Non-suicidal self-injury (NSSI) describes a phenomenon where individuals inflict deliberate pain and tissue damage to their bodies. Self-injurious behaviour is especially prevalent across the autism spectrum, but little is understood about the features and functions of self-injury for autistic individuals without intellectual disability, or about the risk factors that might be valuable for clinical usage in this group.One hundred and three autistic adults who responded to an online advertisement were classified as current, historic or non-self-harmers in accordance with responses to the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT). Multinomial regression aimed to predict categorisation of participants in accordance with scores on tests of autistic traits, alexithymia, depression, anxiety, mentalising and sensory sensitivity. Linear regression examined relationships between these predictors and the range, frequency, lifetime occurrence and functional purposes of NSSI. Qualitative analysis explored the therapeutic interventions that participants had found helpful, and what they wished people understood about self-injury.Current, historic and non-self-harming participants did not differ in age, age at diagnosis, male-to-female ratio, level of employment or education . The most common function of NSSI was the regulation of low-energy affective states , followed by the regulation of high-energy states such as anger and anxiety. Alexithymia significantly predicted the categorisation of participants as current, historic or non-self-harmers, and predicted use of NSSI for regulating high-energy states and communicating distress to others. Depression, anxiety and sensory-sensitivity also differentiated participant groups, and sensory differences also predicted the range of bodily areas targeted, lifetime incidence and frequency of NSSI. Sensory differences, difficulty expressing and identifying emotions also emerged as problematic in the qualitative analysis, where participants expressed the need for compassion, patience, non-judgement and the need to recognise diversity between self-harmers, with some participants perceiving NSSI as a practical, non-problematic coping strategy.Alexithymia, depression, anxiety and sensory differences may place some autistic individuals at especial risk of self-injury. Investigating the involvement of these variables and their utility for identification and treatment is of high importance, and the voices of participants offer guidance to practitioners confronted with NSSI in their autistic clients.The online version of this article (10.1186/s13229-019-0267-3) contains supplementary material, which is available to authorized users. The process of articulating emotions also helped one participant to understand their own feelings more fully .iv.Emotions in control: there was a sense from several participants that their emotions controlled them or were something which needed to be controlled. Increasing emotional awareness and learning strategies to manage emotions changed that dynamic so that participants were more in control, and seemed to consequently help reduce NSSI (‘Not letting them [thoughts and feelings] take control over me’—P11).v.Management strategies: once identified, it was possible for participants to put strategies in place to alter, manage or control these difficult emotions (‘Learning that I have other ways to change how I feel - or don’t feel - and learning to do those things.’—P22). The methods of managing difficult emotions which helped participants were stress-reduction techniques, such as MBSR and relaxation techniques, hypnotherapy, having regular times to check in with emotions. However, despite many strategies helping participants to ‘stop letting [their] emotional pain build up’ (P64) and thus manage their NSSI, one participant eloquently described how management strategies were in fact less helpful than seemingly more basic emotional awareness work  was the most constructive in regards to self-injury’—P12).Other subthemes of ‘Understanding myself’ were:Sensory issues: two participants acknowledged sensory stimulation can be tied up with their need to engage in NSSI, and that increasing awareness of physiological states (‘checking in with myself every few hours to know if I am hungry/too hot/too cold/thirsty/tired’—P39) and being aware of when they needed to do something to change that was helpful.Self-esteem: several participants described how through therapy, they had become aware of the role of low self-confidence or self-esteem in their NSSI, such that building their self-esteem made NSSI less likely .Getting a diagnosis of ASC: being diagnosed with ASC was cited by several participants as beneficial to understanding and/or reducing their NSSI . Notably, the five participants who made statements in this vein were diagnosed after the age of 30, two in their sixties.Comorbidities: three participants also acknowledged the importance of addressing and treating their comorbidities in understanding and controlling their NSSI, naming depression, anxiety, OCD and eating disorders .As a theme, ‘Understanding myself’ seemed the key aspect of therapy which helped participants control and understanding their NSSI. This psychotherapeutic work appeared to enable participants to gain insight into their own feelings, behaviours and other difficulties and to reflect on these in a less judgmental, accepting way. It is possible that this more compassionate attitude to the self made NSSI less of viable option.As well as the psychotherapeutic work which was central to most participants’ experience of therapy, the next theme described learning practical strategies (the next theme) to cope with urges to self-injure, with examples given such as wearing false nails, elastic bands or drawing in red. There is a link, here, with the emotional awareness and the sensory issues subthemes of ‘Understanding myself’, as these strategies were described for the purpose of managing emotions and sensory experiences once these were identified. For example, finding an alternative sensory stimulation to NSSI was found to be helpful for one participant (‘We did however explore options of generating strong sensory input without causing injury (similar to ‘skills lists’ for BPD)’—P5). Although not aimed at eliminating NSSI itself, one participant (P44) explained how they would reduce alcohol consumption if they intended to self-harm, a sort of damage limitation strategy.In this theme, participants mentioned specific forms of therapy, in addition to the relaxation techniques mentioned above, which were useful. These included occupational therapy (P32), CAT (P10) and CBT (P48); conversely, one participant expressed that CBT had made them feel much worse (P10).Several participants mentioned how the therapeutic relationship was itself beneficial, simply for having ‘regular time’ to ‘check in’ (P27), a safe place to talk and the feeling of ‘being heard’ (P48) by ‘someone who understood’ (P62). Similarly, three participants acknowledged the role of social connections not just within the therapeutic setting in reducing their NSSI .. Another participant described the group therapy they had received as ‘totally inappropriate’ and ‘traumatising’ (P46). There were many comments that therapy had been ineffective but where participants did not elaborate on why . It is possible that a ‘one size fits all’ approach to psychotherapy may have also been the reason that these participants found no value in the therapy they had been offered.This theme, which stands in contrast to the rest of the responses to this question, importantly reflects assertions that therapy undertaken had been at best unhelpful and at worst detrimental. Some participants expressed their confusion and difficulty knowing how to respond to questions from therapists . A thematic map for this question can be seen in Fig. The second set of responses we analysed were in response to the following question: ‘Finally, what do you think is important to know if people want to understand and help those who intentionally hurt themselves?’understand the reasons behind NSSI. Instead of resorting to stereotypes about people who self-injure, participants were definite that others should challenge their assumptions and seek to look beyond the behaviour itself to the underlying reasons for it. The most prominent reason, and a theme in its own right, was that NSSI served a function for most participants as a coping mechanism or a means of self-expression. With this new knowledge, others involved with those who self-injure should respond appropriately, that is calmly, non-judgmentally and compassionately, whilst acknowledging the unique role of autism in these individuals who self-injure. A full table of themes and quotes can be seen in Additional file Four themes emerged from analysis of this item. It was clear from the data that participants wanted others to understand the reason in order to better understand NSSI and help self-harmers. It was important to participants that people realise that NSSI in itself was not necessarily the problem (or indeed a problem), but rather ‘a symptom of a significant problem’ (P41), and that ‘the outer wound only hints at a much more painful inner (hidden) wound’ (P59).Participants wanted others to understand that people engage in NSSI for a reason and that people should seek to low self-esteem, emotional pain. It was acknowledged that that there is great individuality in the motivations to self-injure, and that sometimes there are unknown reasons behind participants’ NSSI. NSSI may or may not be a choice. We explore each subtheme in turn.Participants wanted others to know that the main reasons behind the use of NSSI were that it was a response to Emotional pain: The overwhelming majority of participants cited difficult emotional experiences as prompting their self-injury. Specifically, participants mentioned confusing emotions, anger, stress, anxiety, frustration, ‘pressure’, ‘emotional pain’, ‘hurting inside’ and stress as the precursors to self-injury, and one participant suggested that NSSI serves as ‘a coping mechanism to convert emotional pain into physical pain’ (P9).Low self-esteem: One of the less frequent causes mentioned by participants was low self-esteem, which was cited by one participant as resulting from the difficulties they faced as a person with autism (‘I hurt myself because of my self-hatred and desire to punish myself for the problems I have with everything due to my Aspergers’ (P47).Unknown causes: Whilst theoretically self-injury should always serve a functional purpose, several participants explained that people who engage in NSSI may not fully understand why they do it themselves .Individuality: Participants expressed the importance of recognising the individuality of the self-injurer before making assumptions about why someone is turning to NSSI .The question of choice: This subtheme reflected an interesting dichotomy in the data. A number of participants  expressed a lack of conscious control or choice over self-injury  and a clear aversion to the behaviour (‘They don’t want to do it’—P44). The word ‘compulsion’ was used twice , the word ‘addiction’ twice . However, the way NSSI was framed by other participants  suggested it was a conscious choice, a strategy that people could choose to use . In line with this, some explained that NSSI should not always be seen as a negative thing . The words ‘choice’ or ‘choose’ were used by two participants , whereas others use the word ‘strategy’ (P21) or ‘outlet … a form of expression’ (P12), and mention their ability to ‘control’ or ‘resist’ it . Interestingly, one participant used the word ‘compulsive’ to distinguish their self-injury from ‘impulsive’ acts (P27). This participant appeared to be using the word in a different sense to those described above, who seemed to use ‘impulse’ and ‘compulsion’ in an interchangeable way that suggested they were ‘forced to do it’ . Participant 27’s use of the words seems to correspond to their more scientific definitions, ‘impulsive’ as ‘a predisposition toward rapid, unplanned reactions to internal or external stimuli with diminished regard to the negative consequences of these reactions’, and ‘compulsive’ as ‘a tendency to perform unpleasantly repetitive acts in a habitual or stereotyped manner to prevent perceived negative consequences’ , ‘attention seekers’ (P50), ‘drama queens’ (P18), ‘irresponsible and over emotional’ (P18), or had a personality disorder (P50). Another participant alluded specifically to inaccurate attitudes of some health professionals regarding the motivation for NSSI . Notably, with a link to the choice subtheme above, some participants found it unhelpful that self-injury was automatically seen as a negative thing .self-expression, ‘much like any creative or artistic outlet … a form of expression that some people turn to when words or other communicative methods do not fully convey how they feel’ (P12)—a method which served a function when participants had no alternative means of expressing themselves.Participants wanted others to know that NSSI has a functional role in managing a range of difficulties. This links to the choice subtheme discussed above, where some participants expressed that NSSI was not always a negative thing—that it was not, in itself, a distressing thing, and was something they would struggle to do without . The first of two subthemes of this theme was the idea of NSSI as a ‘coping mechanism’ (P9), a tool participants could use to ‘self-regulate or cope with overwhelming emotions or find brief relief from suffering’ (P28), such that they could continue their day and participate in activities like work and social interactions that they would have otherwise been unable to complete (‘Some days things happen and I feel so overwhelmed that I feel like I will break completely and I have no idea how I can get through my day (I work). Seeing the blood is like flipping a switch … then I can go back and get on with meetings and talking to people’—P3). The second subtheme was the idea of NSSI as means of calmly, non-judgementally and compassionately, and recognising the autism-specific needs of the individual.Finally, having helped others to understand the causes behind NSSI, people should use this knowledge to respond appropriately to the self-injurer in a way that will support them best: Calmly, non-judgmentally and compassionately: A calm, non-judgmental and compassionate approach was mentioned as an appropriate way to respond . Above all, participants expressed that others should make the person who self-injures aware that they are not alone, that they are loved, supported and cared for .Acknowledge the role of autism: Participants explained that others should acknowledge the role that autism has in NSSI, especially when trying to discuss it. They should potentially modulate their communication appropriately . One participant conceptualised their NSSI as part of their autism, highlighting that NSSI may need to be conceptualised differently in autistic and non-autistic people .and female patients.The prediction and characterisation of self-injury in autistic people is of high clinical importance, given the relationship between self-injury and later suicidality –9. Our mAn important goal highlighted in this study is the need to identify autistic individuals at heightened risk for self-injury, and we consequently aimed to extend the previous work in this area with consideration of the variables that might be of clinical importance in predicting the presence of self-injury.expressing emotional states that would make communication difficult. The importance of this variable also emerged in qualitative responses, where participants spoke about how learning to identify and express emotions, and understand the cause of emotions, was helpful. The use of NSSI to ‘control overwhelming feelings’, and the ‘traumatic’ and ‘frustrating’ difficulty of communicating how they feel, also corroborated our quantitative data around alexithymia.Alexithymia, difficulty identifying one’s own emotional states, was a prime candidate of interest given its common presence in clinical populations who self-injure –20. ThisA growing literature has highlighted the importance of diagnosing comorbid alexithymia, which may explain some of the socioemotional and communicative deficits of autism and be worthy of targeted intervention –83. Our other people. Impairments in this latter ability, commonly known as ‘theory of mind’ or ‘mentalising’, were, like alexithymia, hypothesised to put participants at particular risk of self-injury. Interestingly, this hypothesis was not borne out: deficits in the popular ‘Reading the Mind in the Eyes’ task (RMET) ); over half were qualified to degree level in each group, and all participants had attended school to GCSE (UK) or equivalent level. As such, our conclusions must be considered with caution as regards their relevance to autistic people ferences , 49, it ferences , and theferences , furtherLimitations of our statistical approach should also be considered. We adopted an a priori analysis informed by prior literature, and did not correct significance values for multiple statistical tests. The issue of multicollinearity, overlapping variance between measures, is also one to be considered. As can be seen in our analysis and Additional Materials, many of the predictor variables explored in this study tend to correlate: previous literature has demonstrated, for example, that alexithymia is strongly associated with autism and autistic traits , that a and without intellectual disability and for identifying those most at risk. Given the divergence in how participants perceive their self-injury, we question the nature of the risk, the link between self-injury, suicide ideation and suicidal acts seen in non-autistic people [Much remains to be ascertained to understand the incidence of NSSI in autistic adults with c people –9. Futurpain from any of these behaviours. There has been rigorous scientific debate as to whether autistic people have different pain thresholds to non-autistic people, or at least have a qualitatively different subjective experience of it [Another broader query, within this study and pertaining to general clinical use, concerns the use of measurement and assessment tools designed for non-autistic individuals. As previously mentioned, tools specific to autistic individuals are now being developed to accurately assess depression and suicidality , 119, buce of it –140. It ce of it , 82, 141ce of it , 119) asThe present study attempted to elucidate the features of self-injury in autistic individuals without intellectual disability, and to explore the thoughts of participants regarding their self-injury and helpful interventions. There was great diversity in the quantitative and qualitative data, with several participants signalling the disruptive effects of NSSI, their distress and lack of control over it, whilst others indicated that NSSI appeared to play a functional role in their lives, compartmentalised as a coping technique under their control. Variables that might differentiate self-harming from non-self-harming individuals were also of interest in so far as they might predict the incidence of self-injury and provide vital clues for understanding and treating the phenomenon. Current and historic self-harmers were set apart from non-self-harmers by their scores in measures of depression, anxiety, alexithymia and sensory sensitivity.Additional file 1:Table S1. Pearson correlation coefficients between predictor variables. Table S2 Qualitative analysis: Experiences with therapy. Table S3 Qualitative analysis: what others should know about NSSI. (DOCX 45 kb)


The temptation to free-ride on others’ contributions to public goods makes enhancing cooperation a critical challenge. Solutions to the cooperation problem have centered on installing a sanctioning institution where all can punish all, i.e., peer punishment. But a new, growing literature considers whether and when the designation of a group leader—one group member, given the sole ability to administer punishment—is an effective and efficient alternative. What remains unknown is whether and to what extent these group leaders establish cooperative norms in their groups via their own contributions to the public good, their use of sanctions, or both. Nor has past work examined whether leaders’ behaviors have lasting effects on non-leaders’ cooperation in subsequent interactions, outside of the leader’s purview. Here I show that leaders’ contributions to the public good predict non-leaders’ subsequent cooperation. Importantly, the effect is not limited to cooperation within the institution: the effect of leaders’ contributions continue to predict non-leaders’ contributions in a later interaction, where sanctions are removed. This process is mediated by non-leaders’ increased contributions in the institution, suggesting that leaders have effects on followers that shape followers’ subsequent behaviors. These effects occur above and beyond a baseline tendency to be influenced by non-leader group members; they also occur above and beyond the influence of peers in groups under a peer punishment institution. Results underscore how critical it is that groups install cooperative leaders: followers model their leaders’ cooperation choices, even in decisions external to the original institution and outside of the leader’s watch. Members of groups and organizations commonly face social dilemmas, or conflicts between their own interests and collective interests. From productivity on team work assignments to the mobilization of social movements, situations often arise where individuals can gain more by free-riding on the efforts of others rather than contributing to group goals. How groups motivate their members to make costly contributions for the good of the group is thus a central concern in the social sciences –7.One key solution to promoting cooperation is the introduction of peer punishment, where each group member can administer punishments to the others –11. WhilPerhaps as a result, researchers have increasingly considered an alternative solution, in which the ability to punish is given to only one group member –22. Desiwithin groups, specific individuals who are free from punishment may be less cooperative than those who are not. The power difference between the punisher and the punished may only exacerbate these potential differences in cooperation. This issue may explain why what Carpenter and colleagues , p < .001, see Table A in B = -1.42, 95% bootstrap CI , p = .28, see also x condition interaction, p = .35, see Table A in B = 2.79, 95% bootstrap CI , p < .001, see Table B in x round one of punishment phase interaction was not significant, p = .26, Table B in all rounds, including those later rounds where we might observe cooperation dropping over time, as in the non-punishment phase. The next analyses consider how the introduction of punishment affected contributions throughout the entirety of the phase.Between the final round of the first phase and the first round of the second phase, participants were told that sanctions would now be possible. An increase in contributions from round nine of the non-punishment phase to round one of the punishment phase would suggest that the introduction of sanctions had a deterrent effect on free-riding behavior, even before knowing how much, if any, one’s group members or the leader (depending on condition) would cooperate or punish. Analyses revealed that contributions were significantly higher in the first round of the punishment phase than in the previous round, i.e., the final round of the non-punishment phase , and that these norms of cooperation will last in subsequent interactions.As noted above, designating a solitary group member to administer sanctions alters the group facing the public good dilemma: it gives the leader enhanced power over the others, by allowing them the sole ability to administer sanctions. Did this group leader have an enhanced impact on his or her non-leader group members’ contributions, and did this impact last? Here I focus on two proposed mechanisms by which leaders may affect their followers’ behaviors and thus, group-level outcomes: the leader’s own contribution decisions and the leader’s use of his or her punishment ability. While on the whole, leadership and peer punishment may appear equally effective, those groups with leaders may have diverged significantly in their ability to provide for the public good, depending on the leader’s behavior.r + 1), and contains terms for the two key leader behaviors in the previous round (round r): 1) the leader’s contribution decision and 2) the punishment received from the leader. The model also controls for the non-leader’s own contribution in the previous round. Because of the inclusion of terms for punishment received and leader contribution, leaders (who could not be punished) and those in the peer punishment condition (who did not have a leader) were omitted from these analyses, though I return to the peer punishment groups later.To consider these differences further, B = .30, 95% bootstrap CI , p < .001, Results revealed that, holding constant the leader’s use of punishment (which I discuss in turn), the group leader’s own contribution decision in a given round is significantly predictive of non-leader contributions in the subsequent round  at establishing cooperative norms, compared to those with leaders, if they have a high (low) contributor. That is, one possibility for the similar overall cooperation levels between leader groups and peer punishment groups is that leader groups can yield either high or low contribution levels, depending on the leader’s behaviors, while peer punishment groups, less able to establish a norm around one salient group member, fall somewhere in the middle. But another possibility is that peer punishment groups are also just as influenced by the other group members and also yield very high or very low contributions, depending on the presence of a particularly high or particularly low contributor.As a result of these issues, in follow-up analyses I matched each peer punishment group with a corresponding, unique leader group.  I designated a “selected group member” in each peer punishment group as the group member whose ID corresponded to the ID of the leader in the paired leader group . This yielded a randomly chosen group member whose influence over the other members of the group could be compared to that of the influence of the leader observed in the leader groups.B = .19, 95% bootstrap CI , p < .001). This occurred even after controlling for own behavior in the previous round, as well as punishment received in the previous round, which  was also associated with cooperation, if it was prosocial in nature .more influential than their counterparts in the peer punishment condition at establishing norms of cooperation? Model 2 demonstrates that they were. The effect of the selected group member’s behavior is stronger in the leader condition, compared to the peer punishment condition, as demonstrated by a significant interaction between the selected group member’s behavior and condition. The main effects are also significant and can be interpreted as follows. In the peer punishment condition, the selected group member’s behavior influences his or her group members’ contributions in the next round . When the selected group member gave 0 in the previous round, giving in the next round was significantly lower in the leader condition, compared to in the peer punishment condition , suggesting that leaders, compared to peers, are more likely to reduce others’ cooperation when they themselves give nothing. Finally, the selected group member’s contribution was more impactful on others’ contributions in the leader condition , compared to in the peer punishment condition . But were leaders p = .86 and p = .44, respectively). Rather, in this study, the introduction of sanctions in round one and then their use throughout the punishment phase appeared to affect participants similarly, regardless of whether the punishment was administered by a peer or a leader. On the other hand, the effect of others’ contributions is particularly high in groups with leaders–leaders’ cooperative choices establish norms that ultimately help or harm their groups.Finally, I also examined whether the effect of receiving punishment differed across conditions. Model 3 demonstrates that the interaction between antisocial or prosocial punishment received and condition was not significant . When leaders gave 0, their followers gave significantly less in the one-shot dilemma than those whose peer had given nothing . And the more the leader gave, the more his or her group members gave in the subsequent one-shot dilemma . The results described above demonstrate that, across the leader and peer punishment conditions, leaders’ contribution behavior (vs. that of a given peer’s contribution behavior) played an especially important role in establishing group cooperative norms. Similarly, a model containing terms for the leader’s or randomly selected peer’s contribution in the final round of the previous phase, condition, and their interaction revealed that, again, the leader’s cooperative behavior was significantly more influential in promoting cooperation among the others, even in the one-shot interaction when the institution was no longer in place and punishment was not possible. Specifically, in the peer punishment condition, the peer’s giving behavior in the previous round did not predict one-shot giving . These results also control for total prosocial and antisocial punishment received from the leader, which were not significantly associated with one-shot giving. Consistent with the findings from the round-level analyses described above . And, once non-leaders’ own giving within the institution was included in the model, the effect of leader giving on cooperation in the one-shot PDG  became non-significant (p = .39).A model with predictors for the leader’s total contributions across the nine rounds of the punishment phase and the total punishment received from the leader across the nine rounds allows for examination of whether either of these leader behaviors predicted their followers’ cooperation in the one-shot PDG—after the institution, i.e., the possibility for punishment, was removed. Results revealed that the more the leader had contributed in the punishment phase of the public good dilemma, the more non-leaders contributed in the subsequent one-shot dilemma . As a result, one unit of punishment may have carried greater weight in the leader condition, resulting in differing levels of punishment use and welfare destruction due to the study design. Note that this issue does not directly bear on the key results in this work, that is, on leaders’ contribution behaviors promoting cooperative behaviors in their followers. Nevertheless, future work might, for example, distribute punishment “points” across group members or centralize them in one group member, holding constant the total number of these points available in the group. Such a study could answer additional questions about the effects of the distribution of punishment power on cooperation that this one was not designed to address.Further, this study relied on the same behavioral outcome both within and outside the institution: contribution to a public good with the members of one’s group. The key difference was that the decision outside the institution was one-shot, not relayed to the group members, and free from sanctions. By relying on a highly similar behavior that participants had experienced over the course of several rounds, it is possible that part of their decision in the interaction outside of the institution was due to inertia: sticking with the same strategy they used previously. Granted, the results stand: those with cooperative leaders behaved more cooperatively while those with cooperative peers were less affected; this enhanced cooperation predicted further cooperation even when sanctions were removed. Nevertheless, future work might consider whether the effect of cooperative leadership “spills over” into subsequent interactions that are more distinct from the interactions within the institution . This wsubsequent interactions, once the leader is no longer present. In addition, past work considering leading-by-example has found that while followers’ contributions are strongly influenced by the leader’s contribution, leaders are often exploited by followers, reducing the willingness to engage in costly leadership; generally, results as to whether leading by example works are mixed [Additional considerations for future work might consider the varying ways that leadership is conceptualized in research on groups facing social dilemmas. While, as noted above, past work has examined designated punishers as authority figures or group leaders –21, othere mixed –46. FutuIn summary, the threat of free-riding on others’ contributions to group goals makes the marshalling of cooperation a critical challenge. Solving the cooperation problem is of paramount importance to promoting productive and harmonious interactions between individuals, groups, and nations. After all, groups, organizations, and the world on the whole face this challenge when tackling major societal issues, including maintaining clean air and water supplies, promoting blood donation, and combating climate change. Notably, we commonly install leaders, given the ability to monitor and enforce cooperation, for the purpose of solving these problems. The results from this study demonstrate how important it is that groups make efforts to promote cooperative leadership. Further, they offer a more thorough understanding of the important role leaders play in inducing individuals to forgo their self-interest for the greater good.Participants were recruited from the general student population at the University of Michigan, via two non-overlapping participant pools–one for payment and one for course credit plus the chance of payment . Specifically, in each of a series of rounds, each group member received an endowment of 20 monetary units (MUs). They independently decided how many of their own MUs, from 0 to 20, to contribute to a “group fund”. Points not contributed to the group fund were kept in a “personal fund”. Contributions to the group fund  were doubled and redistributed equally among all group members, regardless of each person’s contributions. Thus, withholding contributions maximizes an individual’s earnings, but overall group earnings are maximized when all group members contribute. The full text of the instructions is available in the In the first phase of the PGD, after making their contribution decisions, participants could view their own and others’ contributions and earnings, sorted by each group member’s unique letter identifier. Then, they proceeded to the next round. This non-punishment phase was repeated for nine rounds in total and measures baseline cooperation before the punishment phase was introduced. To avoid end-game effects, participants were not told in advance how many rounds they would complete.After the non-punishment phase was completed, additional instructions informed the participants that they would continue making similar decisions with the same three other group members, but some of the rules of the task would change. Now, following each round of the task, either “one group ‘leader’” (leader condition) or “each group member” (peer punishment condition) would, after viewing contribution decisions, be able to deduct points from the others. Note that by referring to the leader explicitly as “the group leader” in the study instructions (rather than a more generic term like “designated punisher”) the condition is likely to have activated in participants’ minds the role of leaders, and status-differentiated hierarchies of leader and followers, in a way that the peer punishment condition (where everyone was simply referred to as “group members”) did not. At the same time, by calling the group leaders what they were—“leaders” given the sole ability to sanction others—the study simulates real world conditions where leaders’ position, title, and enhanced abilities are explicit to leaders and followers alike. It is also consistent with prior work , 21.Following past work, punishment was costly: it cost one MU to deduct 3 MUs from another participant , 19, 21.Those in the leader condition were told that the leader could not be punished, and he or she would have the position for the remainder of the study. They were also told, correctly, that the leader would be randomly selected by the computer program, and were informed whether or not they had been selected to be the leader before beginning the first round of the punishment phase. In both conditions, the instructions further stated that participant identifiers would change in this next phase. This prevented participants from deploying punishments based on the target’s behavior in the previous  phase. The full text of these instructions is reproduced in the Throughout the punishment phase, after simultaneously making contribution decisions, all group members viewed the results (contributions and earnings) before punishment. Then, those who could administer punishments made their deduction decisions. Finally, all group members could see the results after accounting for deductions, including, in the peer punishment condition, who punished whom. This phase was repeated for another nine rounds.After the punishment phase, participants completed a previously unannounced, one-shot PGD; again, this third phase was completed with the same three other group members. Specifically, instructions indicated that all group members would receive one final endowment of 20 MUs and again decide how many, from 0 to 20, to contribute to the group fund. However, unlike the previous task, they would make this decision only once and they would not receive any feedback on their own or others’ contributions or earnings, as they had in previous phases. Likewise, since they could not see others’ decisions or earnings, they and the others  would not have the opportunity to make deductions in this round. That is, the instructions clearly emphasized that 1) this decision was fully private and 2) the punishment institution (whether peer punishment or leadership) was no longer in place. See the Upon completion of the study, participants were debriefed and paid. The study took about 45 minutes. There was no deception. The study procedures were approved by the University of Michigan’s Health Sciences and Behavioral Sciences Division Institutional Review Board (HUM00159425 for pool 1 and HUM00152808 for pool 2).S1 FileFile contents include the full text of study instructions, data and analytic strategy supplementary details, and supplementary models.(PDF)Click here for additional data file.


We describe two cases to emphasize the importance of recognizing symptoms of psychosis underlying a constellation of neurotic symptoms, and to highlight the overlap and potential for misdiagnosis with personality and anxiety disorders. We also provide an overview of pseudoneurotic schizophrenia and familiarize readers about the challenges in making accurate diagnoses in light of this term used in the past. We refer to cases in the literature and point out the implications of this concept on diagnosis, management, and prognosis. Based on the management strategies deployed for the two cases described, we finally recommend that it is imperative to perform accurate and detailed assessments and take into consideration the evolution of the concept of pseudoneurotic schizophrenia to currently accepted DSM-V disorders, in order to effectively treat patients. Pseudoneurotic schizophrenia was the term coined by Hoch and Polatin in the 1940s to describe patients who presented with “neurotic” facade, which concealed thought, emotional and behavioral impairment of regulation, integration, and stemmed from “psychotic” process [We present two cases, initially deemed to exhibit predominant personality and anxiety disorder features, but later revealed underlying psychosis with significant formal thought disorder on detailed assessment, and revisit the concept.Case 1Mr. X, a 29-year-old male with past psychiatric diagnoses of major depressive disorder, generalized anxiety disorder, borderline personality disorder, and history of multiple suicidal attempts by overdose in context of feeling “void”, “numb”, “bored” and “overwhelmed”. He presented with vague and unclear anxiety, panic attacks, feelings of generalized discomfort, and reports of passive suicidal ideation. Upon evaluation, he was guarded, oddly related, occasionally distracted, and unable to provide relevant or logical answers to most questions due to prominent blocking and disorganization of thoughts. He exhibited ambivalence in basic decision-making processes related to treatment and disposition and reported confusion about his sexual orientation and preference. Throughout his stay in the hospital, he displayed poor interpersonal and coping skills, impaired impulse control, and a gradual decline in functioning that had commenced 11 years prior to the current presentation. Records from previous outpatient visits and inpatient hospitalizations described presentations of numbness, emptiness, poor impulse control and interpersonal skills as well as superficial expression of emotions which led to diagnoses of borderline personality disorder, generalized anxiety disorder, and major depressive disorder. Notably, he had also failed several antidepressant trials. He was prescribed an oral dose of 50 mg of quetiapine which was titrated upwards to 300 mg, at which point there was significant improvement in symptoms of anxiety, depression, and suicidal ideation. His thought process became somewhat linear; he slowly started gaining insight into his condition and was able to communicate. Case 2Ms. Y, a 39-year-old female with a history of major depression and anxiety, diagnosed and managed by her therapist for a few months prior to her hospitalization, was referred to the emergency room when she decompensated, reporting vague symptoms of paranoia, auditory and visual hallucinations. She was noted to be anxious, apprehensive, and perplexed, demanding to be seen repeatedly for reassurance. Vagueness, tangentiality, and circumlocution pervaded her conversations. She narrated events that permitted the team to learn about her poor boundaries with strangers, inability to maintain healthy relationships, and difficulty with keeping steady jobs. Borderline personality traits were initially suspected but collaterals from her aunt described her as an “odd, paranoid person” with poor interpersonal skills and said that she had often seen her talking to herself. However, being distant and not causing nuisance in the community, she had not drawn attention to herself and had never been hospitalized. A diagnosis of schizophrenia was formulated and her symptoms of anxiety, hallucination, and thought disorganization improved on oral risperidone gradually titrated to a daily dose of 6 mg.Hoch and Polatin coined the term “pseudoneurotic schizophrenia” in 1940s to describe a group of patients who presented with symptoms of intense anxiety and mood disorder which occurred in the context of underlying psychosis and proposed diagnostic criteria 10 years later . The useThese diagnostic criteria faced criticism due to its broadness, vagueness, and questionable accuracy. Hoch et al. pointed out that, “The organization of the outline (the proposed diagnostic criteria) has many deficiencies. However, they believed that it can lead to more definite and more refined clinical observations, while doing much to maintain a holistic concept of the patient” . BecauseThough no longer acknowledged as a clinical entity, the concept still holds significance in current psychiatric practice because of potential implications of the diagnosis and management. A five to 20-year-follow-up study of 109 patients with pseudoneurotic schizophrenia was published by Hoch et al., which reported a significant incidence of subsequent hospitalization following initial contact . It was In our first case, our patient presented with symptoms of depression, distressing anxiety, and emotional dysregulation for years with no overt signs or symptoms of overt psychosis. His poor social interactions, unstable relationships, and emotional outbursts made all previous providers suspect borderline personality disorder. However, on detailed assessment and more collateral information, it became evident that he was notably indecisive, engaged only superficially in conversations and was unable to provide details. Additionally, he continued to experience bouts of sudden unexplained sadness, depression, and anger that are likely to have stemmed from a primary psychotic thought disorder. And although the classical symptoms of auditory or visual hallucinations and paranoia were the not cornerstones of his presentation, the patient remained oddly related, unable to connect on social levels, and continued to show significant functional decline, which might bear some semblance to negative symptoms. He was treated with antidepressants for years which aimed to target his low mood, suicidal thoughts, and anxiety but responded poorly and had prolonged hospital stays. There was a clear thought block that was noticed while interviewing the patient. He was able to carry a conversation with staff but with attempts to clarify and get more details about his symptoms, there was noticeable thought block, confusion, oddity and inability to relate with the team. Before he was started on quetiapine, he stayed in his room all day and was not interested in interaction. Few days after we started quetiapine, thought block resolved, he was able to relate better with the team and with other peers in the unit, his ambivalence and suicidal thoughts improved. In the case of borderline personality disorder, mood stabilizers and antipsychotics can help in controlling the mood swings, anger outburst and suicidality, which was not the symptoms addressed in this case. The improvement he showed with 300 mg of quetiapine is testament to the fact that some underlying psychotic symptoms were not being adequately targeted.Psychosis was somewhat more evident in the second case. This patient presented with vaguely reported paranoia, auditory, and visual hallucinations and her family confirmed it. She had poor interpersonal, social, and functional abilities for many years. She kept to herself and had very limited social interaction. She did cut ties with many people and family members but as she was not problematic, no one pushed for evaluation or treatment. Borderline personality disorder traits were initially suspected as she appeared dramatic, shallow, and demanding and much like the above case, she also showed marked improvement with oral risperidone. In summary, both patients met the Hoch and Polatin definition of pseudoneurotic schizophrenia on initial assessments and had failed multiple antidepressants trials , but they eventually responded well to antipsychotics. The challenges in teasing apart primary psychotic symptoms in such presentations and making accurate diagnoses are manifold. Distracting symptoms of anxiety, lack of clarity of presenting complaints and unclear previous psychiatric history are few of them. Moreover, providers often view patients with the diagnosis of borderline personality disorder with some bias, which only tends to compound the issue -6.Limited information is available about the treatment of pseudoneurotic schizophrenia when such a diagnosis was made in the past. In the 1962 Hoch et al. follow up study, it was pointed out that, “Since the major part of our study was concluded before the newer psychopharmacological agents were available, their use does not figure in this report” . There iHafner et al. asserted that behavioral and symptom profiles in depressive and psychotic prodromes are difficult to tell apart . In receThe previously made criteria were wide, vague, and commonly shared by personality disorder, and hence, it was abandoned for decades. This unique and interesting presentation deserves further attention and more research to identify targeted strategies for better management of these patients.


To analyze the moderator effect of socioeconomic status in the association between the perceived environment and active commuting to school.A total of 495 adolescents and their parents were interviewed. Perceived environment was operationalized in traffic and crime safety and assessed with the Neighborhood Environment Walkability Scale. Active commuting was self-reported by the adolescents, categorized in walking, bicycling or skating at least one time/week. Socioeconomic status was used as moderator effect, reported from adolescents' parents or guardians using Brazilian standardized socioeconomic status classification. Analyses were performed with Poisson regression on Stata 12.0.Prevalence of active commuting was 63%. Adolescents with low socioeconomic status who reported “it is easy to observe pedestrians and cyclists” were more likely to actively commute to school . Adolescents with low socioeconomic status whose parents or legal guardians reported positively to “being safe crossing the streets” had increased probability of active commuting to school , as well as those with high socioeconomic status with “perception of crime” were positively associated to the outcome .Socioeconomic status showed moderating effects in the association between the perceived environment and active commuting to school. In Brazil, data was collected in the city of Curitiba, state of Paraná, between the months of August 2013 and May 2014. This is a cross-sectional study with household and face-to-face interviews. More information about the study is available in the literature,The 2,395 census tracts in the city were considered primary sampling units and selected according to walkability and incomeAiming to maximize the variability in walkability and income, census tracts were classified in deciles for both variables. Four groups were created to represent locations with: “high walkability and high income”, “high walkability and low income”, “low walkability and high income” and “low walkability and low income”. Eight census tracts were intentionally selected from each group .Street segments were listed for all blocks within census tracts, the first being located on the southeast extreme of the census tract. Homes were visited in person from the left upper side of the block, clockwise. In case a family refused to participate or there were no adolescents in the household, the next home on the left side was visited.For each home, one adolescent and one of their parents or legal guardians were selected. The order of selection was: younger females, followed by older males, to allow for an equitable gender selection. In case the selected adolescent refused to participate, another from the same household could be intentionally recruited. According to recommendations of the project protocol, minimum sample should be of 300 adolescents.Adolescents included were 12–17 years old, residing in the census tract for at least one year from data collection and must be enrolled in school. Those with physical limitations preventing physical activity or cognitive limitations preventing comprehension of the questionnaire were excluded from data collection.Twenty-three undergraduate and graduate students were responsible for interviewing families after 12 hours of training. Sessions included selection criteria, how to approach homes and participants, surveys, concepts, reading questions and emphasis on highlighted topics, identification of appropriated answers, and forms and identification of refusal. Simulation of the data collection process was done to ensure understanding about procedures.Active commuting to school was assessed by the question: “In a regular week, how many days and for how long do you use the following transport mode to go to or come back from school?”. Six options were available: walking, bicycle, skateboard, public transport, school bus or car.versus “≥ 1 times/week”, independent from time spent in commute. This measure and its operationalization have been used in similar studies,For analysis purpose, the variable “active commuting to school” was operationalized by weekly frequency, in “zero time/week” ,Neighborhood environment perception of adolescents and their parents or legal guardians was assessed by the Neighborhood Environment Walkability Scale (NEWS). There are two versions of this instrument, one specific for adolescents (NEWS-Youth) and one for adults (NEWS-Adults). Both were translated, adapted and validated to the Brazilian context,Eight questions were selected from NEWS and NEWS-Youth, related to perception of safety in traffic, and seven on perception of crime, potentially associated to active commuting to school in adolescentsBased on the sum of individual items, a safety perception score was computed for traffic and crime. Some variables were recoded (0 to 1) to better represent the perception of the environment (safer). On traffic perception, questions 1, 3 and 4 were recoded while all questions on crime perception were recoded. Three safety perception indicators were operationalized based on the scores: 1) traffic; 2) crime and 3) general safety (traffic + crime), categorized in tertiles, indicating “low”, “medium” and “high” environment perception.The following variables were included as covariables: gender, age group, perception of time spent walking to school, moderate-to-vigorous physical activity in leisure time and period of the day spent in school. Parents or legal guardians' variables included were: car ownership, active commuting in the neighborhood and leisure time physical activity.,The adolescents' gender was observed  and their age classified into three age groups . Body mass (kg) and height (cm) were measured and used to calculate body mass index (BMI) and estimated nutritional status, categorized in “normal weight”  and “overweight” (overweight and obese), specific for Brazilian adolescents. Perceived distance to school was assessed with the question: “How long does/would it take for you to walk to school? ”An adult considered parent or a legal guardian for the adolescent participated in the survey. For the analysis, the options “grandmother”, “grandfather”, “uncle”, “aunt” and “other” were operationalized as “other”. Car ownership was assessed by the question: “How many motor vehicles  do you own?”. The answer was classified as “no” (zero vehicles) and “yes” (≥ 1 vehicles). Active commuting was assessed by the question: “Do you walk or bike for at least 10 consecutive minutes to go from one place to another in the neighborhood?” . Total leisure time physical activity was assessed by the long version of the International Physical Activity QuestionnaireThe SES was assessed by a standard questionnaire which considers a number of domestic appliances, presence of a housekeeper, and education of the financial provider for the householdversus “high”). After bivariate analysis, the multivariate model was adjusted for individual variable which presented p < 0.20 in the bivariate model . Data were analyzed in Stata 12.0 and significance level was kept at 5%.Poisson regression was used to test the association between the perceived environment for adolescents and their parent or legal guardians and active commuting to school. In order to test the possible moderator effect, the SES was included in the model .A total of 495 adolescents were interviewed (50.7% girls), as well as their respective parents or legal guardians (74.9% mothers). Refusal rate of participation was 16% (n = 94), similar between neighborhood income. Frequency of active commuting was 63.0%, being higher among adolescents of low SES (80.3% Most adolescents were within the 12-13 years-old age group (41.4%), had normal nutritional status (59.3%), their perceived distance walking to school was ≥ 31 minutes (30.7%), leisure time moderate-to-vigorous physical activity was < 300 min/week (60.2%), and studied during the morning period (66.3%) . For parIn the bivariate analysis for low SES adolescents, the fact that it was possible to “see pedestrians and bicyclists from inside their homes” was positively associated to active commuting to school , while “concern of being alone around the home” was inversely associated to the outcome  . On pareAfter adjusting for confounding variables, only the perception of being possible to “see pedestrians and bicyclists from inside their homes” remained positively associated to active commuting to school among low SES adolescents  . For parThis is the first study looking to identify the association between the perceived environment of the neighborhood by adolescents and their parents or legal guardians and active commuting to school in Brazilian adolescents. Moreover, the first to explore the moderator effect of the SES in this association. The methodology allowed to explore how different perceptions of the environment may affect the behavior of adolescents in active commuting to school, that being the strength of this study. Previous studies have tested the association between the isolated environment perception of adolescents and their guardians and active commuting to schoolversus 52.2%, p < 0.001). The premise that the environment perception by guardians could, somehow, influence the decision to allow their children to commute actively to school, was not confirmed in most associations tested independent from SES.The proportion of active commuting to school was higher among adolescents of low SES . This could, somehow, modify the perception of those related to this characteristicIn the present study the perception of being possible to “see pedestrian and bicyclists from inside the home” increased in 18% the probability of active commuting to school for low SES adolescents. Only one study testing this association with a similar variable was found,,,,,,versus 98.3%, p < 0.001) may contribute to more active commuting through neighborhood streets . This characteristic, associated to the impossibility of guardians to pay for public or private transport for their children to go to school, would allow better knowledge of neighborhood characteristicsFor parents or legal guardians of low SES, perception of safety related to crossings may increase in 10% the probability of adolescents engaging in active commute to school. Only one study found similar results,,Parents or legal guardians of high SES had the perception of crime positively associated to active commute to school . Several studies have explored the association between the different variables for perception of crime and active commute to school and have not found significant association between the variables,Most variables of environment perception explored in this study were not associated to active commuting. However, it is important to highlight that these results are similar to those verified in the literature,Some limitations must be considered when interpreting and extrapolating results. The sample is not representative of adolescents in the city, once participants were selected from intentionally selected census tracts to generate contrasts for walkability and income. It is likely that associations tested in this study present different results if census tracts with less variability were considered. Moreover, other characteristics were not considered in this study, as parents' (“father” or “mother”) perceptions and environmental  ones, which can be associated to the outcomeIn conclusion, the SES presented a moderating effect in the association between the perceived environment by adolescents and their parents or legal guardians, with active commuting to school. For adolescents with low SES, the fact that they can “see pedestrians and cyclists from inside their homes” was positively associated with active commute to school. For parents or legal guardian with low SES, perception of safety to “cross the streets in the neighborhood” was positively associated with active commute, while for those with high SES, perception of crime was associated to the outcome.The improvement in the conditions of neighborhood safety may positively influence the perception of safety in adolescents and their parents or legal guardians. Presence of traffic signals in commuting routes to school and in school surroundings could improve the probability of active commuting to school


Background: One of the strongly theorized areas of research associated with learning outcomes has been the approaches to learning. Few studies have been focused on examining the relationship between the approaches to learning medicine (ALM) and learning outcomes.Objectives: The objectives were: (1) to conduct psychometric testing of the ALM questionnaire; and (2) to examine the association between medical learners’ ALM and learning outcomes.Design: We developed the ALM questionnaire which was a modification of the Revised Learning Process questionnaire. We defined the learning outcome of each house officer as the class rank in his/her graduating class. Exploratory factor analysis was used to examine the factor structure of the ALM questionnaire. We conducted Pearson’s and Spearman’s Rank correlation coefficients for examining the linear relationships between two continuous variables, and between a continuous variable and a categorical variable, respectively. Stepwise multivariate linear regression analysis with backward elimination was undertaken to examine the correlation between the ALM and the learning outcome.Results: A house officer with deep strategies (relating multiple ideas and truly understanding the course content) or surface motivations  was more likely to have a better learning outcome as indicated by a better class rank based on his/her academic performance. Furthermore, a house officer with surface learning strategies (minimizing the study scope to merely passing the examination) to learning medicine was more likely to have an unfavorable class rank.Conclusions: This study represents the first report of the correlation between house officers’ ALM and learning outcomes. House officers with deep strategies were more likely to have better learning outcomes. In particular, house officers with a surface motive to learning medicine, i.e., aiming for qualification, were surprisingly correlated with better learning outcomes. Medical students’ learning outcomes have been of great importance both for medical students and for medical educators. Medical educators are concerned with learning outcomes because they are expected to cultivate well-trained medical students in response to the needs of the society and healthcare systems. Medical students are also concerned with their learning outcomes because learning outcomes are so closely related to their future application to residency training, i.e., the specialty they are able to select and the healthcare institution where they will receive residency training.One of the more strongly theorized areas of research associated with learning outcomes has been students’ approaches to learning. ‘Approaches to learning’ implies the learners’ motivations and strategies to learn or process academic work . Prior sResearch has continuously reported that students’ approaches to learning are associated with learning outcomes –8. SnelgAlthough factors associated with the approaches to learning have been well examined in scientific and in non-medical learners ,5,12,13,We conducted this study in a university-affiliated medical center located in northern Taiwan. A total of 126 post-graduate year 1 (PGY) house officers who received general medical training from 2015 to 2016 in this medical center were eligible for this study. At the beginning of their training, we inquired about the 126 house officers’ willingness to join this study. Questionnaires were then distributed to the house officers who agreed to join.To thoroughly assess house officers’ ALM, the ALM questionnaire was developed which was a modification of the previous questionnaire, Revised Learning Process Questionnaire (R-LPQ-2F), established by Biggs and colleagues . The R-LIn order to examine students’ domain-specific approaches to learning , several studies have modified and re-validated R-LPQ-2F questionnaire ,15. For Firstly, we changed the learning context in the R-LPQ-2F to the learning context of ‘learning medicine.’ For example, the original item ‘I find that at times studying makes me feel really happy and satisfied’ in the R-LPQ-2F was changed to ‘When learning medicine, I find that at times studying medicine makes me feel really happy and satisfied’ in the ALM questionnaire.Secondly, we added and deleted some items for measuring house officers’ ALM based on the discussions with house officers. For example, one item ‘I find the best way to pass examinations is to try to remember answers to likely questions’ in the ‘Memorization’ factor was suggested to be deleted because of the unsuitability. In addition, one more item ‘When learning medicine, I use systemic ways to learn’ in the ‘Understanding’ factor was suggested and then added in the final version.Thirdly, some house officers were invited to examine the clarity and understandability of all the items shown in the ALM questionnaire. Further minor revisions for the wording of certain items were made based on their suggestions and comments.Fourthly, a higher education and a medical education expert evaluated all of the 36 questionnaire items and approved the use of the ALM questionnaire. The four subscales and eight factors with sample items are presented below:Deep Motivations: The medical learners have deep motives  to learning medicine.Factor 1: Intrinsic Interest Sample item: When learning medicine, I find that at times studying medicinemakes me feel really happy and satisfied.Factor 2: Commitment to Work Sample item: In my leisure time, I work on the medical issues which I aminterested in, and which have been discussed in medical fields.Deep Strategies: The medical learners tend to use deep strategies  to learning medicine.Factor 1: Relating IdeasSample item: When learning medicine, I try to relate what I have learned in onesubject to what I have learned in others.Factor 2: UnderstandingSample item: When reading medical textbooks, I try to understand the meaning ofthe content.Surface Motivations: The medical learners have surface motives  to learning medicine.Factor 1: Fear of failureSample item: I am worried about my performance in future National LicensingExam if I get bad grades in current exams.Factor 2: Aim for QualificationSample item: Regardless of whether I like it or not, I know that having goodperformance in medicine can help me to find a good job in the future.Surface Strategies: The medical learners tend to use surface strategies  to learning medicine.Factor 1: Minimizing Scope of StudySample item: When learning medicine, the items not tested in the exams aremeaningless to me.Factor 2: MemorizationSample item: When learning medicine, I practice rote memorization of the contentuntil I firmly memorize all of the content.Each factor contained a total of three to seven items. We coded all the items using a Likert scale ranging from 1 to 5, indicating ‘strongly disagree’ to ‘strongly agree,’ respectively. The score of each factor for a house officer was derived by taking the average of all the items included in the factor.We defined the learning outcomes of each house officer in this study as the class rank of the house officer in his/her graduating class . It can Class Rank =  / .For example, someone who is the top student based on her average grade in her graduating class with a total of 100 medical students has a class rank as 0.99 based on the algebraic function. The formula for class rank was purely mathematical – based on the average score derived from all the exams taken, all the ratings given during the 7 years in his/her medical school. The study participants from the same medical schools took the same exams during preclinical years, and mostly the same clinical rotations during clinical years. In addition, medical students from different medical schools were required to take the same courses, and mostly similar clinical rotations by Taiwan Ministry of Education for getting a M.D. degree.The ALM questionnaire was first developed for assessing a medical learner’s various ALM. Thus, exploratory factor analysis was used to examine the factor structure of the ALM questionnaire, as well as its validity and reliability.We conducted Pearson’s correlation coefficients and Spearman’s Rank correlation coefficients for examining the linear relationships between two continuous variables , and between a continuous variable and a categorical variable , respectively.p value of less than or equal to 0.20 were remained in multivariate analysis. The Class Rank in his/her graduating class in medical school was the dependent variable. Adjusted R square was used to examine the model fit.Stepwise multivariate linear regression with backward elimination was then undertaken in this study. Given the potential influence of age and gender , the agep value of less than or equal to 0.05 was considered as statistically significant. All statistical analyses were conducted using SPSS  20.0 for Windows PC. This study was approved by the National Taiwan University Social and Behavioral Research Ethics Committee (201505HS002).A two-tailed One hundred and twelve (88.9%) of the 126 eligible house officers signed the informed consent form, and finally 107 (84.9%) completed the ALM questionnaire and were included in the data analysis. The age ranged from 24.25 to 32.74, with a mean (±standard deviation) of 26.34 (±1.44) years old. Sixty-seven (62.6%) of the 107 participants were male.To validate the ALM questionnaire, we adopted the principal component analysis with a varimax rotation method to clarify the factors of the items. The eigenvalues of all the factors were greater than one, and a factor loading of greater than or equal to 0.5 was used as the criterion for retention of items. According to the factor analysis of the ALM questionnaire, five items were removed, and ‘Relating Ideas’ and ‘Understanding’ were merged into a single factor called ‘Relating Ideas and Understanding.’ Therefore, seven factors with a total of 31 items, accounting for 68.1% of the total variance, were included for further analyses. In addition, the Cronbach’s alpha values for each factor ranged from 0.66 to 0.88, with an overall value of 0.76, suggesting these seven factors in the ALM questionnaire had adequate internal consistency for assessing house officers’ ALM.As shown in Deep Motivations: ‘intrinsic interest’ and ‘commitment to work’; Deep Strategies: ‘relating ideas and understanding’; Surface Motivations: ‘fear of failure’ and ‘aim for qualification’; Surface Strategies: ‘minimizing scope of study’ and ‘memorization.’r = 0.29, p < 0.01), relating ideas and understanding , and aim for qualification . That is, the house officers with deep motivations (such as intrinsic interest) and deep strategies (such as relating prior knowledge or truly understanding the content) were more likely to have a better learning outcome as indicated by their class rank in his/her graduating class. In addition, house officers’ surface motivations  likely fostered their academic performance in the class  and minimizing scope of study , the surface strategy of the ALM. That is, house officers with surface strategies of the ALM were more likely to have a poorer learning outcome as indicated by their class rank in his/her graduating class. In addition, male house officers had a lower class rank than female house officers.In comparison, house officers’ class rank was negatively correlated to male gender  and also ‘Aim for Qualification’ (surface motivation) significantly predicted his/her higher class rank. In addition, a house officer’s ALM, i.e., ‘Minimizing Scope of Study’ (surface strategy) significantly predicted his/her lower class rank .10.1080The results showed that house officers’ ALM played important roles in their academic performance. A house officer with deep strategies  or surface motivations  was more likely to have a better learning outcome, i.e., a higher class rank based on his/her academic performance. Moreover, a house officer with surface learning strategies  to learning medicine was more likely to have an unfavorable learning outcome as indicated by his/her class rank.Two studies have reported that deep approaches to learning were dominant among the learners regardless of their gender and age ,19. DeepHowever, deep motivations, i.e., ‘Intrinsic Interest’ and ‘Commitment to Work,’ did not predict house officers’ learning outcomes. This finding seemed to be inconsistent to prior study results . The stuSeveral studies have shown that learners with surface approaches to learning have had a negative significant impact on their academic performance. Consistent with prior studies, we found that surface strategies  were negatively associated with the learning outcome. Interestingly, we also found that a house officer with surface motivations, i.e., aiming for qualification, was associated with a better learning outcome. This finding based on medical learners was in opposition to those reported based on non-medical learners. Several reasons may account for the finding we identified in this study:Firstly, medical learners are very sophisticated in their ALM based on different motivations. They may have adaptive motivations, i.e., changing from deep motivations to surface motivations, or from surface motivations to deep motivations, depending on many other factors such as learning content, learning context, and availability of time and effort. For example, if a medical learner does not have much time for learning a medical subject, his/her motivation to learn the medical subject may be simply to pass the exam or the fear of failing the exam. Based on the two surface motivations, he/she can still be very good at learning the medical subject and attaining good grades. In comparison, if a medical learner has plenty of time for learning a medical subject, he/she may be encouraged to learn by deep motivations, and still maintain quality learning and earn satisfactory grades. In addition, they may possess deep motivations and surface motivations simultaneously to learning medicine. Chiu et al. reported that Taiwanese medical students with epistemic beliefs related to justifying medical knowledge were more likely to have mixed motivations to learning medicine [20].Secondly, ‘Aim for Qualification’ to house officers is not a good indicator for the surface motivation of the ALM. The most important difference between medical learners and non-medical learners may be how they perceive ‘Qualification.’ Getting accepted into a medical school is so competitive that those who seek entry may start to see each exam as a qualification. In medical schools, not only the results of the National Licensing Exam, but also the grade of each course are closely related to a medical students’ future career. In comparison, non-medical learners may not need to take so many exams, and the results of each exam may not be as related to or important for their future career. Therefore, ‘Aim for Qualification’ to medical learners, unlike non-medical learners, may not be a good indicator of surface motivation.Our study reported that ‘fear of failure’ and ‘memorization’ did not predict medical students’ learning outcomes. The results are not surprising because of the characteristics of the study participants. Our study participants were the house officers with teaching and learning in clinical training years. Therefore, they were not so stressful about pass/fail issues, and rote memorization of countless details of basic medical sciences as compared to the medical students in the preclinical years.We examined the association between house officers’ ALM and their learning outcomes as indicated by the class rank in his/her graduating class in medical school, which has not been used in studies to examine the association between the ALM and the learning outcomes. In addition, the participants from several different medical schools and the high participation rate guaranteed a relatively satisfactory external validity. Nevertheless, there were several limitations in this study.Firstly, this was a single-center study. The health care institution where this study was conducted was one of the best medical centers for training house officers. Thus, the house officers accepted for training in this health care institution might represent those with better academic performance. This might limit the generalizability of our study results.Secondly, it is possible that potential confounding variables were not included in the multivariate linear regression model. Although we already included personal characteristics, i.e., age and gender, as the independent variables in the model, there is always the chance that some unknown potential confounding variables were not collected.Thirdly, the questionnaire was not anonymous, and that might influence participants’ willingness to report their learning strategies and motivations truly.This study first showed that a house officer’s ALM, such as deep motivations, deep strategies, surface motivations, and surface strategies, significantly predicted the learning outcome. In particular, a house officer with a surface motive to learn medicine, i.e., aiming for qualification, surprisingly predicted a higher class rank in his/her graduating class. Although several possibilities have been proposed to account for this phenomenon, future studies are highly suggested to further explore this result which was different from that has been reported in the literature.


Water and sanitation services are fundamental in preventing the spread of waterborne and hygiene-related diseases. However, in developing countries, such as Haiti, access to clean water continues to pose major challenges despite efforts to improve quality and reduce distance. With Léogâne being the epicenter of the earthquake in Haiti in 2010, there were dozens of interventions aimed to improve access to clean water, specifically well construction and use of water treatment strategies. Using the socioecological framework, this study collected qualitative data to supplement a household water insecurity experiences (HWISE) survey in order to fully understand the narratives around water in Léogâne (urban) and its neighboring commune Gressier (peri-urban). The inclusion criteria for this study was that the participant must be a resident of either site, at least 18 years or older, and a female. Only females were included in this study so that researchers could better understand how perceived water insecurity impacts reproductive health, specifically gynecological infections. This cross-sectional study yielded 61 total in-depth interviews using a semi-structured open ended questionnaire to allow participants the ability to elaborate. Results suggest that there are common misconceptions about water and reproductive health specifically that engaging in sexual intercourse in saltwater will not result in pregnancy. Relevant narratives among the two communes included water acquisition, use of water, and bathing practices, among several others. Through understanding the local Haitian perspective and practices that surround water insecurity, we can better tailor public health interventions to improve access to water, female hygiene practices, and ultimately lower and prevent disease transmission. Water insecurity has largely been conceptualized as a result of insufficient “access to and/or supply of” water for daily living –3. The JImproved water sources are still not sufficiently available for the majority of Haiti’s population, which significantly increases the risk of poor health outcomes including malnutrition and/or delayed physical, psychological, and cognitive development in children , 9–10. RThis study looks to investigate water insecurity in the Southern Peninsula of Haiti, in communes Gressier and Léogâne. A primary objective of this research is to examine the perceived heterogeneity between the communes (one being peri-urban and the other urban) in relation to water access, utility, and hygiene as it relates to water. This study aims to identify the current knowledge, attitudes, and practices that surround water insecurity in order to contribute literature on culturally grounded perceptions by local Haitians.Gressier and Léogâne are two communes in the Ouest Department of Haiti that are side-by-side geographically and were selected because of their potential differences due to population size and land use as shown in From March to May 2018, UF researchers and students conducted a cross-sectional household water insecurity experiences (HWISE) survey to create a baseline in Gressier and Léogâne. This study built upon the HWISE survey and administered a qualitative component that this paper will address specifically. Researchers used a sequential explanatory design  for collFieldwork for this study began in March 2018 with UF students, including a PhD student in anthropology as well as a small group of eight undergraduate students with varying health and biological majors, assisting researchers and local Haitian staff. The undergraduate students only performed fieldwork in the second site, Léogâne. Prior to collecting data, all UF students were trained in qualitative data collection methods, which included but were not limited to, cultural sensitivity and competence among participants. A team of three local Haitian staff that have worked previously with UF researchers were employed as translators for the qualitative data collection component and were among the enumerators previously employed for the HWISE survey component. This team was trained previously by the UF researchers in qualitative data collection methods and had demonstrated competence in facilitating focus groups, conducting interviews, enumeration that included open-ended questions, best practices in avoiding bias, and community engagement and recruitment strategies.Following the data collection of the HWISE surveys, selected participants were re-contacted (with permission) and asked to participate in in-depth interviews. These interviews served to contextualize themes from the HWISE survey and develop an understanding of how water insecurity was perceived within Haitian culture as well as to serve as the empirical foundation of the qualitative analyses in this paper . All intInclusion criteria for this study required being 18 years of age or older, female, Haitian, and living in either Gressier or Léogâne. Only females were chosen for this study in order to ask targeted questions around reproductive health and hygiene practices, specifically regarding the transmission of bacterial or viral diseases. Exclusion criteria included any female that had not lived in the household for at least six months or was not knowledgeable about their current water practices. Interviews began in Gressier and were more fluid, with semi-structured questions being manifested from the participant’s specific HWISE survey responses. In doing this, a question bank was established that would be used during the Léogâne interviews. This study only looks to compare questions that were asked in both locations. Interviews were translated in real-time into the participant’s native language with the assistance of a local Haitian translator and lasted no more than two hours per participant. Questions were semi-structured to allow the participant the opportunity to expand on themes not covered by the HWISE survey. Sample size for the in-depth interviews was based on reaching saturation within the priority population, specifically in relation to knowledge, beliefs, and practices around water .Qualitative analyses were conducted on the in-depth interview transcriptions. Ethnographic content analysis, a method used to analyze qualitative data as a means to explore themes, was applied while coding the data . Two UF The UF Institutional Review Board approved this study October 31, 2017 (IRB201702549). The Haitian Ministry of Health ethics review board approved this study on February 22, 2018. Data collection began once both approvals were obtained. Prior to recruiting any participant for this study, oral consent in Haitian-Creole was obtained. Oral consent was preferred in previous studies in this region of Haiti as a result of the low literacy rates [There were a total of 499 surveys from both Léogâne and Gressier; with 32 participants from Gressier and 29 from Léogâne being re-contacted for the in-depth interviews. In Léogâne, themes around water access were primarily related to a shortage of clean, safe water in the area. Due to this perceived shortage, water uses were largely determined by source. For example, it was explained in the interviews that well water was boiled and used for cooking, it was not to be used as a primary drinking source or bathing. There are many non-governmental organizations (NGOs) and international organizations in Léogâne that may contribute to why so many participants shared that they treat the water with aquatabs, tablets for disinfection of drinking water for human consumption. Alternatively, in Gressier, since the reported primary source of drinking water is different than Léogâne, participants described similar problems with access but in regard to piping systems instead of wells. Perceptions on bathing practices and pregnancy risks related to water were explored between the two communes as a result of previous work in the area around vaginal illness and water quality .Issues related to accessing water was consistent across the two communes. Many participants explained that they choose to go to the water source that is closest to them out of necessity, however, it is usually not their preferred water source. Additionally, if the main water source was a well, participants in both communes acknowledged their frustrations with having a schedule around when the well would be unlocked and available for use. As quoted in Water sources being damaged or unobtainable emerged from the interviews mostly as a result of asking participants about their satisfaction with their water situation. However, there was a difference in what type of water source among the two sites. For example, in Gressier, most of the dissatisfaction with water sources came from the informal piping system not being functional. Participants described that either it cost too much money to install and have monthly payments, or they had it installed and it eventually stopped working. Among participants in Léogâne, complaints were primarily about the wells either being damaged, being too difficult to pump, or having a reddish discoloration in the water. Both sites have participants citing the additional burden and risk that comes with a broken or damaged water source. For instance, a participant describes in esprit de corps surrounding their water source–be it an informal piping system or well. This community bond with the water source resembled in unofficial cooperative wherein neighborhood members would either contribute by paying a monthly payment or pay to have the water source fixed if and when it became damaged. Specifically in Léogâne, 2–3 participants appeared somewhat resentful that there was no such commitment among their own neighbors to form a cooperative. As a result, these participants often spoke of the difficulties in having to travel to other neighborhoods to find a functioning water source when their own was broken.Similar to damaged water sources, both sites had pockets of neighborhoods that shared an Water treatment was discussed on a household scale within the socioecological framework, however, a large portion of participants from both populations also spoke about treatment at the community level as well. In this study, water treatment is defined as any method that can improve the quality of water for its intended use, be it cooking, bathing, or drinking. At the household level, it was fairly evenly split between participants at both sites whether or not they treated their water. Treatment options varied from acquiring free aquatabs from an NGO, buying aquatabs, using chlorine, or using a product called Gadyen Dlo, or water guardian. This product is a chlorine solution and is distributed throughout Haiti by Deep Springs International, UNICEF, and Jolivert Safe Water for Families . In mostFor the most part, participants across both sites separate water into buckets dependent on the use of the water. For example, the participants from Gressier quoted in With regards to water uses, participants from both communes used water collected from their water source for cooking, laundry, cleaning, and bathing. However, in Léogâne a small portion of participants indicated that when they use the water from their water source, specifically a well, they get a rash or skin infection. Many participants explained that water for bathing purposes should be boiled first, to avoid infection or disease.Bathing practices was detached from the previous theme, water separation and uses, in order to capture if and how participants were sharing containers and/or reusing water for bathing purposes explicitly. There was variation between participants in both sites in regards to whether the same buckets were used, however, a majority of all participants stated they replace the water that had previously been used to bathe in. Very few stated that they treat the water they bathe in with any chemicals, such as chlorine, and rely primarily on boiling. Furthermore, even less participants shared that they clean the bucket(s) used for bathing between baths.The risk of pregnancy reported by participants varied depending on the type of water. As indicated in In several neighborhoods throughout Léogâne specifically, community members would describe either sharing the costs of maintenance of a well with neighbors or the opposite—feeling isolated and sometimes bitter because neighbors did not want to form an informal cooperative. As a result of wells being unregulated in Léogâne, this creates an unfortunate example of “The Tragedy of the Commons” paradigm, wherein individuals in certain neighborhoods act in their own self-interest instead of working together . CooperaAccess to drinking water is essential for the most aspects of living and is goal six of the Sustainable Development Goals which states clean water for drinking and sanitation should be accessible and affordable for all . Water iEscherichia coli occur after water collection, despite the water being high quality [Water storage and container sharing differed between the two sites. For example, several participants in Léogâne described using the same bucket for collecting, cooking, washing clothes, and sometimes bathing. Whereas in Gressier, buckets were generally separated by use and water used for bathing was not reused for something or someone else. Despite those in Gressier relying largely on informal piped water systems, which may be slightly more safe than traveling for well water, these unregulated systems of water perpetuate a paradoxical arrangement that leaves the government unaccountable and can increase water insecurity in the future –43. Conv quality –50. Reas quality . Increas quality . Similar quality . SubsequWhile this study investigates a local phenomenon around water access and utility, due to its small sample size, it cannot be considered generalizable to the country as a whole, nor was that the intention. The sample for this study was derived from those surveyed with the HWISE survey, therefore, as with any survey, limitations exist from surveying those who were available and home during the hours enumerators conducted the survey. Additionally, despite having local Haitian translators translate in real time and re-listen to recordings to ensure translations were correct, there is always the potential for nuanced linguistic meaning that is lost through translation.This study explored the knowledge, attitudes, and practices around water insecurity in urban and peri-urban Haiti to better understand the issue. Results have shown that there are several culturally based perceptions surrounding water and illness, specifically related to reproductive health. This gap in knowledge opens the door for future interventions to focus on tackling common misconceptions with the spread of disease and what role water can play in preventing and contracting disease.Researchers are currently working with local partners , and encourage others seeking to work in this region, to focus on preventative measures with regards to waterborne diseases as a result of water insecurity. A study done in Bangladesh  around w