all subjects, for each grapheme we calculated entropy H using the following formula from The value of H for each the 36 graphemes was calculated for each of the 45 subjects. Does phoneme assignment variability as indexed by H differ from subject to subject? Every subject had an H value of 0 for at least one grapheme: so for every subject there was at least one grapheme to which that subject consistently assigned the same phoneme. But as For example, Subject 42 had a mean H of 0.25—this subject tends not to assign many different phonemes to the same grapheme. In contrast, Subject 9 had a mean H of 0.71—this subject produces many different phonemes in response to some graphemes. To illustrate, both subjects always assigned the same phonemes to the graphemes B, D, F, Z in a consistent way, but whereas Subject 42 was also consistent at assigning phonemes to the graphemes GE, C, G, L, O, P, PH, R, T, CH, I.E, Subject 9 exhibited much variability for each of these graphemes—the last two graphemes were particularly unstable, with H values of 1.68 and 1.84, respectively (for these graphemes Subject 42 had Hs of 0). Subject 9 translated CH as /ʧ/ (three times), /k/ (11 times), /s/ (once), /ʃ/ (twice), /θ/ (once) , and I.E as /aɪ/ (once), /ɛ/ (once), /i/ (twice), /ɪ/ (three times) .Hence, we have established not only that subjects vary greatly in the degree to which they assign the standard phoneme to a grapheme, but also that they vary greatly in how many different phonemes they assign to a given grapheme .In this section we discuss variability in graphemic parsing and phoneme assignment from an item-based perspective.Does the way people perform graphemic parsing different from nonword to nonword? Yes. The percentage of nonstandard parsings varies across nonwords from 0% to 93.33% see .Thirty-nine nonwords out of 412 were always parsed in the standard way, by all participants. These included nonwords with single-letter graphemes such as BREC, MOLF, and NOF, but also nonwords with multi-letter graphemes such as OOSH, SNOWL, and THUSE.Nonwords like DONGE , SCROME , and GANC  evoked more variability, and produced the median level (9%) of nonstandard parsings .Nonwords with more than 50% of nonstandard parsings were, for example, GNEUTH  which had nonstandard parsings as in /gwɛnθ/, /knut/; PSIRP  which had nonstandard parsings as in /psɜːp/, /psɪrəp/; and CLALF  which had the nonstandard parsing as in /klæf/.A prominent feature of the nonstandard parsing data was that a multiletter vowel grapheme was often assigned two or more phonemes rather than one because the grapheme was parsed as not one, but two graphemes, on the basis of its constituent letters. Examples are given in gneuth /gənuθ/, where the single grapheme gn was nonstandardly treated as two graphemes. However, this occurred far less often than it did for multiletter vowel graphemes. The failures of graphemic parsing illustrated in This phenomenon was also seen with multiletter consonant graphemes as in the example Hence, we have observed that the percentage of nonstandard parsings varies from nonword to nonword: so variable 4 does contribute to variability in nonword reading.Does the way people perform phoneme assignment differ from nonword to nonword? This question cannot be addressed directly, because different nonwords consist of different graphemes. Instead, we can ask—is the variability of phoneme assignment different from grapheme to grapheme? If we find that some graphemes evoke more variability in phoneme assignment  across subjects than others, then it is legitimate to infer from this that nonwords containing these graphemes will also be pronounced more variably than those consisting of graphemes with a low entropy, which gives us the answer to our question.So for each of the 36 graphemes that a subject parsed out at least four times, we calculated grapheme entropy H across subjects i.e. how variable across subjects are assignments of phonemes to particular graphemes. Does phoneme assignment entropy differ from grapheme to grapheme? The mean value of H varies across graphemes, from 0  to 1.498 (grapheme Y). For example, the number of phonemes assigned to the grapheme I.E was highly variable across subjects. Some subjects consistently assigned just one phoneme to this grapheme in all nonwords that contained the grapheme . Other subjects were highly inconsistent in reading this grapheme in different nonwords  is contributing to variability in nonword reading.There is a great deal of variability across subjects in their tendency to graphemically parse nonwords in the standard way;There is a great deal of variability across subjects in the probability that they will assign the standard phonemes to graphemes;There is a great deal of variability across subjects in the number of phonemes they assign to particular graphemes;There is a great deal of variability across nonwords in their tendency to yield standard graphemic parsings;There is a great deal of variability across graphemes in the number of different phonemes assigned to graphemes.We have thus identified five factors which contribute to the variability of responding seen when skilled readers read nonwords aloud:the correct response when a subject is attempting to read a nonword aloud, simply because of the substantial variability on the actual responses produced when skilled readers of English read nonwords aloud.Although we would not follow In this paper we attempted to identify sources of the substantial variability in how people read English nonwords aloud. We adopted the account of nonword reading in English offered in Between-subject differences in grapheme parsing, i.e., subjects vary greatly in the degree to which they produce nonstandard graphemic parsings;Between-item differences in grapheme parsing, i.e., nonwords vary greatly in the number of different graphemic parsings the nonword yielded;Between-subject differences in phoneme assignment, i.e., subjects vary greatly in the degree to which they assign the standard phoneme to each grapheme, and also in the degree to which they assign a variety of different phonemes to any particular grapheme;Between-item differences in phoneme assignment, i.e., items vary greatly in the degree to which the standard phoneme to their graphemes, and also in the degree to which a variety of different phonemes is assigned to their graphemes.Variability in phoneme blending made no contribution here, because there was no such variability: all subjects always produce a blended set of phonemes  when reading aloud a nonword. In contrast, there was a great deal of variability, across subjects and across items, of both the graphemic parsing stage and the phoneme assignment stage. So our answer to the question ‘What are the reasons for the variability in nonword reading in healthy adult readers?’ isThese are the factors which underlie the variability of responses in the task of reading aloud nonwords.Our analyses in this paper have shown that some of this uncaptured variance is due to variability in what phonemes are assigned to graphemes. In the present version of DRC model, only one phoneme is associated with each grapheme, and we have observed here that there are only a few graphemes to which every human reader assigns a constant phoneme. This issue might be dealt with in future modelling work by investigating the suggestions by grapheme sets. Perhaps subjects who read aloud the nonword gwene as ‘/gwini/’ , the Woodcock Word Attack subtest  when children’s reading is being assessed. This is because a critical component of reading acquisition is the child’s ability to correctly derived phonology from print when the child encounters a word on the page that has never been seen before. Application of standard English GPCs will not achieve this for all words, but it will for the majority of such words , and therefore is a productive strategy that will assist learning to read. For that reason, it is important to assess just how well a child can produce GPC-governed responses when reading nonwords aloud.The correspondences between orthography and phonology are more complex and more subject to exceptions in English than is the case for any other language that is written alphabetically. Might this be one reason for the variability of nonword reading that we have documented here? What might one see if a nonword reading study corresponding to that of set of letters rather than just one letter. Any such letter set has to be treated as a unit, i.e., as a grapheme). What is more, the nonlexical mapping of hiragana or katakana characters to their pronunciations is fixed in Japanese: there are no words which disobey the standard mappings; that might be expected to reduce or even eliminate variability in reading nonwords written in hiragana or katakana.One might expect an even great deal of uniformity in nonword reading aloud when the script used is a syllabic one such as Japanese hiragana or katakana. This is because graphemic parsing, one source of variability in nonword reading, is not needed when reading these syllabic scripts, as there is one-to-one mapping from each individual kana character to its pronunciation. Alphabetic scripts are different because in most such scripts some phonemes are represented by a 10.7717/peerj.4879/supp-1Supplemental Information 1Click here for additional data file.


This paper provides an in-depth account of general practitioners’ (GPs) experiences of living and working with mental illness and distress, as part of a wider study reporting the barriers and facilitators to help-seeking for mental illness and burn-out, and sources of stress/distress for GP participants.Qualitative study using in-depth interviews with 47 GP participants. The interviews were audio recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method.England.A purposive sample of GP participants who self-identified as: (1) currently living with mental distress, (2) returning to work following treatment, (3) off sick or retired early as a result of mental distress or (4) without experience of mental distress. Interviews were conducted face to face or over the telephone.The findings report GP participants’ in-depth experiences of distress and mental illness with many recollecting their distressing experiences and significant psychological and physical symptoms relating to chronic stress, anxiety, depression and/or burn-out, and a quarter articulating thoughts of suicide. Many talked about their shame, humiliation and embarrassment at their perceived inability to cope with the stresses of their job and/or their symptoms of mental illness.These findings paint a concerning picture of the situation affecting primary care doctors, with participants’ accounts suggesting there is a considerable degree of mental ill health and reduced well-being among GPs. The solutions are complex and lie in prevention and provision. There needs to be greater recognition of the components and cumulative effect of occupational stressors for doctors, such as the increasing workload and the clinical and emotional demands of the job, as well as the need for a culture shift within medicine to more supportive and compassionate work environments. Few studies employing qualitative methods, using in-depth interviews, have been used to examine this topic and depict the experience of distress among general practitioners (GPs).This study carried out 47 interviews with GPs from across England and contributes to a growing body of research illuminating and examining the experience of living with chronic stress and distress among this population of doctors.Participants were self-selecting, which may be perceived as a limitation; however, the recruitment of participants ensured that the sample was varied in terms of age, gender, number of years as practising GPs, level of seniority/employment status in the practice and geographical location.This variation provided a range of perspectives; however, uniform differences between the groups were not observed.The researchers did not employ respondent validation; however, the second coders included academic GPs and team members with lived experience of mental illness which afforded some checks and balances to the validity of the analytical process, interpretation of data and generalisability of the research findings.In recruiting individuals with experience of mental illness and burn-out, we also included the perspectives of GPs who had no disclosed history of mental illness which enables the data to be more widely transferable to the UK GP population.The multidisciplinary research team independently analysed a subset of transcripts in order to contribute to the generation and refinement of codes to maximise rigour.Emergent themes were subsequently discussed by the whole team to ensure credibility and confirmability.Compared with the general population, doctors, including general practitioners (GPs) working in primary care, experience high levels of psychological distress linked to chronic stress, anxiety, depression and burn-out.4The increasing prevalence of mental ill health among the medical profession, including GPs, has been attributed to a number of factors, most notably the escalating occupational stresses related to workload, long hours and the emotional demands of the job.4 13 14 23Evidence of the extent of mental ill health and burn-out among GPs is largely derived from survey data, with some small-scale qualitative studies exploring the topic.This multicentre, qualitative study employed in-depth interviews with 47 GPs in England. Information about the study was advertised through professional publications such as Pulse, study newsletters, social media and national and local GP networks  in Bristol, Manchester and London. A subsample (n=12) was recruited through a specialist treatment service. GPs interested in taking part were asked to self-select into the following groups: (1) Living with anxiety, depression, stress and/or, burn-out; (2) Returning to work following treatment; (3) Off sick or retired early due to psychological ill health (4) No mental ill health. GPs were offered reimbursement of £80 to recognise the time for their participation.GPs who expressed an interest in participating were purposively sampled to represent as even a spread as possible across these four groups, although the largest number of participants were in group 1. We intended to recruit approximately 10 participants per group. However, the majority of GPs who contacted us self-selected into group 1 and, due to the emergent rich data, continued recruitment to this group and further exploration of emerging themes was justified in meeting the study’s aims and objectives. We endeavoured to recruit more participants into groups 2 and 4 using targeted publicity information, but because of time constraints those groups remained marginally under-recruited. In the event, many GPs who identified as living with no stress reported as having had experiences of stress and distress at some juncture in their career. More female GPs contacted the study team expressing an interest in participating, and therefore the disparity in numbers interviewed reflects this. The iterative process of recruitment, sampling and analysis ensured that emerging concepts and themes could be tested out among participants with different characteristics .Box 1Describe average working day in practice  and any additional responsibilities.Explore current well-being, feelings about work, levels of stress, work– life balance.Explore causes of stress/distress .Explore reasons for early retirement/sickness (if relevant).Explore how general practitioners (GPs) manage their workload/stress in their day-to-day work life, what they do to relax, to look after themselves .Explore relationship with colleagues and whether/how/if concerns are raised, how they are responded.Explore if GPs have received informal/formal supervision or mentor (1:1 or group) and experience/value of group.Explore thoughts/feelings about seeking help, barriers to seeking help .Face-to-face or telephone interviews lasting between 27 and 126 min (mean=69 min) were conducted between April and September 2016. The majority of interviews were conducted in participants’ homes. The in-depth interviews were conducted by two authors  using a flexible topic guide see . This waMembers of the multidisciplinary research team independently analysed a subset of transcripts in order to contribute to the generation and refinement of codes to maximise rigour. Emergent themes were discussed by the whole team to ensure credibility and confirmability.Willing participants were purposively sampled from GPs who expressed an interest in the study, based on demographic and practice characteristics as well as self-selected group type. The characteristics of the participants are found in Burn-out—loss of empathy or compassion fatigue, feeling empty and/or exhausted, difficulty making decisions, low job satisfaction and loss of enjoyment in seeing patients.Anxiety—psychological symptoms relating to anxiety, including feeling anxious or on edge, worrying, irritability, inability to relax and physical symptoms related to anxiety such as panic attacks, hyperventilating, palpitations, sweating and nausea.Depression—distressed at work, insomnia and exhaustion, negative thoughts, low self-esteem, irritability and anger.Suicidal ideation—thoughts of suicide.Shame, as well as feelings of failure and humiliation, resulting from a perceived lack of resilience and inability to cope.For this paper, we will present the following five main themes and corresponding subthemes relating to:It should be noted that some participants described or disclosed symptoms that could be clearly attributed to chronic stress, anxiety, depression and burn-out. Other participants described or framed their symptoms in terms of diagnostic concepts associated with these categories, while others talked about their feelings and emotional state without necessarily labelling them. Notably, the symptomatology was identified across all groups including group 4, that is, individuals who self-identified as having no mental health concerns. The themes also applied to participants irrespective of seniority or role in the practice, age or gender. There was no clear distinction in terms of presentation or severity of symptoms between the groups and so no typology could be developed along these lines.Some participants reported feeling a loss of empathy or compassion fatigue, feeling empty, exhaustion, difficulty making decisions, low job satisfaction and loss of enjoyment for their work, using language which highlights the depth of the feelings:I’d lost my empathy with my patients. You know, and er I’m just—I was just—you’re just like a ketchup bottle in a production line […] But from a personal point of view I’m still feeling a bit washed out by it, you know, I feel a little bit empty. You know, I feel like I’m burnt out really a bit, to be honest. I was saying all the right things but […] I felt quite detached from it. The following participant describes how feeling overworked can lead to a reduced ability to offer compassion and support to patients:If you find yourself working too many sessions, I can, you know, I feel it, and you almost feel like you lose the milk of human kindness. And you can’t do that job if you’re not (pause) at your best. The majority of participants, including those who self-identified as having no mental health concerns (group 4), described psychological symptoms relating to anxiety, including feeling on edge or hyperalert, persistent worrying, irritability and an inability to relax. The following examples demonstrate how difficult and distressing these symptoms and feelings were for some participants to negotiate:Everything was running around in my mind at 200 miles an hour. I was in sort of hyper drive and, yeah, you wake up to super stimulated, super awake, super, you know, on edge and anxious. Many participants also described physical symptoms related to their anxiety, such as panic attacks, hyperventilating, palpitations, sweating and nausea:Erm (pause) and I, and I was getting quite bad chest pain, palpitations, I was feeling anxious in many circumstances, like the school run, just meeting people, going to meetings and it was becoming incapacitating where it felt like somebody had got a knife in my chest all the time. And I knew it wasn’t anything to do with my heart. Many GP participants described symptoms relating to depression, which included: feeling distressed at work, low mood, hopelessness, sleep problems, low self-esteem, guilt, restlessness, fatigue and suicidal feelings. Some participants employed a range of poignant and powerful metaphors which illustrate the extent of those difficult emotions:And, to be honest with you, that kind of er—the best way that I could describe that is that it’s kind of like a dark shadow that’s in the corner of the room […] I basically felt like I was treading water but drowning slowly. Many participants recalled their experiences of feeling distressed, anxious and tearful, with some describing breaking down at home, after or during work or in front of patients:I mean there were times certainly when I arrived at work and just sat outside and cried before I even went in the building. And I often cried on the way home. I’d often cry when I came in from work, um just collapse in a heap, and get to bed actually crying. I remember once actually sitting under the desk, hugging my knees to my chest, I was so anxious. I would just end up in tears all the time at the end of each session. Among the myriad of symptoms, insomnia and exhaustion were a commonplace experience for study participants:Um - so I wasn’t sleeping and I wasn’t—wasn’t eating very well, and—and it just all sort of took its toll. It’s very hard to function when you’re not ever getting refreshing sleep […] And I just wouldn’t stop. And absolute, incapacitating terror. Um—So, but one’s having um—night, night terrors maybe two, three, four times a week. Sometimes more than one a night. Many GP participants detailed their exhaustion, which was often linked to insomnia and could be symptomatic of their anxiety, depression and/or feeling burnt-out, demonstrating the ways in which different elements of GP experience combine to add to distress:Probably like sort of swimming through treacle, so everything seemed—um—much harder. So like you can’t, you can’t avoid that fatigue. You might be able to put it off a bit (laughs) but you’re going to pay interest on it. Some participants talked about grappling with cycles of negative thoughts, symptomatic of low self-esteem and a common symptom of depression, as this participant illustrates:And so then I’m really struggling, because I’m struggling with my internal dialogue saying, you know, ‘Not good enough, could be doing a better job. Not really, not really er making people better.’ […] persistent negative cycles of er (pause), yeah, of negative thoughts about yourself Some study participants described feeling irritable and sometimes angry; a possible symptom of depression in this context:But I think, towards the end when I stopped locum-ing again, I was beginning to feel very tired as a result and that it was taking more out of me than it ought to really, and feeling um, yeah, feeling more irritable. This account demonstrates how feeling stressed and irritable can sometimes manifest itself within a work context:…it was fairly um traumatic really, I have to say… I think I’d become quite stressed at work actually and I’d lost my temper in meetings at times and um nobody quite knew what to do about it. One in four GP participants described having had suicidal thoughts, with the following participants reflecting on occasions when they had contemplated and ruminated on ways of taking their own lives:And it just came on me like a wave. And then I started thinking, ‘I’m going to jump onto those train tracks.’ And um constant ruminations on suicide and doing myself in. And the trick with suicide is to persuade yourself that those around you would be better off without you, um and I got to that point and I decided on ways that I might (pause) do myself in and ruminated about that all the time. Just, it just filled my waking and sleeping nights. This latter data extract demonstrates how suicidal thoughts can be both constant and normalised for some GPs.The following GP reflects on the advice she gives to her patients who express suicidal thoughts and how her feelings mirrored her patients’ expressed hopelessness and despair, again showing the ways in which GP experiences can combine to add to distress:Um, and then I think the hard thing, the worst thing I think I found was when people were feeling suicidal, and they were saying they were feeling suicidal and why they were feeling suicidal. And normally I’d be like, ‘Look, you know, it’s temporary, it’ll get better. These are the things that we can do,’ but I just sat there thinking, ‘Well, you’re probably right, it is rubbish,’ you know. Perhaps symptomatic of the stigma attached to mental illness and the culture of invulnerability within medicine, some GP participants described how they felt ashamed, embarrassed, humiliated and a sense of having failed, due to their perceived lack of resilience and inability to cope. These quotations illustrate the depth of that emotion for two of the participants:And you do feel a huge sense of shame, huge sense of shame. Because even though I treat patients day in, day out with anxiety and depression, it felt like this was my not coping. And I was thinking, ‘Why are the partners all able to cope with this but not me?’ and that sort of thing. So it was all rolled into one really. Er (sigh) yeah, I think for me it was very embarrassing. Didn’t want to admit it. Couldn’t believe that like I’d got to this stage. Cos I’d never been someone like that […] yeah, I did find it really hard, I think, to actually accept that this had happened. Um (pause) yeah, bit of a failure? I suppose, in a way. Kind of feel like you’re not strong enough? The participant below highlights how the denial and intolerance of mental ill health among some colleagues can enter into an individual’s internal dialogue, thus compounding existing feelings of shame:‘Yeah, well you don’t get ill, do you? You know, you, you refuse to accept any illness in yourself, don’t you? It’s just a question of that’s why doctors present late with illnesses because they don’t like to make a fuss. We see it as a sign of weakness, which I think probably is why we are intolerant of illness in our partners, because we’re doctors. And I think it’s just part of the sort of macho thing which is first drummed into you at medical school and the end product of that generation, which—if you can’t take the heat get out of the kitchen, type thing’. The accounts of the 47 participants in this study suggest there may be an undetermined population of GPs who are living and working with poor mental health. Participants vividly described and recollected their distressing experiences and troubling symptoms, with one in four GPs articulating thoughts of suicide. Such findings are currently under-reported in the literature with few studies providing evidence of suicidal thoughts and extreme levels of distress among this GP population. The GP participants described numerous troubling psychological and physical symptoms relating to chronic stress, anxiety, depression and/or burn-out with several breaking down at work—crying, feeling despair and some contemplating suicide. Many also talked about their shame, humiliation and embarrassment at their perceived inability to cope with the stresses of their job and/or their symptoms of mental ill health. The experiences and feelings of many GP participants depict a dispiriting emotional landscape, with notable signs of poor mental health and striking levels of distress.There has been a paucity of in-depth qualitative research exploring this topic area with doctors, including GPs.The findings from this study and the related papersThese findings present a concerning picture of psychological difficulties and reduced well-being affecting primary care doctors. The experience of chronic stress and anxiety in GPs  appears commonplace, including in those who did not identify themselves as having mental ill health. Our findings reflect the evidence that doctors frequently normalise, minimise, deflect or downplay how stressed they feel, which may preclude help-seeking and the availability of appropriate support.37Normalising and acknowledging chronic stress as an occupational hazard associated with being a doctor is helpful, but only if solutions are sought which focus on prevention and the provision of support to maintain the health and well-being of frontline clinicians. Since January 2017, GPs and GP trainees in England suffering from mental ill health and addiction have been able to access free support through the National Health Service’s GP Health Service.11Access to personal, relational and environmental resources are protective factors for good mental health and well-being and impact on individuals’ resilience.22Balint groups or similarly structured group work or supervision continue to be employed in general practice and are valued by GPs,Tackling the culture of invulnerability early on in medical training is also key. Schwartz Centre Rounds, for instance, are currently being piloted in medical schools with early evidence supporting their value.Greater recognition of the components and cumulative effect of the occupational stressors for doctors, such as increasing workload and the clinical and emotional demands of the job.A culture change within medicine, with a shift to more supportive and compassionate work cultures.The destigmatising of mental ill health and the recognition of GPs’ experiences and emotional responses as symptomatic of occupational stress as opposed to any perceived failure to cope in the individual.In the light of the findings of this study, we recommend the following:These findings, together with those from the wider study,