A growing number of studies shows that it is possible to induce a phenotypic transformation of cancer cells from malignant to benign. This process is currently known as “tumor reversion”. However, the concept of reversibility hardly fits the current cancer models, according to which gene mutations are considered the primary cause of cancer. Indeed, if gene mutations are causative carcinogenic factors, and if gene mutations are irreversible, how long should cancer be considered as an irreversible process? In fact, there is some evidence that intrinsic plasticity of cancerous cells may be therapeutically exploited to promote a phenotypic reprogramming, both in vitro and in vivo. Not only are studies on tumor reversion highlighting a new, exciting research approach, but they are also pushing science to look for new epistemological tools capable of better modeling cancer. The first clinical evidence of spontaneous cancer regression came from teratocarcinoma. In 1907, the Swiss pathologist, Max Askanazy, observed the spontaneous reversion of an ovarian teratocarcinoma .In 1959, Pierce made his first observations on the spontaneous differentiation of embryonal cancer cells deriving from testicular teratocarcinoma in the 129/SvJ mouse . Pierce In 1974, Brinster confirmed Pierce’s hypothesis. He injected testicular teratocarcinoma cells from the 129/SvJ black agouti into murine blastocysts, and then implanted these blastocysts into albino female mice. This resulted in a healthy black-white hybrid offspring, suggesting that “the embryo environment can bring under control the autonomous proliferation of the teratocarcinoma cells” . Similar“The capacity of embryonal carcinoma cells to form normally functioning adult tissues demonstrates that conversion to neoplasia did not involve structural changes in the genome, but rather a change in gene expression”.Subsequent experiments demonstrated the role of the embryonic microenvironment in controlling the proliferation of different cancer types such as Rous sarcoma , leukemiDespite this experimental evidence, the “reversion” approach in cancer research remains insufficiently explored. One reason may be in the epistemological tools needed to model reversion processes: experimental results on tumor reversion need a systemic approach in cancer modeling. This approach forces us to reconsider entire cancer models developed under a mainly reductionist approach. The aim of this article is, therefore, to investigate how the epistemological tools that we need to model tumor reversion processes may reshape our perspective on cancer and offer new heuristic models for cancer research. Rethinking the carcinogenic model is mandatory to plan a very different strategy in cancer treatment. During the last 40 years, the survival rate of patients suffering from different kinds of cancer has increased up to 20%. This is an appreciable result, although it mostly depended on early diagnosis and the development of improved surgical and radiation-based therapies, while medical treatments provided only marginal benefits in solid cancers . A similDifferent experimental models  have pro(a)Cancer cells display relevant plasticity, and their fate is not “irreversibly” determined.(b)It is possible to inhibit the phenotypic expression of the malignant characteristics of cancer cells mostly through epigenetic processes, although other mechanisms are likely to participate.(c)Depending on the tumor type and stage, some context-dependent conditions/constraints (such as those pertaining to the microenvironment of specific embryogenesis stages) can induce a phenotypic reversion of malignant cancer cells.(d)Gene mutations do not play a “causative” role as the somatic mutation theory (SMT) posits, albeit they can be associated throughout the process of cancer development.Besides the complexity of the experimental and interpretative framework, some conclusions from the most recurrent elements can be drawn, namely:Despite such experimental evidence, the concept of cancer reversibility has not been systematically explored. It is important to specify that reversibility does not mean the return of cancer cells to the original state. Rather, it indicates a phenotypic transformation during which cells lose their main malignant traits (migrating and invasive capabilities) and acquire a benign-like architecture. From a clinical point of view, this response can be associated with either regression or tumor dormancy. Eventually, fibrous transformation can occur.These results have been mostly underestimated, chiefly because current cancer models essentially rely on the somatic mutation theory (SMT). Indeed, the SMT focuses on gene mutations as the primary causes of cancer and can hardly provide a convincing explanation of the reversion process.Rather, the fact that cancer cells can undergo a phenotypic normalization without entailing their “mutational” status contradicts the very basic premises on which the SMT is grounded.This draws attention to the concept of phenotypic expression, that is, the process mediated by a complex network of signals and biological mechanisms that govern DNA expression. For a long time, specific genes were associated with certain functions and characteristics expressed at a phenotypic level: “a gene–a function” had become a sort of axiom. Based on this approach, the SMT has implicitly excluded the concept of tumor reversion: if the malignant cell characteristics are the result of genetic mutations, then it is impossible to eliminate them without first correcting these coding errors .However, the limits of the gene-centric view of cancer in accounting for certain experimental observations have already emerged.Notable is this quote from an editorial published in Nature Magazine, which clearly states that “it urge(s) us to revisit the role of gene mutations in cancer (...) if not gene mutations, what else could cause cancer?” .“the identities of mutant cancer genes varied considerably from one type of tumor to another (…) Each tumor seemed to represent a unique experiment of nature (…) We cannot really assimilate and interpret most of the data we accumulate. How is all this going to end? I wouldn’t pretend to know. It’s a job (…) for the next generation” ..189].The system can change state moving toward different attractors thanks to the bifurcation points that lead to a break in symmetry, that is, a metastable state that favors a sort of phase transition. The symmetry break gives the system a historical dimension, a sort of memory of an event that occurs at a critical point and will influence the next evolution. This leads to relevant consequences studied in depth by thermodynamics .From a thermodynamic perspective, a living organism is described as an open system that is far from equilibrium. It is characterized by dissipative structures that self-organize through fluctuations between stable and unstable states . Each flThe systemic perspective offers models, methodological tools, and a lexicon that can contribute to a more complete interpretation of tumor reversion processes.From this perspective, attention shifts from entities to relationships, from genes to the cellular context, and from the characteristics of DNA to the processes that guide the entire organization of cells in higher-level structures. We no longer interpret the tumor as an entity in itself but rather a pathology of biological organization.What Is Life? This famous physicist investigated what allows living organisms to remain the same over time and, therefore, their identity principle [The main issue relates to the concept of identity: what is cancer? Such a question recalls the famous essay by Erwin Schrödinger, rinciple .Clearly, DNA represents the element of continuity that, from cell division to cell division, reproduces copies of itself and maintains the unaltered, genetic “identity” of the cell. In this case, genetic identity refers to the precise sequence of purine and pyrimidine bases (ATCG).However, each cell expresses only some genes of the entire DNA. For this reason, different cell types are distinguished at the histological level: hepatocyte, neuron, cardiomyocyte, mesenchymal stem cell, etc., as their identity is defined “phenotypically”.hallmarks of cancer are criteria that do not allow us to affirm that the tumor cell owns a proper ontology, identified by a well-recognizable genotype; rather, the identification is based upon structural and behavioral traits [In fact, the well-known l traits ,195. MorSimilarly, tumor reversion represents a case of modification in phenotypic expression: the same genes, even if mutated, change the way they express and, consequently, the features and behavior of the cell. In this sense, research on tumor reversion shifts attention to the relationship between genotype and phenotype and aims to study the dynamics that direct the process of phenotypic expression.Increasing evidence shows that the idea of a linear correlation between genotype and phenotype does not correspond to the reality of biological dynamics . For a lThese processes can, in fact, be described using concepts such as network, network state, phase space, attractor, and epigenetic landscape. The phenotype can, therefore, be interpreted as a specific functional state of the cell that results from the expression of a well-defined combination of genes . These cPhenotypic changes are determined by one or more perturbations that destabilize the entire system. These perturbations cancel the action of the attractor corresponding to a specific state of phenotypic expression—a “valley”  or, in eIn addition, it should be considered that the phenotype characteristics are not determined exclusively by the activation or deactivation processes of gene expression, but also by processes of non-genetic plasticity that involve the dynamics of post-transcriptional regulation. This has also been observed in cancer cells ,201.All of these dynamics contribute to determining the functional state of individual cells, their organizational architecture, and, consequently, the characteristics from which functional tissues derive.Therefore, it is theoretically possible to identify a discrete and finite number of classes of attractors that correspond to the configurations allowed by their genetic and biophysical constraints. The set of these correlation constraints and environmental factors drastically reduces the number of conformations that the system can take by channeling the behavior of the cells ,186,202.In order to provide relevant information, this type of model requires a huge amount of data . For thiAn interesting example is the gene regulatory network (GNR). Genes are not independent entities but belong to complex networks known as “gene regulatory networks”. Here, genes influence and bind to each other, further limiting the possible combinations of gene expression .The GRN structure represents a constraint for the genes and a sort of “background field” that coordinates its functioning. Within the metaphor of the Waddington landscape, each valley corresponds to a stable state of phenotypic expression that derives from a precise configuration of the GNR . When a Since the stability of cell functional states also depends on external signals , this apWe are now able to interpret cancer as a particular state of the cell that evolves over time within the “landscape model”. This transition from one state to another is fundamentally determined by two variables: the external signals and constraints, and the internal adaptive response of the cell.Accordingly, cancer should be interpreted as an epiphenomenon that emerges from the disintegration of the cell–microenvironment system. Hence, it is essential to identify suitable indicators to highlight the state of system integration, as well as the correct level of observation.The consequent therapeutic strategy should, therefore, no longer try to eliminate tumor cells. Rather, it should aim to induce a benign modification of the phenotype. Tumor reversion research points out that this phenotypic change can be induced through specific biological signals. These modify the microenvironment or, more generally, the morphogenetic field, and channel the cell toward new stable states.Disease can be interpreted as a non-linear process that is subject to various subsystems, different attractors, and their multistability, resilience, and robustness. The redundancy of alternative pathways within the network allows the expression of the same phenotype through different attractors .The landscape model may also describe pathological states. Here, stable states  represent the physiological states of health, while unstable states (“hills”) represent the unstable processes that determine the onset of a pathology. When an external agent (a pathogen) disturbs the system, then the system tends to move away from its attractor and signals the fluctuation of certain critical parameters . The perBy modeling the disease process in this way, the sudden deterioration of a state can be seen as a phase of transition occurring at a bifurcation point .The various critical stages, as well as the pre-illness stage, therefore, correspond to bifurcation points. Here, the fate of the system depends on a set of internal and external conditions, which can guide the process toward very different destinies. Recognizing such critical points by building a dynamic network will likely help to understand the logic of the process . BiomarkIndeed, the current challenge is to move from molecular parameters linked to specific targets toward the system parameters of the pathological process and its state. This approach is partly developed through the study of metabolomics ,214, sinIn conclusion, it is impossible to deterministically predict the patho-phenotype of even a monogenic disease .We can read the pathological process as a complex and multilevel network of non-linear interactions between the various components of the organism. In fact, a complex network of non-linear interactions between stroma, extracellular matrix (ECM), and epithelium guides the development of tissues . The relMultilevel organization is an intrinsic characteristic of living organisms. The terms “organism” and “organization” share the same roots, from Greek ὄργανον  and ἔργον . Both terms refer to an energy aimed at a specific function. In other words, organism and organization are both structured systems for channeling energy in such a way as to perform a specific function.If a tumor is a “pathology of biological organization”, then network science offers the best language for defining it. Accordingly, we want to propose the use of the term “reorganization”, which refers to a transformation process directed toward a more organized state than the starting one. The empirical term “reversion” suggests a backwards process of the cells. The term “differentiation” does not take into account the spontaneous processes of apoptosis. The term “regression” says nothing about the typology of its cytotoxic, spontaneous, or differentiative processes. On the contrary, reorganization offers a more complete and centered perspective within the conceptual framework of the systemic approach. It does not refer exclusively to a single cell. Rather, it directs attention to the organizational aspect that can be both internal and external to the cell because there is a network of cells in the environment.We propose the introduction of the expression, “process of cellular reorganization”, to indicate a biological-state transition process.Several studies have shown that numerous molecular and biophysical factors—namely those obtained from eggs/embryonic cells/microenvironments—can efficiently promote the reversion of the cancerous phenotype toward a “normal” physiologic condition . Noticea


Healthcare personnel who deal with COVID-19 experience stigma. There is a lack of national-level representative qualitative data to study COVID-19-related stigma among healthcare workers in India. The present study explores factors associated with stigma and manifestations experienced by Indian healthcare workers involved in COVID-19 management. We conducted in-depth interviews across 10 centres in India, which were analysed using NVivo software version 12. Thematic and sentiment analysis was performed to gain deep insights into the complex phenomenon by categorising the qualitative data into meaningful and related categories. Healthcare workers (HCW) usually addressed the stigma they encountered when doing their COVID duties under the superordinate theme of stigma. Among them, 77.42% said they had been stigmatised in some way. Analyses revealed seven interrelated themes surrounding stigma among healthcare workers. It can be seen that the majority of the stigma and coping sentiments fall into the mixed category, followed by the negative sentiment category. This study contributes to our understanding of stigma and discrimination in low- and middle-income settings. Our data show that the emergence of fear of the virus has quickly turned into a stigma against healthcare workers. This is a study conducted in India to explore the stigma experienced by healthcare workers (HCWs) involved in managing COVID-19. The study aimed to understand the factors associated with stigma and its manifestations, with the goal of formulating intervention strategies to support HCWs.The study included 93 HCWs from 10 different sites across India. Data was collected through in-depth interviews, which focused on various aspects such as the impact of stigma on their jobs, family life and well-being, coping mechanisms and suggestions for reducing stigma. Thematic analysis was performed on the interview data using NVivo qualitative data analysis software.Social distance and discrimination: HCWs reported experiencing stigma and discrimination from the public due to their involvement in COVID-19 management. They shared instances where people avoided them, made negative comments or accused them of spreading the disease.Perceived stigma: Some HCWs perceived stigma even though they had not directly experienced it. They mentioned feeling a sense of worry or anxiety among people in their communities or social circles.Neighbourhood stigma: Many HCWs faced stigma from their neighbours and people in their communities. They described instances where neighbours avoided them, refused to talk to them or spread rumours about their work.Avoidance: HCWs expressed feelings of being avoided by known people. They mentioned instances where friends, relatives or even strangers ignored them, which led to a loss of self-esteem.The analysis revealed several themes related to stigma among HCWs:The study findings highlight the negative impact of stigma on HCWs’ lives and well-being. The experiences shared by HCWs indicate the need for intervention strategies to address and reduce stigma. By understanding the factors associated with stigma, policymakers and healthcare organisations can develop support measures and interventions tailored to the needs of HCWs.COVID-19 is a worldwide epidemic that has infected 486 million and killed hundreds of thousands of people. India, a country of over a billion people, pronounced inequity and inadequate healthcare systems make combating the pandemic a major challenge. Increased workload, institutional shifts, risk exposure and social stigma, the COVID-19 pandemic considerably impacted the healthcare staff (HCW), especially those involved in COVID-19 screening, tracing and treatment  of each site. This analysis was a part of a large multi-centric mixed-method study. There were 10 study sites across India , namely The data was collected from both public and private facilities from every site, which were chosen purposively based on the feasibility of approaching them. The study group consisted of doctors, nurses, ambulance emergency response teams, lab personnel, X-ray technicians and others who were directly involved in patient care in COVID-designated hospitals, from facilities involved in diagnosis, triaging and referrals services. The healthcare workers chosen for our study included accredited social health activists (ASHA) and community health workers who were involved in case identification, contact tracing, prevention and control measures. The healthcare workers were further stratified as those employed in private and public facilities. The larger study employed a cross-sectional design to calculate the sample size, assuming a 50% prevalence of psychological distress, a 15% non-compliance rate and an alpha error of 5%, with a relative precision of 10%. Quantitative data was collected from a total of 967 participants across the 10 states. To gain a deeper understanding of the stigma and its manifestations, approximately one-tenth of this sample size, which is approximately 93 participants, was included for qualitative investigation. The qualitative investigation covered a total of 93 participants across various sites, with 9–10 respondents per site. This sample size was considered sufficient to reach data saturation, which is crucial for comprehensive qualitative data analysis.In-depth interview: Based on the mutual convenience of the investigator and the participants, an appointment was arranged for a telephonic interview with 93 participants across 10 centres during October–December 2020. Consent forms and information sheets were then read out. An audio consent was obtained from the participants. Their consent was also acquired for the interview to be audio-recorded and also for the transcripts to be used in the future. The participants were also informed that they had the option to leave the study at any moment. After that, each interview was digitally recorded, and notes were taken at the same time. To protect the participants’ safety and privacy, any personal identifying information disclosed during the interview was encrypted. All interviews were translated from the local language to English and transcribed into a Word document. The interview focused on five primary areas: impact on their job, influence on family life, impact on the sense of well-being, coping with COVID-19 and suggestions for reducing the stigma associated with COVID-19. Each domain was given a set of questions to answer, followed by context-relevant probes to elucidate and unpack their responses, experiences and perceptions with respect to the phenomena under study (Supplementary Table 1).Thematic analysis: NVivo qualitative data analysis software, Version 12  was used to analyse the data. The site investigators reviewed the audio-recorded interviews before the analysis was conducted at the coordinating centre. The data was imported into the NVivo software package to link the concepts contained in the data. To gain deep insights into the intricate phenomenon, thematic analysis was performed by categorising the qualitative data into meaningful and related categories. The researcher (1) became familiarised with the content and information in the transcriptions; (2) read each transcription line by line to find keywords, meanings or concepts related to the study’s objectives; (3) refined coding by assembling similar codes and attempted to group codes together; (4) collected all texts coded with the same code in one place using the Microsoft Word programme; (5) organised and gathered all coded data into themes and (6) common themes were identified and inferences were drawn from them, with sample quotes chosen to illustrate the emerging themes.Sentiment analysis: NVivo’s sentiment scoring employs a scoring system. Each sentiment-containing word has a pre-determined score. Each sentiment node represents a range on a scale (of sentiment), ranging from very negative to very positive. Using the NVivo package “sentiment,” we calculated and aggregated text polarity sentiment at the coronavirus heading level and specific words of the phrases for insightful findings. The sentiment analysis software is based on a database of positive and negative words and phrases.  didn’t behave well. What can we do about it? They would close their doors and windows if they saw me coming from a distance. At marketplaces, people cover their faces when they see me. They would cross me or supersede me very fast by accelerating their vehicles. I even avoided my relatives completely. When I went to them, they went away. They didn’t want to be face-to-face with me. There was hatred in their minds. They would avoid me and would go away on seeing me.” – Ambulance driver, 55 years old, BhubaneswarPerceived stigmaPerceived stigma is entirely subjective, indicating how people perceive themselves to be stigmatised and believe they are subjected to discriminatory conduct by others, independent of the real stigmatic ideas and actions. During the interview, we found that a set of HCWs strongly perceive stigma although they have not experienced it.“They all asked whether I drive a vehicle with Covid patients. There was a function with 20 members near my house. It was an engagement function. Even though they had invited me, I feel that they would have worried thoughts in their minds. So, I didn’t attend that function so as to avoid unnecessary talks and complaints about me. I avoid going to most of the functions near my house, like engagements and birthday parties. Worry will be there in their minds as I am driving a vehicle with Corona patients.” – Ambulance driver, 30 years old, Male, Kerala“I cannot say that I have experienced something like that. During the initial COVID-19 period, people have expressed huge hatred for the disease. The local people near the sub-centre where I live had a fear or anxiety within them, especially during the initial days of the outbreak, but they have not expressed any highly intolerant hateful behaviour towards COVID-19.” – ASHA worker, 42 years old, Female, Dibrugarh“Ah, sometimes it’s evident from their body language, their actions, or at times, even from the individuals who don’t turn up when we expect. I remember when we had our first patient, even my staff stood at a distance.” - Doctor, 35 years old, Male, MeghalayaNeighbourhood stigma“My neighbours used to think that if I am working in the COVID-19 ward, I am COVID-19 positive myself. So, they stopped talking to me and my family. They used to hide inside on seeing me on the road. They even used to tell the vegetable and fruits vendors that she is working with Corona patients, so the vendors refused to sell me vegetables.” – Nurse, 33 years old, Female, JabalpurThe majority of people experienced stigma from their neighbourhood at some point in time. They faced this experience while coming home after performing duties such as going to the market, shopping, etc. Some of these participants experienced stigma in the neighbourhood where they had grown up or spent most of their lives. For example,“When we went to the village and when I used to say that I work in a hospital, people there avoided coming close to me. They were not even ready to talk to me. When I was quarantined in my house, my other brothers and friends also were not ready to come near me or meet me.” –X-ray technician, 56 years old, Male, Maharashtra“After 10 days of Covid-19 duty, I used to get 7 days to quarantine. During those 7 days, once I was passing through my neighbourhood to buy bananas, when I heard my neighbour saying, ‘Look at her, she is roaming around being in quarantine’. I even get worried about entering shops with my ID card, thinking it would worry the shopkeepers.” – Nurse, 47 years old, Female, Kerala“My neighbours and relatives kept a distance from me. Even after my report tested negative and I stayed isolated for three to four days, they said, ‘Brother, you stay away from us.’ If my car would get damaged, then nobody would give me a lift also.”– Nurse, 28 years old, Male, NoidaAvoidanceAvoidance-related stigmatising thoughts are connected with considerable loss of self-esteem. Some participants expressed the feelings that known people are avoiding them as described below.“Once I and my sister, who is also working in a hospital, were under a home quarantine routine, people often ignored us despite clear eye contact. It hurt us because we never knew their reason to avoid, but we consoled ourselves to their ignorance with times.” Nurse, 27 years old, Female, Dibrugarh“I mean, what happened was that those people who know about it, who understand this scenario, have fewer people in that category, as in 5–10% people in that context, despite knowing me. When they come to the hospital, their behaviour would be different, but if they remain around us, near us, then their behaviour would change, Or they keep some distance from you, something that we can call paranoia.” -Doctor, 32 years old, Male, Noida“It really hurts, they talk so much. I could come back home every day after work, as we didn’t come in direct contact with the patients and overall we were following protocols, so we were allowed to come home; we just had to transport the patients, but people take it otherwise, that is why there is this stigma in the society. It also affected my sister, but she is very brave, and she cares about me a lot. But even then, because of this, I didn’t stay at home anymore even though I could. I preferred staying in a hotel instead.”- Ambulance driver, 34 years old, Female, MeghalayaStigma at work placeStigma in the workplace can influence people’s attitudes and views about persons who are working in COVID care. A few proportion of people experienced this and shared their feelings. For example.“Whenever I encounter stigmatic experiences, I feel people are just using us; they didn’t bother me even when I am in a problematic situation. I have recently been posted in another district for COVID duty. The same department staff was scared to talk to me or come close to me since I came from Chennai. It makes me feel stressed.”- Nurse, 32 years old, Female, Chennai“Some staff at my workplace say that you’re working in a Covid ward and do not need to come near like that, wear the mask properly, and whatnot, like that. They used to say don’t come since you are working there; you might bring the disease and even get infected.” -Nurse, 32 years old, Female, MeghalayaStigma associated with landlordsFew HCW landlords forced HCW to vacate the facility on multiple occasions through various means because they were engaged in COVID-19 duties. They felt that the friendly neighbourhoods are turning into frigid, stigmatised zones of irrationality and bias. For example.“Our landlord started mentally mistreating us for staying in their house during the period just because we are COVID staff. People are afraid of us during door-to-door survey work in villages, even if we’re in PPE for the whole day. We are also not provided with govt. quarters while we were working with COVID.” – Community Health Worker, 29 years old, Male, Bhubaneshwar“Actually, when I used to stay with my landlord, I had to face a lot of issues, and it was really difficult for me to continue my stay there because I couldn’t change their mentality, and I also couldn’t stop working because of them. So, I discussed this in my hospital, and they allowed me to stay at a hotel. I used to stay in the hotel with the same people who were on COVID duty.” – Doctor, 27 years old“I can say that there’s a lot of stigmatisation on us, for example, if those who are staying in rented houses are healthcare workers, landlords don’t want to rent them anymore. We cannot go for a haircut because we are healthcare workers, and to be honest, sometimes we don’t get to do the everyday things we want to do because of stigmatisation.” – Nurse, 34 years old, Female, MeghalayaStigma among family members and friendsThey were few proportions of participants who felt stigma from close friends or family members. For example.“My friends stopped coming to me, and they stopped meeting me completely. So, everything had changed suddenly. Everything in my life is not the same and normal as before, and a lot has changed still. Since I have started doing the duty related to COVID, all this, I mean everything, has changed. Nobody has got anything to do with me, neither do I go to them.”- Nurse, 26 years old, Male, Noida“I mean, of course they are caring, but it is just that you know, like when your family members are scared of you, it is not a nice feeling. Especially when you feel accomplished at work, when you feel good at work, you have done something good and then come home at work, they appreciate you, but the home they are scared of you. When I am going home, they all will prepare not to stand in the way……in the workplace, we are okay because we are all on the same boat” -Doctor, 32 years old, Female, MeghalayaThe sentiment analysis of the stigma and the coping topic is shown in This study contributes to our understanding of discrimination in LMIC settings and the contextual factors that influence it in India. Our interview data show the emergence of COVID-19-related stigma; fear of the virus quickly turned into fear of discrimination against HCWs because HCWs are involved in the care of COVID-19 patients. Similar findings were found during the early stages of the pandemic in India as well as globally, where a relatively high level of stigma associated with COVID-19 was observed among HCWs , ranging from very negative to very positive. The study concluded that the majority of the stigma and coping sentiments fall into the mixed category, followed by the negative sentiment category.Grover et al. supplementary material Respected Sir/Madam,
We wish to submit an original research article entitled “Stigma drivers and manifestations experienced by Indian Health Care Workers involved in COVID-19 management in India: A Qualitative study” for consideration by your renowned Journal. We confirm that this work is original and has not been published elsewhere, nor is it currently under consideration for publication elsewhere.
In this manuscript, we have reported that Healthcare workers (HCW) usually addressed the Stigma they encountered when doing their COVID duties under the superordinate theme of Stigma. Among them, 77.42 % said they had been stigmatized in any way. Analyses revealed seven interrelated themes surrounding Stigma among health-care workers. It can be seen that the majority of the Stigma and coping sentiments fall into the mixed category, followed by the negative sentiment category.
This study contributes to our understanding of stigma and discrimination in low- and middle-income settings. Our data show that the emergence of fear of the virus has quickly turned into a stigma against Health-care workers.
We believe that this manuscript is appropriate for publication by your renowned journal because it specifically aims at public and mental health problem and concept of Cambridge Prisms: Global Mental Health which are among one of the main objectives of your journal.
In this study we conducted in-depth interview across ten centers in India which was analyzed using NVivo software version 12. Thematic and sentiment analysis was performed to gain deep insights into the complex phenomenon by categorizing the qualitative data into meaningful and related categories.
Cambridge Prisms: Global Mental Health being a pioneer journal in field of Mental health and Medicine is a perfect place for this type of work as the readership of this journal is quiet interested in viewing research work which would address the areas that are untouched or have very few literature available.
We have no conflicts of interest to disclose. I am happy to accept this paper in its present form. This paper presents the results of a qualitative study examining the experiences of stigma faced by 93 healthcare workers from 10 distinct centers in India in relation to the COVID-19 pandemic.As there are few studies of this type and methodology covering this population in the given region, the results presented here are important from a public health policy perspective.Certain aspects of this paper require correction or clarification, and these are enumerated below:1. The term “stigma drivers” is not a standard one used in the literature. Moreover, as this is a qualitative study, direct inferences regarding causality or mediation cannot be drawn. It would be better to use a neutral term such as “Factors associated with stigma” in the title as well as the text.2. In the introduction, the authors refer to “200 COVID-19 related atrocities”. However, a careful reading of the original paper cited by them suggests that this term is somewhat exaggerated. The incidents described in the original paper cover a wide range of experiences, from subtle forms of discrimination / avoidance to actual acts of physical violence. Moreover, these are related not so much to “COVID-19” as to stigma, fear of infection, fear contagion, etc. This sentence should be reworded more carefully to underline the links between fear of COVID-19, fear contagion in groups / communities, stigmatization of those perceived to be “infectious”  and the wide range of problems they may face as a result, ranging from exclusion / avoidance to actual “atrocities” .3. The Introduction is somewhat limited in its scope as it focuses mainly on older literature from the period 2020-2021. Recent research in this field, particularly from the same geographical region, could be cited. Some studies worth mentioning in this regard are: Giri et al. (2022), Narita et al. (2023), Gaber et al. (2023), and Sachdeva et al. (2022) - the latter involving Indian healthcare workers. This literature should be cited and discussed where appropriate both in the Introduction and in the Discussion.4. Given the authors' concerns about including a wide range of healthcare workers, the authors should provide more details about the sampling method / sample size estimation. Was a representative number of staff from each category  recruited from each center? This should be mentioned in the Methodology. Any barriers to recruitment / frequent refusals and the reasons for the same could also be mentioned.5. Concerning the Discussion, see point #3 above. The authors could also discuss more specialized studies, such as those covering violence against healthcare workers during the pandemic  or other Indian studies that have been published in 2022-2023 .6. Many of the authors of this study appear to have conducted a similar study in 2021 (https://doi.org/10.4103/ijmr.ijmr_2204_21); it would be useful to compare the results they have obtained there with those of the current study.7. Figures 2 and 7 are not very informative and may either be deleted, or submitted as supplementary material. No accompanying comment. No accompanying comment. Dear [Editor’s Name],
I hope this letter finds you well. I am writing to submit the revised version of our article entitled “Factors associated with stigma and manifestations experienced by Indian Health Care Workers involved in COVID-19 management in India: A Qualitative Study” for consideration in “Cambridge Prisms: Global Mental Health.” We greatly appreciate the opportunity to revise and resubmit our work following the constructive feedback provided by the reviewers.
We are grateful for the valuable feedback and suggestions provided by the reviewers, which have undoubtedly strengthened the quality and contribution of our research. We have carefully addressed each point raised, and have made significant revisions to improve the clarity, organization, and overall impact of our article.
We believe that the revisions have significantly improved the quality and contribution of our article and have addressed the concerns raised by the reviewers. We remain confident that our work aligns with the scope and objectives of “Cambridge Prisms: Global Mental Health” and will be of interest to its readership.
Thank you once again for considering our revised submission. We are grateful for the opportunity to contribute to the field of global mental health through the esteemed platform provided by “Cambridge Prisms.” We remain committed to working closely with the editorial team to ensure the successful publication of our article.
Please find attached the revised version of our manuscript in Microsoft Word format, along with a point-by-point response to the reviewers' comments.
Thank you for your time and consideration.
Sincerely,
Dr U Venkatesh
Assistant Professor
Department of Community Medicine & Family Medicine
AIIMS Gorakhpur The revisions made by the authors are satisfactory in my opinion. I have no further major changes or corrections to suggest. No accompanying comment. No accompanying comment.


This is a peer-review report submitted for the paper “In-hospital Mortality and the Predictive Ability of the Modified Early Warning Score in Ghana: Single-Center, Retrospective Study”This paper  describeThe two objectives were not described precisely nor were they carefully tied to the methodology. For example, the first objective refers to both “prediction” and “detection” of “deterioration.” It is not clear whether the methodology measures prediction or detection, and it is not clear how deterioration is defined. Mortality is prominent in the results, so this paper might be using mortality as a synonym of deterioration, but that is not clear. In addition, both objectives refer to MEWS, but the results give equal attention to MEWS and LMEWS; it is not clear whether LMEWS is a synonym for the “physiologic measures currently monitored” in the second objective statement; otherwise, LMEWS should be added to both objective statements along with MEWS. In either case, “physiologic measures currently monitored” should be carefully and clearly defined before being used in a statement of objectives.P value of the Hosmer-Lemeshow goodness-of-fit test because I am not familiar with this particular measure. Unfortunately, the reporting of the results did not explain the measure at all.Several statistical measures and tests were reported without being described or explained. I am familiar with some of them, such as the C-statistic, but a reader who is not would need some context for the numbers 0.838 and 0.833—something along the lines of, “where 1.000 means perfect accuracy and 0.500 means perfectly random associations (or ‘the flip of a coin’).” I am not able to suggest explanations for the Pearson chi-square value or the Hosmer-Lemeshow goodness-of-fit test, or the The order of MEWS and LMEWS results is completely inconsistent; please always report LMEWS before MEWS or always report MEWS before LMEWS.Abstract contains an extraneous semicolon, and the third sentence of the Abstract contains an extraneous comma.The grammar and punctuation should be edited throughout; for example, the second sentence of the


Food insecurity continues to be a problem throughout the world. When estimating food insecurity, few studies analyze the contexts where the phenomenon takes place. By bearing in mind levels of marginalization in four states of Mexico, this paper answers two questions: (I) What problems are experienced with access to food, and how these difficulties affect the amount of food consumed in households? and (II) How do households experience the concern of running out of food?Our qualitative study draws data from urban and semi-urban areas of four Mexican states: Mexico City, Tamaulipas, the State of Mexico, and Oaxaca. Each state presents different levels of well-being. The study’s participants are selected using the snowball method. Eligibility criteria are based on demographic characteristics such as education, age, and gender. A thematic analytical approach is conducted to analyze collected data from a total of 212 semi-structured interviews.quincena in México. This psychological state of mind changes through the payday cycle, a period when the direct relationship between food accessibility and consumption weakens. In response, individuals develop strategies to cope with the uncertainty of experiencing food insecurity, such as rationing food portions and/or hoarding food supplies. Even when food accessibility exists, interviewees identify insufficient income as the primary issue in contexts of low and very low levels of marginalization.The study’s findings indicate that concern of food scarcity is a generalized feeling among participants across different levels of marginalization. Individuals with stable jobs living in contexts of low levels of marginalization experience worriedness when their budgets tightened before the end of the payday, a bi-weekly payment format, named the quincena’s end, food insecurity increases, even in contexts of very low marginalization. Our study calls for rethinking the scales employed to measure food insecurity, specifically the questions related to fear of food scarcity. Coping strategies are implemented by surveyed individuals to resolve issues and repercussions that emerge from experiencing food insecurity differ by context of marginalization.Conclusive remarks drawn from our analysis underline the importance of the context of marginalization in influencing households’ experiences with food insecurity. At the  Food provides the basic physical and psychological means to obtain and maintain well-being. The concept of wellbeing integrates objective factors such as health, income, and food as well as subjective factors such as perceptions of a satisfactory lifestyle, built environment, and social capital . Within Approximately 2.3 billion people lack access to food . RecentlFood insecurity is measured through different instruments including the Food Security Scale of Latin America and the Caribbean (ELCSA), the FAO Food Insecurity Experience Scale (FIES) and the Mexican Food Insecurity Scale (EMSA). EMSA shares the purpose of the FIES and ELCSA within the Mexican context. These instruments typically include the following dimensions: (a) the concern about food scarcity in the household; (b) the quantity and quality of food; (c) the omission of any of the meals by household members; (d) the sensation of hunger by household members; and (e) the suspension of any of the meals in the household due to lack of money and/or other resources. Undoubtedly, scales to measure food insecurity incorporate solid dimensions of analysis that guarantee validity and reliability . In addiPeople who suffer from food insecurity see their living standards decline , their pAccording to the National Council of Evaluation (CONEVAL – in Spanish), only 57.8% of the Mexican population can secure food for consumption, while 42.2% (around 53.5 million people) experience food insecurity . ApproxiFood insecurity has a different impact on urban, semi-urban, and rural areas . SubjectFurthermore, food insecurity is aggravated with the presence of children and older adults . When a Regional contexts and other socioeconomic factors also determine food insecurity. Consequently, analyzing how experiences of food insecurity are shaped by diverse contexts of marginalization is of the utmost importance to advance the study of food insecurity. Our analysis addresses the following two questions: (I) What problems are experienced with food access, and how this affects the amount of food consumed in households? (II) How do households experience the concern of running out of food? We argue that a study on contemporary food insecurity demands an insightful analysis to design competent public policies. Our study accounts for the context where food insecurity is generated and regenerated. By considering levels of marginalization, findings from this study indicate that food insecurity breeds diverse experiences. In this sense, the gap this effort aims to close is rethinking how food insecurity is measured by delving into how the context of marginalization can affect food accessibility, food consumption, and the concern of food scarcity. The study’s ultimate objective aims at rethinking current scales utilized to measure food insecurity.The study accounts for four central measures: food access, the amount of food consumed, concern about food scarcity, and levels of marginalization. The first three measures build upon FAO ’s concepthe Consejo Nacional de Población  to gauge levels of marginalization at the territorial level. The IMM considers states and municipalities as units of analysis  ends up being a little bit cheaper…[tianguis] is better in terms of quality and price almost all the time… When there are sales of something in the supermarket we buy [in this venue], but at times…fruits are no tripe enough, even though [they are] cheaper. You end up throwing them away.” (31-year-old woman)“[We buy] in the tianguis because fruits and vegetables are fresher and cost less and are of higher quality. [We buy sometimes] in the supermarkets because sometimes buying a little bit of more quantity helps you in planning until the next quincena.” (40-year-old woman)Based on the IMM, households with very low levels of marginalization display the highest living standards of the sample. 93% of the interviewees have no issues with accessibility. To supply food demands, participants visit near convenient venues, including supermarkets and “Well yes, lately we’ve tried to increase food variety because before, well no, I believe that all these [factors] influence to be in good health. And now, when one is sick, now, one tries to eat better.” “Yes, thanks God, now we do plan for the week, what’s needed for [food] consumption over the week.” (45-year-old woman)“Mh well […] sometimes it’s like this, because at times it’s not enough now. Yes, the money, but lately, we’ve prevented this [shortage]. Well, thanks God we are better established, that is, better programmed on what needs to be purchased in the weekends for the rest of the week. Afterwards, we buy [food] as needed.” Regarding consumption, 71% of the participants have enough food to satisfy the household’s needs. In this respect, 66% of respondents can maintain—what they considered to be—a variety diet, particularly when medical recommendations are given and associated with the presence of a(n) ill family member(s) in the household. Nonetheless, some of these interviewees recognize the negative impact their low earnings have on the quality and quantity of food purchases. Food portions are insufficient to feed all family members.“No difficult, it is not difficult, because there is food everywhere, the problem one has is no money, that’s the problem.” .“Well, to save [you buy] in the supermarkets […] one only visits the [convenient] store only because you are in a hurry. In big establishments [supermarkets], we don’t save much but we can buy more things.” (40-year-old woman).In contexts of low levels of marginalization, 73% of the interviewees face no difficulties purchasing food in their neighborhoods. The main criterion for food selection is a combination of price, location, and quality. Despite having no difficulties with food availability, low-income levels remain the primary issue that limits the interviewees’ ability to secure food for consumption within a context of high levels of IMM:“Yes, we always plan for all of us to eat. Something our parents have taught us, our grandparents, is that always all [family members] need to eat and the parents are the last ones to be fed, right? Parents sacrifice themselves for their children. But well, we are not expecting to sacrifice ourselves. We hope that all [family members] are satisfied.” In this category, almost all interviewees (94%) report having enough food to meet household needs. Even though some participants face difficulties, they have not skipped any of the three daily meals. Nonetheless, some of these participants must reduce food consumption to secure supplies for the entire family. A three-meal pattern is an eating habit that appears in contemporary societies to replace de-structured forms that involved greater breaks between food intakes, snacking and non-ritualized settings of food consumption . Such pa“Sometimes we look for the cheapest food, to make ends meet.” (35-year-old woman)“Well yes, because there is sometimes well…if we don’t have enough, we must figure it out…if I’m going to [usually] eat two or three tortillas, well, I only eat one [tortilla] so there are enough [tortillas] left for my children.” (39-year-old woman)“We don’t have enough to buy everything at once […] if you buy chicken, then you don’t buy milk. If you buy milk, you don’t buy, well, fruits, or buy fruits and no milk […] I mean there is always something lacking.” (37-year-old woman).Despite having no issues with accessibility, individuals are unable to purchase food of high quality due to their low earnings. Generalized low levels of income across categories of marginalization underline a distinction between issues related to accessibility versus consumption. Living in a neighborhood that grants access to food does not necessarily guarantee that required levels of food consumption to be in good health will be met:tianguis or convenient stores can be found nearby. Once again, the low earnings are still reported as the primordial limitation to buying enough food.“I believe that right now, no, it’s not difficult to get food…the difficulty is to have the economic resources to be able to…well, to obtain it. And well, I believe that this is the most difficult.” .tianguis, convenient stores, and supermarkets comprise places where interviewees purchase food, setting as main criteria for food selection: price, quality, and variety.In this category, “At different stands of the tianguis, for example, at the butchery that we have here, the fruit store. Also, there is Lores (a self-service store). We also go to Tuxtepec, to the big stands that they have. Sometimes we take advantage of going to Tuxtepec, and just get there, and calculate where food is a little cheaper.” .“The other advantage that we have is that we live only ten minutes away from the city of Huajuapan de León. There, one can find practically everything.” (40-year-old woman).quincena’s end. Other expenditures take prominence in the household’s budget. Consequently, resources allocated for food consumption and purchases of high-quality food are reduced:Regarding food consumption, 85% of surveyed individuals indicate that no family member has gone a day without eating food. However, the same interviewees must skip one of the three meals of the day in addition to reducing food quantity and quality. These participants must prioritize the payment of other expenses in the household (such as the imbursement of utilities) to make ends meet all the way to the “Mh no, thanks God, at least beans, we’ve had food to be able to eat the three meals of the day.” “Here sincerely well […] for lack of employment […] sometimes we’ve not had enough economic liquidity [financial stability] to be able to eat three times a day. But my daughters do, I try my best so they can always have three meals per day. At least we always eat beans and eggs.” (42-year-old woman)Resembling descriptions from the previous category, localities characterized by medium levels of marginalization experience no difficulties with accessibility. In these neighborhoods, enough venues to purchase food such as a Interviewees at very high and high levels of marginalization live in the most vulnerable contexts. Even though these areas are considered semi-urban localities, they are still located at a far distance from urban centers. Among participants under this category, food accessibility issues are present. The long commute from homes to urban centers creates a natural barrier to access food. Experiencing issues with transportation also enlarges the distance and increases the time to gain accessibility. Issues with transportation—such as not owning a vehicle or having to take several rides to reach the closest urban center—impose a serious inconvenience to approach centers of food distribution. In this case, participants strive to find areas/neighborhoods where food stores offer variety, higher quality, and lower prices:“In Santa Fe, the municipal head, this is where I purchase, every Sunday holds a market. And, well, there are some who purchase two weeks of food supplies, but it depends on one’s budget, also. But to go to Santa Fe, you must also pay the bus fare or find someone to give you a ride, and one only pays gasoline expenses. The trip lasts almost an hour” .“… When we go to Ixtlahuaca, days before we put some coins aside …for example, the [cooking] oil is a little bit cheaper in Supercompras [convenient store] or Soriana [supermarket].” .“To be able to feed ourselves with a variety of foods, unfortunately sometimes, one cannot [do so] for the low salary or the high prices of the basic consumption basket. You go and purchase something from the store and spend 100 [Mexican pesos], 200 [Mexican pesos], one does not earn [those monies] in one day.” .“[…] If there is no money, sometimes only for example you buy, what can I tell you? potatoes and there will be no meat, and there are […] no other things, the cheese, the milk, or something like this. And well, it’s like this under these conditions.” (47-year-old woman).Limited consumption of food represents a serious challenge. Purchasing food outside of the neighborhood signifies a higher cost. In addition to low-income levels, the context indirectly reduces the quantity and quality of food to be purchased. As a result, 93% of the interviewees acknowledge the lack of economic resources to afford a variety diet:“Above all, at the end of the payday, there is not much money, well like I was telling you at the beginning, we must look for substitutes or look for less expensive food.” (32-year-old woman).“It happened at some moment that I was laid off. I was very sad but, did not last long…  [w]e stopped having dinners to economize [reduce cost].” (35-year-old woman).The descriptions above are supported by 48% of the interviewees, who after identifying the sharp increase in food prices had to reduce food quantity and quality due to insufficient disposable income. In this category, 80% of the interviewees have had to eliminate one of the three meals of the day:“It’s a little of a difficult situation to set limits and limits more on what relates to food or to stop doing other things to be able to eat […] First and foremost is food, but at times, other factors gain [prominence] and you must stop doing something to cover [these expenses], taking a toll on nourishment.” (56-year-old woman)At low levels of marginalization, interviewees prioritize buying sufficient food supplies. Nourishment is counted as one of the primary factors of well-being among participants in this category. The novel finding in this regard is how decreasing income levels negatively impact consumption among individuals, who are presumed to hold the highest standards of living:quincena’s end. For some interviewees, job instability or precarity becomes a key factor that increases levels of concern in a context often assumed to have individuals with sufficient income to meet food demands:“Now, well, when one is working you don’t feel it, because to say something, we get a good job in two or three weeks and there we must move forward while another good job drops on us.” “Oh, true that! Because sometimes one says: damned! The money is gone, and I am in need [of food] and the pantry is empty, and I don’t have [money].” (42-year-old woman)In this category, around 56% of the participants feel concerned about the possibility of running out of food, particularly at the “Well yes, yes, yes, really, I’ve worried about food. I mean about food supplies, because well, one can handle everything little by little, but well […] my children.” (34-year-old woman)Mirroring findings from the category described above, interviewees from low levels of marginalization also feel concerned over the possibility of facing food scarcity, particularly individuals with children.quincena or when food demands cannot be met due to lack of money. Their uncertainty relates to participants not having a permanent job that provides a stable source of income. Medical expenses incurred by the household to unexpected illnesses tighten the family budget, restraining individuals’ ability to work. The difficult condition further reduces the low income earned in unstable-part-time jobs. In these case scenarios, food insecurity exacerbates when a breadwinner suffers a sickness-related setback:“Obviously, I’m the head of the household and I’ve felt sick and have not had the chance to work, so they deduct from my salary the days that I don’t work “At the end of the quincena, [there] is not enough [money] to purchase meat or chicken sometimes, one needs to eat more plain things.” (29-year-old woman)“Yes, well there are things that we cannot buy, for instance, canned tuna or things like that are more expensive. For example, I buy cheddar cheese or double cream cheese, but cheaper, but they would like to have gouda cheese, but this one is more expensive. Well, one would like to have turkey breast, but it costs more, and there are some [turkey breasts] that are very cheap, but don’t taste good […] So, there are things that we cannot buy.” This cluster of participants manifests less frequent worries. Nonetheless, worriedness intensifies at the end of the quincena. Lack of money is the reason why some participants accumulate non-perishable edibles to guarantee supplies for the family. With the purpose of stretching out already depleted supplies, food is accumulated until the next quincena’s payment:“Yes, we’ve been worried because when we’ve nothing in the pantry and there are still days left before the pay day[…] That, generates a lot of concern.” (57-year-old woman)“When one has money all the month’s pantry is purchased—the non-perishable food staples—and then, one only buys perishable items daily.” In this classification, interviewees express worriedness about food scarcity. Several interviewees pursue strategies to avoid skipping one of the three meals of the day. Once again, not having enough money increases feelings of concern about food scarcity. The level of concern intensifies days before the “Well […] no, it feels really bad, isn’t? One gets desperate, you can say at the beginning, if someone gives us a taco or something like that, one says: well no, I don’t want to be in that situation—well, it does feel ugly, one reacts and says: well, work hard, hustle it!—and there is no way out but that’s it! Thanks God! here we go, our economy began to improve.” (65-year-old woman)In this category, 67% of the interviewees identify feelings of concern over the possibility of running out of food or not being able to satisfy their needs or those of family members, particularly when children and/or older adults are present in the household. Some interviewees have confronted food scarcity in the past. This experience severely impacts their perceptions of uncertainty and concern about running out of food again. In this situation, individuals struggle to ensure food supplies, granting priority to buying food above paying other household expenses:“Feeding has always been my priority […] then, I believe that, well, is the last item that I would cut back from the budget even though everything is more and more expensive overtime.” “Ungracefully, the farmer is no longer harvesting the land […] and it’s going to be a fucking moment when we will have no food. And even, if we have the fucking money to buy food, there is not going to be food.” A significant share of interviewees in this category identifies two key factors of concern: increasing food prices (100% of the participants) and a decline in agricultural production (67% of the participants):A plethora of factors generate food insecurity including mounting poverty, unemployment, and inflation . Based oEvidence from this study demonstrates that individuals who experience food insecurity adopt preventive strategies to confront and resolve food insecurity. Coping strategies become stricter as the worriedness of facing food scarcity in the household materializes. Coping mechanisms are not necessarily more difficult to endure because of restricted food access, as previously discussed , but, beThus, a linear path between food access and consumption does not necessarily follow. In contexts that present very high and high levels of marginalization, food insecurity is experienced differently compared to households with medium and lower levels of marginalization. In the latter, issues with accessibility are resolved. Nonetheless, accessibility does not guarantee consumption among individuals who despite being employed in white collar occupations experience a severe decline of purchasing power through the payment cycle due to depressed salaries and high levels of inflation.Households located in contexts with very high and high levels of marginalization face difficulties with ensuring the supplies needed for a varied diet, considering the issues with food accessibility that characterize semi-urban areas. These geographies tend to be sparsely populated and as a result encounter difficulties with transportation more often . IndividConsequently, some interviewees report not eating one of the three daily meals, while the other two meals are insufficient and consist of low-quality ingredients and small portions. Modifications on consumption increment the degree of food insecurity . InterviConcerning contexts with medium levels of marginalization, interviewees identify venues to buy food in their neighborhoods. As in previous categories, the most prominent issue is the limited income to purchase food. Interviewees from this category must not inevitably skip any of the three daily meals. Nonetheless, a few participants have had to implement a course of action to guarantee food for all the family such as lowering food quality and/or reducing meal portions.quincena cycle deteriorates the quality of food supplies. In this context, the payment cycle determines food consumption. At the end of the quincena, a food basket of high quality is not affordable whereas at the beginning of the quincena sufficient food can be purchased. As the end of the quincena approaches, individuals must wait until the next payday to purchase food. The study’s participants recognize that financial difficulties affect food consumption even though their living context present high IMM levels. Although meals are not skipped, to make ends meet, portions must be reduced. The tactic illustrates one of the most relevant coping strategies that stems from the fear of running out of food.At low and very low levels of marginalization, participants implement strategies that resemble the tactics employed by individuals from higher marginal contexts. Our findings indicate that food access does not represent an issue. It is the low income that participants earned that is the subject of concern. Reduced purchasing power through the quincena, a factor that relates to a specific cultural context, reflects how feelings of concern are experienced across the changing purchasing power of interviewees in a month- span. Feelings of concern increase as consumption capacities decline. This implies—when food variety changes—that food portions are diminished and meals are omitted, which propels a perception and fear of not being able to meet a household’s food needs for a specific number of days. Therefore, days before payday, evidence indicates that food insecurity increases. In this sense, measuring food insecurity in those days can change the result.The Findings from this study also indicate that problems with food consumption generate concern about running out of food. However, different levels of concern must be considered, each level influences households’ decisions and strategies to confront food scarcity. Furthermore, the study’s findings demonstrate that participants are well-aware of the significant increase in food prices. Inflation augments the concern over the uncertainty felt of not being able to purchase food or having to minimize meals’ quantity and quality. Feelings of concern are present among participants from all levels of marginalization. This type of anxious psychological state of mind exacerbates when children are present, and when the breadwinner does not have a stable job is unemployed or ill.quincena. This phenomenon might become the future norm if a social policy is not implemented.The experience of participants from low and very low levels of marginalization sheds light on the raising precarity of the job market. That is, employed individuals, who work in what are considered professional occupations, might not necessarily have a steady source of cash flow. Considering that an increasing number of jobs might be temporary or flexible in nature (not guaranteeing enough hours per week) . IndividThe uncertainty triggered by periods of food scarcity has a detrimental psychological impact. Higher levels of stress are associated with the uncertainty that is brought forth by the fear of running out of food . In MexiAt this point, it is important to acknowledge the limitations of this study. Due to the low number of interviews administered to individuals who live in high and very high levels of marginalization, the semi-structure interviews from these categories must be pooled for analysis. Furthermore, the study’s qualitative approach sets limits to generalize from our results. Despite these limitations, analytical themes are saturated, which allowed us to find a link across analytical categories that offer confidence and consistency to the results.tianguis.Based on different levels of marginalization, the instruments to measure food insecurity must be recalibrated to account for the change in food consumption considering the changing patterns of purchasing power through the payment cycle. Drawing from our sample and data analysis, we conclude that public policies must be drafted to account for the food insecurity that is experienced at the end of the payment cycle, the period when food insecurity increases, particularly in contexts of low and very low levels of marginalization. Social programs can be drafted based on our evidence. For instance, depending on the context of marginalization, a money transfer could be granted to consumers for food or vouchers to be exchanged at a convenience store or Our analysis calls for rethinking the scales to measure food insecurity. According to our findings, four conclusions must be drawn. First, the fear of experiencing food scarcity is generalized across levels of marginalization. Uncertainty pushes individuals to develop different strategies—cutting back in consumption and lower food quality—to deal with food insecurity. Furthermore, the inability of individuals to secure adequate supplies for the household negatively impact individuals’ well-being: psychological—increasing levels of anxiety and stress—and physical—increasing levels of obesity or malnutrition—due to food consumption of low-cost and high calories. Although current scales inquire about the concern related to food scarcity, the questions are not able to capture the complexity of this important factor. It is therefore vital to redesign questions related to the feelings of concern over confronting food scarcity to measure more precisely the fear of running out of food or living without food.quincena in contexts of low and very low levels of marginalization whereas food insecurity remains constant in areas with high and very high levels of marginalization. Consequently, it is essential to include a different weighting factor—specific to the area under study—that allows for comparison over time to track its evolution.Second, although severe levels of food insecurity show the adverse conditions experienced by many people, more studies need to be conducted to determine if descriptions related to food insecurity effectively capture the most adverse episodes of hunger. Otherwise, an additional level of food insecurity to account for this type of experiences must be generated, particularly for countries like Mexico where the endemic conditions of poverty, inequality, as well as the minimum impact of social policies , 2 produOverall, this study shows the relevancy of accounting for levels of marginalization in the design of public policy to eradicate food insecurity. Drawing from our findings, food insecurity is linked to the context where it develops. Governmental efforts must have a territorial  and regional component.


In the published article, there was an error regarding the affiliations for Jizhong Mao. As well as having affiliation 1, they should also have “Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, Zhejiang, China”.The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.