Drawing upon the Triadic Reciprocity Framework, this longitudinal qualitative multiple-case study examined how three Hong Kong secondary English as a second language (ESL) teachers exercised their teacher agency to take control of their teaching and professional development. More specifically, the study aimed at exploring how teachers’ intentions and actions for the establishment of their professional identity were afforded and constrained by their workplaces. Findings reveal that these ESL teachers exercised different degrees of proactive, reactive, and passive agency. The four properties of human agency, i.e., intentionality, forethought, self-reactiveness, and self-reflectiveness, influenced the teachers’ proactive, reactive, and passive agency when they responded to personal, behavioral, and environmental determinants. The findings shed light on a three-layered Triadic Reciprocity framework on teacher agency and contributes to a systematic and comprehensive discussion about the various internal and external factors that might exert influences on agency of early career teachers. This study offers pedagogical implications for school teachers, school leaders, and policy makers in Hong Kong and beyond. Confronted with heavy workload, lower positions, and high social responsibilities, language teachers at their early career stage are likely to undergo identity struggles and professional burnout. Understanding of teachers’ professional development and practice in contexts is crucial for providing responsive support for them. Recent literature on second language teacher education has highly appreciated the concept of agency, as it “critically shapes their [teachers’] responses to problematic situations” , p. 11. Language teacher agency is a relatively under-explored area in teacher education . An undeThis study explored how three English as a second language (ESL) teachers exercised their agency to take control over their teaching during their early in-service years. Agency is dependent on a combination of personal, behavioral, and environmental determinants. To explore teacher agency in secondary school contexts, this study employs the Triadic Reciprocity Framework Core Agency Concepts (TRFCAC) model  to examiAgency is often conflated with action and is often framed in opposition to structure, i.e., factors that influence or limit the available choices or capacity to be agentic . Agency Studies in delineating professional teacher agency has reported that teacher agency, or teachers’ ability to act toward teaching requirements, are inseparable from the contexts in which they operate . Such deFrom a sociocultural perspective, teacher agency entails a teacher’s conscious efforts to “resist feelings of powerlessness and negativity experienced as a by-product of the environmental conditions” , p. 607.Hence, teacher agency is not an attribute residing in individual teachers, but rather something achieved through engagement with specific contexts . In respBeginning teachers often encounter problems in exercising agency for professional development. Given the crucial role of agency in teachers’ professional development, there were also studies specifically focusing on teacher’ agency development. For example, in a study focusing on Chinese language teachers in international schools in Hong Kong , the finIn a recent study by The studies presented above indicate that the development of teacher agency is imbued with affordances, challenges, and uncertainties in teachers’ working environments. Meanwhile, it is complex to underpin teachers’ decision to join, stay in, or leave the teaching profession. Individual teachers’ capacity in exercising agency may vary in different situations. The intensity of individual engagement with social suggestions may also vary, depending on individual interest and intentionality. Consequently, teachers’ professional agency may vary in its manifestations across individuals and situations and under different levels according to different aspects of a teacher’s professional work. It is thus essential to understand how teachers respond to contextual realities – opportunities and challenges – in exercising their professional agency in a longitudinal way. In this connection, it is fruitful to examine in-depth, teachers’ proactive, reactive, and passive agency during their early years of school teaching.This study analyzes data through the TRFCAC model  developeIn This study adopted the TRFCAC model to examine Hong Kong ESL teachers’ professional experiences in their early years of school teaching, with the following rationale. First, the four core features of personal agency, including intentionality, forethought, self-reactiveness, and self-reflectiveness  are crucIntegrating two agency models of This study investigated the teaching lives of three ESL teachers, focusing on how they exercised their teacher agency to take control of their teaching and professional development at the early stage of their teaching career. The study was guided by the following research questions:What beliefs did the ESL teachers uphold in the early years of their teaching career?How did the ESL teachers exercise their teacher agency to take control over their teaching and professional development?This study is primarily interpretative and qualitative in the sense that the same phenomenon can yield an array of interpretations from multiple perspectives by the research participants, researchers, or other observers. A generally qualitative design allows individuals to “construct reality in interaction with their social worlds” , p. 22, Kristy, Joyce, and Sammy were full-time ESL teachers in different secondary schools in Hong Kong. The anonymity of the participants and the schools where they were working was secured. These three female teachers were purposefully selected, meeting all the basic requirements, including teaching English in Hong Kong secondary schools for a few years upon graduation from a teacher education program, and being willing to share their life and teaching experiences with the researchers. This study also adopted a convenience sampling approach. All the three participants were former students of the first author. They were from the same cohort of a B.A. and B.Ed. English double degree program in a local university. They all began their school teaching after completing the English double degree program in summer 2013. More specific information about the participants is as follows.Kristy returned to her alma mater to start her first year of school teaching upon graduation from the English double degree program. She left the school 3years later because she was not able to renew the contract. She then took up a teaching position in a directly subsidized school (DSS) in 2016. Although she encountered various difficulties in the DSS in the first year, she gained a sense of control over teaching in subsequent years. After finishing the fourth year in her second school, she had an opportunity to return to her alma mater to continue her teaching journey in the place where she started her teaching career.Joyce also started teaching upon graduation from the double degree program. She left her first school after 1year of teaching due to geographical distance and perceived inadequate professional learning opportunities. She proceeded to another secondary school to continue her English teaching journey from September 2014 to August 2016. It was a Band One government school located closely to her home and she reported that she had a good time in this school. She left that school due to funding unavailability after 2years. In order to better prepare for her teaching career, she joined a 2-year part-time M.Ed. program, while taking a few temporary substitute-teacher positions in a few secondary schools, during 2016–2018. She went to the third school after completing the M.Ed. program. However, Joyce left the teaching position after 2months owing to the unfair treatment she received there. She later worked in an education-related NGO as an administrative officer for about half a year. She decided not to renew her contract and stayed home to take care of her young daughter, thinking about whether she would leave the teaching profession permanently.Sammy taught English in a boys’ school upon graduation from the same double degree program. She spent 1year for her first teaching job, leaving that school in 2014 due to various challenges she encountered there. For instance, the overall atmosphere of a boys’ school did not suit her nature. After leaving her first school, she then enrolled in a 1-year full-time postgraduate diploma in psychology. She joined another school in 2015 after completing the program. During her service in the school, she pursued a 2-year part-time M.A. degree in comparative and literary studies. During the fourth year in her second school, she realized that she had hit a plateau in terms of her self-development. She began to search another job. Starting from September 2019, Sammy started teaching in her third school, a Band three school. She thought she could contribute more to teaching and student development than in her first and second schools.Aiming to reveal the complexities of teacher agency in the secondary school contexts in Hong Kong, the major source of data was in-depth interviews with three ESL teachers, Kristy, Joyce, and Sammy, to listen to their lived stories. Two main rounds of interviews were launched. The first round was conducted from 2013/2014 to 2014/2015, within the first 2 academic years of their in-service school teaching after graduation; and the second was conducted from 2018/2019 to 2019/2020, within their sixth and seventh/eighth academic years after surviving their initial years of school teaching. Each face-to-face interview lasted for more than 1h. The interviews were audio-recorded. English or Cantonese language was chosen for an interview when the interviewees felt more comfortable expressing ideas in English or Cantonese at that particular moment. All the interviews conducted in Cantonese were translated into English by a senior research assistant who is highly proficient in both Cantonese and English.via email/WhatsApp exchanges) with all the participants were maintained by the first author. All these supplementary forms of data other than in-depth interviews contributed to the understanding of each participant’s professional experiences in the Hong Kong educational settings.In addition to interviews, other data sources included personal communication with the participants and school documents from their workplaces, such as Schemes of Work and school timetables. Within the middle period , formal and informal conversations . At university, she cherished the teaching practice incorporated into the overseas English immersion program at the end of the third academic year and also her two teaching practicums in local schools scheduled in the last 2years of the double degree curriculum. The school atmosphere nurtured her initiative to learn teaching. The positive experiences strengthened her determination to become an English teacher. She reported:When I was in Primary 5 and 6, my English teacher provided me with some interesting and innovative ways for us to learn English. In secondary school, we had a good teacher model. We admired her and wanted to learn from her. After being admitted to the university education program, the teaching practice in the immersion program in Australia was really great. I was determined to be a teacher .In short, Kristy’s personal experiences and feelings in becoming a teacher were built on her positive navigation during primary, secondary, and university education. The word “determined” indicates her goal to be a teacher.Having graduated from university, she started her teaching career on a contract basis in her alma mater. Kristy felt it grateful to work there despite some challenges. She attempted to implement activity-based teaching in her classroom through working hard to strike “a balance between the reality and ideal pedagogies learned in university” .She was assigned two S2 (Secondary 2) classes and one S3 class in her first year. She faced a problem of learner diversity. Another difficulty was the curriculum. As she was new, she needed time to be familiar with the curriculum and design relevant materials to meet her students’ diverse needs. She also faced the problem of learners’ low English proficiency. She tried to orient her lessons to be task-based, and expected her students to be motivated. Her reported difficulties included the “lack of knowledge in dealing with weaker students,” and “arranging classroom activities” being “a luxury” in classroom teaching . The school explicitly emphasize both assessment for learning and assessment as learning. Kristy regarded such policy aligned with her teaching beliefs. However, during her first year of teaching, she reported she was rather “passive” in developing materials to meet students’ diverse needs and the school’s assessment requirements.Her second and third years seemed easier. To help her better blend into this new working environment, her panel leader continued to arrange experienced teachers to guide her. With continuous support from colleagues, Kristy adapted better into the teaching environment from her second year. The initial experience and confidence obtained from her first year teaching, together with her perceived reduction of workload, enabled her to act more proactively in her own classroom. An informal interview in her third year of teaching was conducted when she paid a visit to the university, where she obtained her B.A. and B.Ed. double degree. She shared her experience with the first author (interviewer/discussant) highlighting proactivity in her second-third years, including “experimenting with task-based or activity-based methods” and “implementing assessment for/as learning” rather than “simply following assessment of learning” . She explained further in the interview:I was able to adapt better into the environment from the second year. During the first year, it was indeed challenging to get hold of the curriculum…. In my second year, I was assigned two English classes only and the teaching materials for classes I taught in my first year could be used again…, and I also got four classes of Religious Studies, which did not add much workload.We [Kristy and an experienced teacher] have been assigned to teach in the same form for 3years. There were a lot more chances for us to exchange ideas and insights mutually, rather than having her who simply told me what to do.Overall, Kristy felt grateful in working in her alma mater. However, she had to leave the school unwillingly 3years later due to a reduction in the total number of classes which in turn affected staff funding.Kristy then joined the DSS. She found it particularly difficult to adapt to the new teaching environment. She still felt the emotional attachment to her alma mater as she put, “I still missed the first school I worked in” . Worse still, the new workplace provided no structured support for her. As the school was relatively new with less than 20years of history, the teaching staff were quite young compared with those in her first school. Apart from the school system, students here were also different in terms of behaviors and characteristics. While her past students were quite conforming and easy to control, her new batch of students here were seen as “more challenging,” as they would “test the bottom line” of new teachers . Kristy reported that those students thought they were more familiar with the place than the new teachers. In terms of teaching content, although colleagues were quite open to discussions regarding the procedures and overall design of their lessons, they rarely shared teaching materials. Another challenge was lesson observation. As the school needed to have an External School Review (ESR) enacted by the Education Bureau, the administrators had an even more critical eye on the performance of individual teachers. She repeatedly told herself, “I am not the worst. I will not be fired” . She reported:We needed to do ESR. I felt it not easy. There have been requirements on how to use different tools in implementing e-learning. The panel head filled in a lesson observation evaluation form and conducted an appraisal with me. The appraisal is related to the promotion… I wish I am not the worst .Kristy found it difficult to adapt to the new teaching environment. She felt she was deprived of professional autonomy in teaching. She was stressful in handling the “top-down” appraisal and peer observation, for which, she had to strike “a balance between lesson preparation work, administrative work, and marking assignments” . She was thus thrown in bewilderment.Nonetheless, Kristy’s positive beliefs  motivated her to adapt to the new environment. After her first year in this school, she developed a better sense of the workplace and understood her own positioning as a teacher. She attempted to create more space for self-reflection and take greater control over teaching. She signed up for workshops and seminars provided by the Education Bureau to enhance her professionalism and to bridge the “theory-practice” gap . She endeavored to build a sense of efficacy and control as a teacher.After working for 4years in the DSS school, Kristy decided to return to her alma mater to start her eighth year of school teaching and she was successful in the end. She described the second school as “stressful” because teachers “have to take up responsibilities not only to the students but also to the parents” . She described some of the students as “spoiled.” Their mindset was “why the teacher cannot make me understand the knowledge” rather than “please teach me about this. I do not understand it” because they were “the one who pays the tuition” . In contrast, she descried her enjoyment as a teacher after returning to her alma mater as the students were more motivated.Here, the students will ask as many questions as they can. They will ask you if you can mark extra writing too. And that brings you a bit of pressure. It is a pleasure to see students’ growth .It appears that students’ diligence and desire for knowledge is a source of stimulus for Kristy’s teacher agency development. In addition, the school system is an important factor. According to Kristy, although the previous DSS school seemed to allow more flexibilities in teaching, there was an obvious insufficiency of specific guidelines. In her alma mater, the teaching schedule was tighter, but the school provided more ready-made resources, specific guidelines, and support from senior teachers. These were important for busy teachers in Hong Kong, as described by Kristy.Continuing her teaching journey in her alma mater, Kristy started to highlight the importance of “work-life balance.” She expressed that she could set a roadmap that could relieve her stress in her alma mater. In her views, “work is not the only thing” in her life, though working is important. She mentioned that work-life balance made her feel “being integrated to the working environment” .Joyce has a cheerful personality. She studied in a primary school where English teaching was, in her words, “teacher-centered.” She completed her secondary education in a prestigious girls’ school, where the teachers adopted a more naturalistic approach to language teaching and created a less structured and more relaxing environment for language learning. After the A-level examinations, she decided to enroll in a teacher education program in a local university mainly because of the teachers she met. The idea of being a teacher budded when she was in primary school. It got shaped and reinforced throughout her secondary education. As she often found joy in teaching, she embarked on her teaching career after graduation. In an interview at the very beginning of her first year of school teaching, she clearly explained her passion in teaching:Being a teacher is very good because we are helping the kids grow. It is an honor to be a teacher. As I found joy in teaching others, I embarked on my teaching career right after graduation. I just wanted to be a teacher .This quote indicated being a teacher was her desired identity. Although Joyce was optimistic toward her first teaching job, her career path turned out to be the least stable among the three teacher participants.Joyce started her first teaching job at a local secondary school in summer 2013. When asked whether she would be confident to find her place at the school, she highlighted the heavy administrative workload. Like other novice teachers, she was assigned a mentor-teacher who would chat with her about life and teaching affairs. She also benefited from the teaching materials shared by other teachers. In her students’ eyes, she was not a strict teacher, but she communicated expectations and rules very clearly with students at the beginning of the school year. As time elapsed, she was like a friend to her students. It was her philosophy that the teacher does not just impart knowledge but also life values. This “teaching-beyond-schooling” approach was in line with her broader belief that it is “an honor to help somebody grow.”In summary, Joyce enjoyed the initial months of her teaching. After the first half of the academic year, her self-doubt grew, as she remarked :When I do not find job satisfaction sometimes, I think whether I am suitable in this job and sometimes I wonder if I should ever be a teacher. Should I just leave the school and the whole industry completely because if I am not doing a good job, I am not only affecting myself, I am affecting the others as well…I do not feel being appreciated [by students]… [I get] not really positive comments from colleagues…Her perceived mediocre job satisfaction and her self-doubt as quoted above stemmed from several classroom management challenges, a couple of complaints from her students and a lack of appreciation from her colleagues. The lack of appreciation might partly explain why she chose not to renew her 1-year contract. Two other factors also contributed to this decision. First, the geographical distance took her one and a half hours to travel to work. Another crucial factor contributing to her quitting despite the gloomy job market at that time was her desire to work with people whom she could feel more connected to. The school was a young school with young teachers and administrators who did not bond well with her. Some colleagues may compare themselves with her as she explained below some years later:I did not feel the sense of connection even though we were not enemies. I would really love to collaborate with and learn from teachers from different backgrounds and of different ages. However, since other teachers and I are more or less the same age, our mentality and thoughts were too similar as well…. Also, there were comparisons among teachers. When all the teachers are almost at the same age, students tended to compare. Anyway, that was not the working atmosphere that I prefer .Continuing her teaching journey, Joyce joined another secondary school, which was a Band One government school in closer proximity to her home. The position was based on a 2-year contract. She was responsible for teaching senior form English and this gave her some pressure. In addition, the school required lessons in the same form to cover exactly the same content, which constituted a particular difficulty for teachers like Joyce who wanted to develop materials and strategies to meet students’ different needs. As a result, she found her first year there “unsatisfactory” and described it as “a period of exploration” .Fortunately, her colleagues shared materials among teachers and were eager to collaborate and exchange pedagogical ideas, during lunch or after school. This motivated Joyce to improve her teaching. She thought that she did not actually know her students well enough; she held a firm belief that “taking students’ learning needs into consideration is of primary importance” . She then started to collect students’ feedback on her teaching through casual chats with students after class and giving out a piece of paper to collect feedback.In her second year, she adjusted her teaching with reference to students’ feedback. Although her teaching was guided heavily by the Scheme of Work, she did not find it constraining and was able to create space for manouevre in delivering the content . Her 2 years at this school concluded in joy and satisfaction, leading to a higher level of teacher agency.After working in two schools for consecutively 3years, she desired a break from full-time engagements and turned to a part-time 2-year (2016–2018) M.Ed. program.The M.Ed. studies with intermittent breaks also indicate Joyce’s turning point. She decided to devote more time to nurturing her young daughter. When asked whether she was considering a full-time teaching job after completing her M.Ed. studies, she said it was “a possible option” , although the (third) school she served did not give her a pleasant experience. She was only informed of the classes that she was teaching a few days before teaching was meant to start. She received little concrete support from the department and colleagues and there was no recycling of shared teaching materials. Moreover, surveillance mechanisms, like homework inspection and lesson observation, were implemented as part of the “quality control” measures in the school. While these measures may be common in Hong Kong nowadays, “this school would do it repeatedly until the ‘bosses’ felt satisfied.” She reported further:I have never experienced such a lesson observation. Some teachers observed my lessons and commented that I could not live up to their standard. The principal stood at the door of my classroom for a long period without leaving, and I felt offended. I was also offended by the fact that a Chinese history teacher was there to evaluate my teaching and I do not see why this Chinese history teacher was qualified to judge how I teach English. I felt untrusted and disrespected… .The observers criticized Joyce’s performance. Joyce described the criticism as “denouncing opponents during the Cultural Revolution” in China. A second lesson observation was scheduled and Joyce handed in her resignation next day to quit the job she did for only 2 months. The experience was traumatic, making her consider “whether I am still suitable to be a teacher or not.” It took her at least 1 whole month to restore a mental balance and she said that she still found herself “mentally and spiritually vulnerable” half year after the lesson observation .Joyce had doubt over her teaching capability and fear of repeating the traumatic episode on the teaching frontline. She later resumed teaching as a cover teacher in a school during January–July 2019, and worked as an education administrative officer in an NGO during August–December 2019. The administrative experience provided her a chance to compare the nature of school teaching and administrative work. Given a choice, she would prefer to be a teacher as demonstrated by what she explained in several interviews during 2019–2020: “Being a teacher is never just because of the salary”; “I see teaching as everyday creativity”; “As a teacher, you can develop a rapport with your students.” However, at this point, she prioritizes her family commitments and being the teacher on a long-term basis became unrealistic.After a year of struggle due to the need to take care of her daughter during the COVID-19 pandemic and the “suppressing political environment in Hong Kong” since 2019, she finally decided to “leave Hong Kong for her daughter’s future education” . She continuously questioned her teacher identity because “there were incidents regarding teachers’ so-called professional conduct in the educational field” .Sammy is a cheerful girl. With her sincere attitude, she befriended a lot of like-minded people in the university. She did not expect to be a teacher. She regarded the education component of her English double degree would afford “more chances to interact with people, like during my teaching practices.” Throughout the university education, she kept reflecting on the question, “Am I suitable to be a teacher?”During the 4years of university study, I reflected on myself how to make a change for my life. I have never thought of being the teacher before entering university. Am I suitable for being a teacher? .However, Sammy was determined to become the teacher upon graduation because she considered herself as an agent of pedagogical innovation who would definitely bring changes to the educational landscape.After weighing different offers upon graduation, she finally settled into a Chinese as medium instruction (CMI) boys’ school. She set out with an approach described as “half-new-half-old” in her own words . She preferred traditional direct instruction and drilling for grammar and vocabulary especially for weaker students; meanwhile, she strived to “create space for interactive classroom activities with an emphasis on the practical use of English in a fun and authentic way.” She believed that her role was to facilitate her students’ learning to the degree that they were able to “use English to communicate and interact with people, to love the other countries, to love the cultures, to love humanity” .In her first year, she was responsible for one S3 class and two S1 classes, on top of her duty to run the English Corner, to organize a joint-department competition and to be a Parent-Teacher Association member. Her mentor gave her much advice but other colleagues were too busy to help her. Like many beginning teachers, she struggled to prepare materials. Another difficulty she encountered was the group of students with special education needs (SEN).My class was mostly SEN students. I lacked knowledge in dealing with SEN students. I tried to incorporate interactive activities to make English teaching fun, but such efforts were in vain .It appears that dealing with SEN students and preparing teaching materials mainly contributed to her hectic life as a beginning teacher. This compromised her original work-life balance. She was generally not satisfied with the fact that she “could only fulfill the assigned job duties with limited creativity and innovation” .At the end of the school year, she decided to leave this school for three reasons: first, the overall atmosphere of a boys’ school did not suit her nature; second, she was only assigned junior forms in her first year and this might weaken her competitiveness as a capable secondary school teacher; third, she was responsible for helping coordinate the Parent-Teacher Association and this duty was not what she desired. Then she started a postgraduate diploma (psychology) study in a local university, hoping to get inspired by seeing matters with new perspectives. Satisfactory completion of this program also promised alternative career pathways like a counselor and an educational psychologist. At that point, she still thought that being a teacher allowed her to design powerful and innovative learning environments for her students.After a 1-year study break, she continued her role as a teacher in the DSS. She perceived more room for manoeuvre here as there was a core central curriculum. She had freedom to interpret the curriculum and teach in the ways she considered appropriate and effective. She saw more learner diversity accentuated by some SEN students. The relationships among colleagues were not bad; she had the best relationships with her panel head and peers of her age range. Her first year at this school was not too difficult, although a considerable amount of time was spent exploring the school policies and culture.I managed to negotiate for a change in curriculum to enhance teaching and learning. I received professional support from my panel head and my teacher fellows. I was able to bring in new ideas for my students’ various needs. There were more flexibilities than in my first school .She obtained her first opportunity to teach a senior class. She was eager to teach the class and witness the students graduate. Her school did not usually allow teachers to take courses within school hours. She took advantage of her after-school time to take courses or seminars organized by the Education Bureau and British Council to keep herself abreast of the latest pedagogical knowledge. Another way she adopted to empower her teaching was that she often exchanged ideas with her university classmates. She was able to pick up various teaching strategies as her classmates were teaching at different schools.From the start of her third year, she started to feel teaching duties were the same and there was much less she could learn from her colleagues, as sharing was not a norm in the department. She only managed to talk with her peers for new ideas and comments. In spite of this, her strong belief led her to pursue her second higher qualification, M.A. in comparative and literary studies, in the same university where she obtained her postgraduate diploma: “If I just do things to satisfy the basic requirement, I will not be able to improve my teaching” . This degree did not bring explicit impacts on her teaching, as this school did not stress the acquisition of literary knowledge. Nonetheless, she gained the necessary knowledge and tools to critique various literary works. The professors were mostly inspiring and taught the courses through classroom activities. This activity-based approach combining with a problem-solution model derived from her previous psychology background formed her teaching style. Whenever she saw a problem arising from her class, she would start researching and evaluating ways to solve the problem.The fourth year at this school was not too easy as she realized that she had hit a plateau in self-development. While expecting to be newlywed toward the end of that year, she felt more intensely about the plateau and stagnation she faced in her job. With increasing administrative tasks, she felt “a sense of powerlessness”; moreover, she acknowledged that this situation is “not healthy” and that it depended very much on her “own initiative to sustain professional growth” , as she thought there was limited new pedagogical input and discoveries for her. As a capable teacher, the school tended to assign her more duties and responsibilities to the extent that she felt the workload was “saturated” . Feeling confused, she started to send cover letters to other schools to see how much she was treasured from other schools’ perspectives.After rounds of interviews, she finally secured an offer from a lower-achieving CMI school. This school expected her to take up more functional roles. The school had a strong emphasis on students’ mental well-being and self-management, providing her with opportunities to draw on her counseling expertise to support students. Since the students’ English proficiency was generally low, she spent more time scaffolding their learning process and employing activity-based approach in teaching. The students began to like her and some sent cards to show appreciation.In her second year, catering for her students’ diverse abilities was still challenging for Sammy. Fortunately, she benefited greatly from the sharing culture, which in turn informed her material preparation and lesson planning. She explained how “by far the best sharing practice here” and the reflective atmosphere would foster her professional growth:… Almost every teacher is willing to share. I think that my colleagues are very reflective. Since they prepare a lot of resources for their own classes, and if they consider resources prepared by them useful for other colleagues. They will share for sure .Another good practice was lesson observations:… Lesson observations are absolutely professional. Teachers or supervisors discuss together after observing a lesson. Observing teachers have a pre-meeting with the panel head before sitting lessons. …Although I have experienced many lesson observations in the past…, the practice here is still an in-depth learning process to me .This presented a stark contrast to lesson observations as a routine administrative measure almost devoid of meaning in many other schools. In addition to lesson observations, there were many other professional development opportunities for English teachers. For example, the school organized 5–6 professional sharing sessions about what individual teachers have learned in their professional-development courses each year. The activities aimed to disseminate good practices within the English department.Interestingly, Sammy became more willing to take on non-academic duties after joining this school. She requested to join the careers team to which she thought she could contribute more. She did not confine herself in her comfort zone and had opened up herself to challenges and opportunities. She also became more confident in teaching and demonstrated a sense of self-actualization through capitalizing on her strength.In summary, Sammy has been engaging more in reflective teaching and pedagogical innovations since joining her third school. When asked whether this school was for her long-term development, she steered away from the focus to a more philosophical argument and subtly dismissed this question as unimportant:What is more important is to go with the flow as everywhere has its own constraints and opportunities. It is never-ending to be on the quest of being a teacher. So long as you know your place, you can be a good teacher .This zen-like mentality is definitely an inspiring one that blends well with her own philosophies and her other aspects of life. Within 2 years of teaching here, she has definitely enhanced her sense of agency and her capacity to take control over teaching and personal-professional development.The findings document how three Hong Kong secondary ESL teachers exercised their teacher agency to construct their desired professional identities at the early stage of their school teaching. Based on the findings, this study proposes a three-layered triadic reciprocity framework on delineating the complex process of teacher agency development . The thrIn the first inner layer, the three teachers demonstrated different degrees of proactive, reactive, and passive agency. Proactive agency enabled teachers to obtain a sense of ownership, and possibly, “goal-directed, effortful, and proactive engagement in work practices” , p. 20. In the case of Joyce, her positive feelings toward future teaching career determined her attitude in pursuing a strong sense of teacher agency. When encountering obstacles and setbacks , and when perceiving inadequate connection to the teaching community and collaboration among colleagues, in her first school, she merely wanted to fulfill the school requirements reactively. However, she exhibited proactive agency in teaching innovation in her second school, afforded by full and friendly interaction with colleagues, adequate collaboration among colleagues , and the establishment of a good rapport with her students. After 2 months of teaching in her third school, she resigned her full-time teaching position triggered by, in her own words, an “insulting” and “Cultural Revolution” alike lesson observation, and the perceived authoritarian school culture . The critical experience in her third school made her become passive in enacting professional agency. She needed to make a difficult choice between leaving the teaching profession permanently and resuming teaching to continuously “see kids [her students] grow” .In the case of Sammy, feeling confident upon entering the teaching profession and considering herself as an agent of educational innovation, she took proactive agency in her own classroom at the beginning of her first year in her first school through a mixed mode of what she termed “traditional teaching”  and communicative teaching . Given the perceived various contextual constraints in her first school, she demonstrated reactive agency in seeking necessary pedagogical implementation to simply meet learners’ diverse needs . In the first 2years in her second school, she was able to exercise proactive agency , when she was given the first opportunity to teach a senior class (which she could not have in her first school), when she was granted the freedom to interpret the curriculum, and when she had successfully built good relationships with her colleagues. However, after working for 3 or 4years in this school, she became passive in taking actions to improve teaching because she realized that she had hit a plateau in terms of professional development. She demonstrated proactive agency in her third school again because she found the real meaning of being a teacher from students’ recognition and respect and from colleagues’ genuine sharing of new ideas and classroom practices. Overall, Sammy’s experiences in the three schools tended to reveal that teacher agency is dynamic and fluctuating and thus mirrors a close relationship between self and others, and between self and contexts.In the second layer, the three ESL teachers’ attempts to exercise proactive, reactive, and passive agency were influenced by the four properties of human agency, i.e., intentionality, forethought, self-reactiveness, and self-reflectiveness . As arguKristy’s outcome expectations (forethought) originated from her positive navigation of experiences during primary, secondary, and university education. She formed intentions to orient her innovative lessons, and hoped her students could be motivated in learning English in her first school  and second school. However, the “top-down” appraisals and peer classroom observation in her second school deprived her positive reactions and self-reflection in teaching.Joyce was frustrated in her first school, due to inadequate collaboration between teachers and a disconnection to the teaching community. This affected her forethought for teaching and professional development. Sammy was disempowered by having little knowledge of teaching practices for SEN students until she started to really benefit from her colleagues’ genuine sharing of materials and ideas for teaching SEN students in her third school. The institutional structures of Sammy’s second school also suppressed her self-reflection, for which, she felt intense about the plateau and stagnation in teacher development. Sammy thus perceived passive agency in innovating teaching in her second school.Overall, tensions and constraints in the teaching community impacted the three teachers’ intentionality, forethought, self-reactiveness, and self-reflectiveness, for which they may not adopt attitudes “that will sustain them in teaching” , p. 291.In the third layer, personal, environmental, and behavioral determinants functioned together and influenced the three teachers’ professional agency. The mismatch between the perceived and actual practices of teaching was a constraint to the teachers’ awareness of actions for exercising agency in teaching. The three teacher participants daily teaching routine was inhibited by prevailing institutional expectations and standards of what they should achieve in their profession. For example, Joyce’s second school required lessons in the same form to cover exactly the same content. This environmental determinant may lead to the fact that Joyce found it challenging to address students’ various needs. In Kristy’s case, the ESR in her second school exerted pressure for her to strike a balance between reality and imagination and between administrative and teaching work. Kristy found it challenging to “negotiate multiple demands within schools and school districts” , p. 59. The current research highlighted how personal determinants were influenced by environmental and behavioral determinants. One incidence was that Joyce felt particularly “offended” in her third school, as a Chinese history teacher evaluated and criticized her teaching. The battle for place and presence in a school curriculum had weakened her willingness to exercise agency. Sammy felt unsatisfied with difficulties in teaching SEN students due to the lack of relevant psychological knowledge and with the assigned duties of leading the Parent-Teacher Association in her first school. Kristy’s extra burden was brought by ESR, inadequate colleagues’ support, and demotivation of students in her second school. The imbalance in work influenced her “exploration of new possibilities for action and new assumptions about context, self and practice” , p. 28. This study examines the teaching lives of three secondary school ESL teachers in Hong Kong. The findings uncovered struggles that impeded their exercise and development of teacher agency. The findings provide insights into emerging ESL teachers’ personal and professional development. The discussions on teacher agency development point toward a three-layered Triadic Reciprocity Framework in explaining ESL teachers’ agency. The framework sheds light on the enactment of agency, which is context-specific. The three teacher participants experienced high agency in one area and low agency in another. The extent to which agency was exercised by the teachers depended on their positions within their collective organizations that were characterized by institutional cultures, such as administrative style, working atmosphere, special policies, and peers’ attributes.We acknowledge some limitations of our inquiry, for instance, a small sample size in the Hong Kong context. However, this in-depth study based on different data sources over 7–8years portrayed a fuller picture of teacher agency. We conclude with pedagogical implications based on the findings.First, system-wide structures may hinder teachers’ capacity in taking control of their teaching and personal-professional development. The subtle, yet sensitive power relation between teachers and school stakeholders can lead to teachers’ tensions regarding classroom authority and their confusion regarding their status as a teacher. It is thus essential for policy makers to attend to teachers’ needs in autonomous teaching, and to provide early career teachers with the time to develop their teacher identities rather than expecting them to cope with the work normally reserved for more experienced teachers.Second, the findings suggest a possibility for creating conditions for teachers to take initiatives in constructing, generating, and extending their knowledge in teaching. Teachers need support to sustain their development and construct their professional identities. One worthwhile pursuit is guiding teachers to instigate deeper reflection on being and becoming the teacher. The early career teachers should be reminded to attend to the aspects that may not be readily apparent to them during their initial years. Finally, a suppressive environment may result in a lack of teacher agency, which may also give rise to the chronic problem of teacher attrition among early career ESL teachers. Teachers should reflect on the working conditions that affect their teacher autonomy, their beliefs and motivation in adopting agentic behaviors, and their professional identity development .The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Hong Kong Baptist University Committee on the Use of Human and Animal Subjects in Teaching and Research (HASC). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.JH led the research project and contributed to the research design, data collection, data analysis, article drafting, and reviewing and revising. JY analyzed the data and reviewed and revised the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the Research Grants Council of the Hong Kong Special Administrative Region, China (RGC Ref No. 12607418).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study examined the relationship between intercultural social efficacy (ISE), coping strategies, Mandarin Chinese and English language proficiency, and depression. In total, 1870 foreign students in Taiwan participated in the study. Study results indicated that aspects of background demographics may influence depression levels. Participants with an immigrant background and those who are older are more likely to suffer from depression; however, gender and length of stay do not seem to affect depression. The moderating effects of Mandarin Chinese and English language proficiency and ISE on the relationship between coping strategies and depression were examined. Based on the results, the moderating role of Mandarin Chinese and English language proficiency was not supported, suggesting that coping strategies are independent of linguistic proficiency. However, knowing both languages is an important factor in reducing the stress of studying abroad. Additionally, the results confirmed the moderating effects of ISE, suggesting that a higher level of social effectiveness reinforces the negative association between coping strategies and depression. Students who are better able to interact with other cultures may be able to develop effective coping strategies. Moreover, this study found that although most of the study abroad students were not depressed, early intervention and prevention measures could help alleviate possible mental health crises. Renewed interest in study opportunities abroad has recently increased as the anticipation of a post-COVID-19 scenario grows. In addition, with the gradual return to face-to-face teaching, there is an increased focus on the provision of mental health support services, as indicated by 70% of potential study abroad applicants ,3. A recAs part of discussing the subject of study-abroad-related depression, it is also pertinent to highlight the importance of coping strategies. Importantly, as international students have become increasingly significant contributors to the college population, their mental health needs in particular need to be taken into account . Study aPrior to the COVID-19 pandemic, there were approximately 130,000 foreign students studying in Taiwan . A signiAs a theoretical framework for the study, Yu et al.’s  socioculWithin the psychological adjustment of the sociocultural adaptation process, individuals may experience various stressful aspects of the acculturation process that stem from practical or environmental factors such as adapting to new foods, living arrangements, transportation systems, etc. . These aAs a result of this framework, the present study aims to test the hypothesis that language  and intercultural social efficacy (ISE) act as moderators within the relationship between study abroad coping strategies and depression see . In addiTo validate an instrument used to measure study abroad students’ coping strategies and ISE;To determine the role of coping strategies, ISE and Mandarin Chinese and English language proficiency in predicting depression.In addition to testing the proposed moderating effects of language (Mandarin Chinese and English) and ISE, two other goals are also included:The present study was designed as a cross-sectional study in which this type of data collection can be used to examine information with different variables in order to obtain information about a population over a specific period of time . The datBased on the 2016 Ministry of Education statistics, there were approximately 112,000 international students studying in Taiwan during that academic school year. The Sampsize program  was usedAs noted within the framework, participant background included information regarding age, gender, study level, length of stay (in months), whether the families were immigrants or not (answerable with a yes or no), and whether they were from Asia or not (answerable with a yes or no). The level of study was included because graduate study presents increased challenges in terms of research, raising funds, and securing future career opportunities; therefore, it was believed that a higher level of education would be more onerous . MoreoveTo measure the degree of depression in the participants, the 20 items Center for Epidemiologic Studies Depression Scale (CES-D) was administered . The CESIn terms of language proficiency, participants were asked to rate their self-perceived proficiency levels of Mandarin Chinese and English. Among the ratings were beginner, low intermediate, intermediate, high intermediate, and advanced. Depending on the field of study, international students in Taiwan are required to take either a proficiency test in English or Mandarin Chinese ,45. AlthSocial support—comprising eight items that describe the presence of someone who provides support or comfort during times of joy or sorrow. Sample items are “there is a special person who is always there to assist me” and “there are some friends with whom I can share both joys and sorrows”;Self-actualization—comprising six items that describe the realization of one’s talents and potentials. Sample items are “I feel that I am growing and changing in a positive direction” and “I look forward to the future”;Classroom rapport—comprising five items that describe the relationship the students have with their peers. Sample items are “I have a harmonious relationship with my classmates” and “I am comfortable interacting with my classmates”;Family support—comprising five items that describe the relationship the students have with their family. Sample items are “I get the emotional help and support I need from my family” and “I get in touch with my family all the time”;Health responsibility—comprising four items that describe how students are responsible and aware of their physical and mental well-being. Sample items are “Observe my body at least once a month for signs of changes” and “seek information from health professionals (doctor and/or counselor) about how to take good care of myself”;Daily routine—comprising four items that describe how students maintain a healthy lifestyle. Sample items are “I engage in recreational physical activities” and “I exercise regularly”;Self-relaxation—comprising three items that describe how students recognize the importance of slowing down and enjoying life. Sample items are “I take some time to relax each day” and “I am aware of my limitations”.In terms of coping strategies, as indicated by Yu et al.’s  frameworData were collected using a five-point Likert-type scale  perceiveAbsence of social difficulty—comprising eight items that describe how students interact with their peers and faculty. Sample items are “I find it easy to hold a conversation with most people” and “I am able to talk to university staff”;Social confidence—comprising five items that describe how confident the students are in dealing with others. Sample items are “I feel confident asking a question during class” and “I feel confident talking to my teachers”’Showing interest—comprising three items that describe the manner in which students are interested in social interaction. Sample items are “I enjoy activities that most Taiwanese students enjoy” and “I have common topics for conversation with Taiwanese students”;Friendship initiative—comprising two items that describe the students’ enthusiasm for social engagement. Sample items are “If I see someone I would like to meet, I go to that person instead of waiting for him/her to come to me” and “When I’m trying to become friends with someone who seems uninterested at first, I don’t give up easily”.For the ISE, a total of 18 items were adapted and revised from the Social Self-Efficacy Scale for Students . Within Data were collected using a five-point Likert-type scale perceived level of agreement, wherein 1 = strongly disagree to 5 = strongly agree. Further information on construct validity and reliability can also be found in t-test and ANOVAs were computed with SPSS version 26.0 , on lease agreement from Hearne software. No significant differences were found with regard to gender, study level, or length of stay. Significant differences in depression scores were found among participants’ ages with F  = 10.73, p < 0.001, whereas post hoc analysis showed that both 26- to 35-year-olds  and those aged over 35  were significantly higher than participants aged 25 years old and under . Significant differences were found among participants who were immigrants with t (1868) = 3.12, p = 0.002, wherein participants with a migrant background  showed significantly higher depression scores than those without a migrant background . Significant differences were also found among participants who were Asians with t (1868) = 2.21, p = 0.027, wherein participants from Asia  had significantly higher depression scores than those who were not from Asia .The characteristics of the participants and the distribution of depression are shown in F  = 6.17, p < 0.001, whereas a post hoc analysis showed that participants who rated themselves as high-intermediate  were significantly more depressed than those who rated themselves as advanced . Lastly, for English proficiency, significant differences in depression scores were also found among participants with F  = 12.23, p < 0.001, whereas post hoc analysis showed that participants who self-rated as beginners  were actually depressed (scores above 16) and had significantly higher depression scores than the participants who self-rated as intermediate , high-intermediate , and advanced . In addition, participants who rated themselves as low-intermediates  were also depressed and had significantly higher depression scores than the participants who rated themselves as intermediate (G3), high-intermediate (G4), and advanced (G5), whereas intermediates (G3) also had significantly higher depression scores than those who rated themselves as advanced (G5). For Mandarin Chinese proficiency, significant differences in depression scores were found among participants with The current study also aimed to validate the instrument used to measure study abroad students’ coping strategies and ISE. For the scale validations, initial factor analysis was performed with SPSS version 26.0 , whereas the succeeding confirmatory factor analysis was carried out using structural equation modeling with SPSS AMOS version 26.0  as part of a Hearne software lease.χ2 (595) = 36,548.65, p < 0.001, signifying sampling adequacy  = 24.61, p < 0.001) of the variance in depression. The results also indicated that the control variables age , Mandarin Chinese proficiency , and English language  significantly predicted depression. In addition, coping strategies , ISE , and the interaction between coping strategies use and ISE  were all statistically significant in the model. The effect size of the interaction was considered small, with f2 = 0.14 [2 = 0.14 .p < 0.001) and low  ISE  [< 0.001) . Figure In order to determine the primary objective of this study, several analyses were conducted. Participants were described along with the distribution of depression. As already mentioned, the participant population consisted of 925 female and 945 male students. The average age was 26 years old and the average length of stay was about 15 months. Upon further comparisons with the extent of depression, no significant differences were found in gender, study level, and length of stay. However, several significant differences in the group mean were found. In terms of age, the results showed that older participants were significantly more likely to have higher depression scores (but not to the point of depression). This finding is in line with an earlier study of American students in which younger students tend to have higher positive effect and less depression . NonetheAs expected, significant differences were found with participants who are immigrants. Participants who have an immigrant background have significantly higher degrees of depression as compared with the non-immigrants. Thus far, it has been assumed that participants with an immigrant background would tend to be more familiar and exposed to intercultural situations; hence, less depression. In reality, studies have found that many immigrants still suffer from identity issues or gaps that may actually contribute to depression . SignifiAs for the issues of language and depression, both Mandarin Chinese and English language proficiency showed significant differences. Although there is no clear trend that depression is related to either higher or lower Mandarin Chinese proficiency, post hoc results merely indicated that participants with high intermediate levels in Mandarin Chinese tend to have a higher degree of depression as compared with the other language levels. It would be understandable that entry-level Mandarin Chinese participants would have higher levels of depression, concurring with previous studies on the necessity to master the language of the host country in order for study abroad to become fruitful and effective ,81. It sIn terms of English proficiency, it is quite evident that participants with less proficiency in English are more likely to experience depression; to the effect that participants who are new to English are actually depressed. This might also be due to the fact that more and more courses in Taiwan are shifting to English as a medium of instruction, although Mandarin Chinese is still the majority. Nonetheless, this is quite interesting, because Mandarin Chinese is supposedly more widely spoken in Taiwan, not English. However, as Yu et al.’s  frameworHierarchical multiple regression analysis confirmed Yu et al.’s framework, wherein language (both Mandarin Chinese and English), coping strategies, and ISE were key factors in sociocultural adaptation, thus having the effect of lowering depression. These findings appear to support the role of language, coping strategies, and ISE in alleviating depression. As for the moderation analyses, neither Mandarin Chinese nor English language proficiency have been able to establish a significant interaction in the relationship between coping strategies and depression, suggesting that coping strategies are probably not language-dependent. Therefore, it can be presumed that both Mandarin Chinese and English language proficiency are not moderators; however, they can be considered as predictors of study-abroad-related depression as presented in the regression results. Initially, it was hypothesized that the language proficiency (Mandarin Chinese and English) acts as a moderator in the relationship between coping strategies and depression. The better one is at either of the two languages, the greater the impact it will have on coping strategies and depression. The results of this study, however, only showed that both languages were significant predictors (including coping strategies themselves), and which were noted to have the tendency of lowering depression levels. The moderation analysis showed that ISE is capable of moderating the relationship between coping strategies and depression. More specifically, ISE can help relieve depression. It is important that although both Mandarin Chinese and English language proficiency were not moderators, improved skills in either language should be able to help build the participants’ confidence towards better interactions . Furthert-test and analysis of variance) analysis showed that background demographic variables seemed to exert some influence on the level of depression. Participants that are older and have an immigrant background are more prone to depression; however, gender and length of stay appear to have no effect on depression, in stark contrast to previous studies [This study provides a close-up view of depression among international students and argues for further investigation. First, descriptive, correlational, and group (independent samples  studies ,28. SecoDiscussions of implications would be incomplete without mention of the broader global structural context of international students in host nation higher education institutions. This means that contemporary elements of modern life could also influence the mental health situation among international students. For example, an expanding awareness of mental health literacy and media reporting on mental health and illness are developing on many social media platforms. Increasing mental health awareness through social media is a contemporary phenomenon because it reaches many people in a short time frame. This might include reports of increased rates of mental illness among the youth and expanded definitions and available resources for making sense of what constitutes mental health problems among international students in host nation institutions worldwide. At the same time, recent structural and cultural changes, along with growth in the global economy, have produced greater pressures and stress in the lives of all students.Recent trends in higher education are also part of the broader structural context; the marketization of higher education and the construction of students as “consumers” creates new opportunities as well as new pressures. New individualized online learning environments, for example, are more complex and demanding than those of the past, when collective supports were more available. That said, these new learning environments may induce social isolation that can be addressed within institutions committed to ensuring good mental health conditions of international students.This global snapshot suggests a mismatch between the broader structural context and the intricacies of micro-level practices and services. Although university support services fill a vacuum for mental health resources for all students, the difficulties faced by international students might be intensified. Despite the low levels of depression found in this study, preventative measures are still required to reduce the severity and risk of negative consequences associated with depression. This could include the provision of Mandarin Chinese language courses and English language courses for non-English speakers. International student offices could help organize activities where students can make new friends and help newcomers settle. Forming co-national clubs could also be beneficial to make students feel at home, hence promoting greater social interaction. However, co-national clubs can also act as a deterrent to further intercultural contacts or interactions and should therefore be treated with caution. This might be the case for international students who find themselves without traditional social markers with which to navigate experiences.The current study has certain limitations which should be noted. The data analysis revealed only limited information about the students’ personal, situational, and contextual characteristics. In addition to the characteristics included in this study, there may be other factors which contribute to the challenges international students experience while studying abroad. For instance, these factors may include the students’ country of origin, their academic discipline and performance, their housing, and the location of the host institution. Future research could examine these variables from a narrative perspective to include student voice and identify the unmet needs of international students. This would benefit international students as well as higher education institutions and universities worldwide that are positioned in a competitive, market-driven environment.In summary, study-abroad-related depression is a real phenomenon and not limited to students studying abroad in Taiwan. The most effective action universities can take to prevent this from happening is to identify students at a heightened risk for depression. Early intervention and prevention measures to avert mental health crises are tools all universities should earmark as a priority. Ongoing awareness to determine potential solutions should be included as an essential component of university mental health resources for all students.


Preoperative undernutrition is a prognostic indicator for postoperative mortality and morbidity. Evidence suggests that treating undernutrition can improve surgical outcomes. This study explored the provision of nutritional screening, assessment and support on surgical cancer wards in low- and middle-income countries (LMICs). This was a qualitative study and participants took part in one focus group or one individual interview. Data were analysed thematically. There were 34 participants from Ghana, India, the Philippines and Zambia: 24 healthcare professionals (HCPs) and 10 patients. Results showed that knowledge levels and enthusiasm were high in HCPs. Barriers to adequate nutritional support were a lack of provision of ward and kitchen equipment, food and sustainable nutritional supplements. There was variation across countries towards nutritional screening and assessment which seemed to be driven by resources. Many hospitals where resources were scarce focused on the care of individual patients in favour of an integrated systems approach to identify and manage undernutrition. In conclusion, there is scope to improve the efficiency of nutritional management of surgical cancer patients in LMICs through the integration of nutrition assessment and support into routine hospital policies and procedures, moving from case management undertaken by interested personnel to a system-based approach including the whole multidisciplinary team. There are five billion people who do not have access to safe, affordable and timely surgery, and only 6% of all operations performed worldwide are conducted in low- and middle-income countries (LMICs) . For canOne in every nine people worldwide is undernourished, and in 2019 there were 690 million people who were hungry , which iUndernutrition is one of the few modifiable risk factors contributing to higher surgical mortality and is a negative prognostic factor for morbidity and mortality in surgical patients . When nuThe Global Surgery 2030 Roadmap recommended improving access to timely and essential surgery and decreasing perioperative mortality against their international targets to improve surgical outcomes . UnsurprThis exploratory investigation aims to establish baseline knowledge of nutritional screening, assessment and nutritional support interventions used on surgical cancer wards in LMICs for the identification and treatment of undernutrition. Secondary aims were to understand the organisation and management of nutritional services in LMICs along with barriers and facilitators to implementing optimum nutritional practice within clinical environments in LMICs.Qualitative semi-structured interviews were conducted one-on-one with healthcare professionals (HCPs) and patients on surgical cancer wards, together with a focus group with HCPs. Inclusion criteria were any HCPs working in a hospital with surgical cancer patients or any patient on a surgical cancer ward in a LMIC defined by the Organisation for Economic Co-operation and Development (OECD) and the Development Assistance Committee (DAC) . A snowbThe sample was chosen to reflect different LMICs and the patient sample was included to provide triangulation of data . As the Data collection was loosely underpinned by principles of phenomenology. Phenomenology in its broadest sense is concerned with consciousness and the subjective view of experience  In this The semi-structured interviews and focus groups were conducted either face-to-face or via video conferencing and followed an interview schedule, which was adapted for focus groups . Each paData were managed using NVivo Version 12  and analysed thematically using the six-step process from Braun and Clarke . These sEthical approval was obtained from the University of Edinburgh Ethics Committee and where necessary, local ethical approvals were sought in the individual countries. All participants gave informed consent but did not comment on the findings. Rigour was introduced by having two researchers discuss and agree on the codes and themes. In addition, the consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used . In total, 34 participants were included in this qualitative study. There were 10 patients from the Philippines. In addition, there were 24 HCPs: 16 were interviewed and 8 were involved in a focus group. HCPs were from Ghana, India, the Philippines and Zambia. There were two nurses, ten dietitians or nutritionists, three oncologists, one study coordinator and eight surgeons.Four themes were identified in the data. These were the experience of participants of (1) nutritional assessment, (2) support, (3) the barriers and (4) facilitators of nutritional management. An overview of the practices in different countries is provided in The participants reported a variety of practices relating to nutritional assessment see . At one A similar situation existed in Ghana. A surgeon commented that he would use height and weight to assess nutritional status. However, as these were not taken routinely, he also relied on observing patients, referring any who looked wasted to the nutritionist. Nutritionists in Ghana commented that although most patients with cancer would be malnourished, there was no established pathway for treating malnutrition and referring to them was at the discretion of the doctor. In contrast, surgeons from India reported routinely using the objective measures of weight and height to assess nutritional status. One commented that weight, height and body mass index (BMI) would be recorded in the nursing notes and the anaesthesiologist would take these measurements again. Having these measures consistently taken by two HCPs would ensure that patients did not slip through the gaps. For these surgeons, scales and height measures were readily available “height measures and scales are available on the wards” (I-HCP1). However, calibration of the scales could be a problem, as one surgeon said, “They are not calibrated” (I-HCP1). Although this was not always the case, another commented that in his hospital, there was a cycle for scales to be calibrated “all instruments have to be calibrated in a specific period of time… in 6 months or 1 year” (I-HCP2).Although surgeons from India reported using the objective measures of weight and height to assess nutritional status, screening tools were not normally used in their hospitals. As one surgeon commented “people are just not aware that there are these screening tools…people think that if albumin is normal and BMI is ok then nutrition is ok…they are not aware that with a normal BMI and albumin patients can be malnourished” (I-HCP1). These experiences can be compared to a systematic approach to assessing nutritional status reported by HCPs in the Philippines. The initial assessment would occur when patients attended as outpatients: “Even upon the first consult of the patient, we assess the patient” (P-HCP4). The doctors reported using a methodical approach. They would ask about weight loss, “We ask…about the weight loss, first directly” (P-HCP2). If the patients could not answer directly, the doctors would probe further using ”surrogate parameters like if their clothes become loose, or if other people have been noticing that they are losing weight” (P-HCP1). They would also ask about oral intake and the patient’s appetite. Further nutritional assessment of patients occurred on admission using a screening tool. As one said, “for our screening tool…we use the Nutritional Risk Assessment tool” (P-HCP4). Part of that screening includes measuring a patient’s weight and height. Thus, subjective assessment would be combined with making use “of the objective method, when we get their height, weight” commented a dietitian (P-HCP5). From weight and height, dietitians would calculate BMI.The purpose of nutritional assessment is to identify and treat patients who are undernourished. If the person was an outpatient, doctors in the Philippines could refer them to the nutritionist for advice. In other countries, the surgeon might advise the patients themselves. As one surgeon in India commented, he would prescribe supplements and a multivitamin. However, patients would have to buy the supplements. Therefore, surgeons might give advice about what foods to eat. As one surgeon in Zambia commented, patients might be advised to eat more nutritious foods that they could buy for the same cost; for example, “get eggs or milk instead of cornflakes” (Z-HCP2). A surgeon in India recommended increasing protein from food, he advised “those who can take non-vegetarian diet. I encourage them to have egg whites—6–8 in a day. If a patient cannot, we advise them to have cottage cheese, 100 to 200 g cottage cheese”. For those who cannot take solid food, he advised “soya-based protein, two to three scoops in milk” (I-HCP2). Once admitted, treatment of malnutrition seemed to be easier, with patients being given oral supplements. This could be readymade supplements from the pharmacy, which HCPs in the Philippines said were available to patients, “if they are admitted…it’s actually free” (P-HCP8). Alternatively, nutritionists could prepare nutritional supplements in the hospital kitchen. This occurred in Ghana, as commented on by a surgeon and dietitian. The dietitian said that they “do not have prepacked therapeutic food, but fortunately as nutritionists we are trained to prepare the local foods” (G-HCP3).Healthcare professionals commented that parenteral nutrition was very expensive and rarely used. However, HCPs in the Philippines said it was occasionally used and surgeons in Zambia said they might have it if there had been donations. There were a range of barriers related to the assessment and treatment of malnutrition. First, there could be no systematic treatment pathway or protocol of screening patients for malnutrition, as commented on by HCPs in Zambia and Ghana. However, even when a pathway existed for identification of malnutrition such as in the Philippines, there was a problem of whether this happened in practice. A surgeon said that it was the junior resident’s job to screen the patients using the Nutrition Risk Score screening tool, but “they never complete them, maybe they complete in the first week, then they forget about it” (P-HCP11). However, other HCPs talked about the nurses completing the screening tool. A dietitian said, “the screening tool basically is a task for the nurses…supposedly upon admission, the patients are screened to determine who are nutritionally at risk or not”, and that they had provided training for the nurses: “we conducted a series of seminars” (P-HCP5).A recently qualified nurse collaborated this saying that she had completed screening tools during her undergraduate training. Although, there seemed to be other issues with the nurses completing the tools now. The dietitian said, “I just lost track if the nurses do this…because of the pandemic” (P-HCP5). The nurse commented on a different problem “since we use [Electronic medical records], most of our charts are computerised. Then there’s no feature in [Electronic medical records] that the old chart is included there so mostly it’s just words. Charting as if it’s a journal entry” (P-HCP6). This would mean that the nurses would not have the questions as a prompt, and it would be easier to miss doing the assessment. Weighing patients is a key aspect of assessing nutritional status. As noted above, this was not routine practice for surgeons in Zambia and Ghana. A nutritionist in Ghana commented, “You cannot do much without weighing the patient for energy requirements and assessment” (G-HCP2). However, they were hindered in this, as they did not have scales readily available. Whereas, weighing patients was usual for HCPs interviewed from India and the Philippines. Interviews with patients in the Philippines confirmed that weighing of patients was happening routinely—only one person who could not stand had not been weighed. Availability of food in hospital is a crucial element to maintain the nutritional status of inpatients. In Ghana, both a surgeon and dietitians commented that the food supply from the hospital kitchen was precarious. The dietitians said that many patients came from out of town and needed to rely on food from the hospital kitchen, but it was not reliable. In contrast, HCPs from the Philippines said that patients received a ration of food daily from the kitchen and patients or relatives would generally buy food to supplement it. Patients had a range of views on the food from “It’s fine…it’s enough” (P-Pt6) to “it shouldn’t be bland. Because people like us patients, sometimes we have poor appetite that’s why we eat so little” (P-Pt9).If patients required oral supplementation in addition to food, there were various problems with patients accessing them. Dietitians in Ghana did not have access to readymade supplements but would make them themselves in the hospital kitchen. However, one dietitian commented, “We do not always have the food and ingredients for the recipes.” In addition, they did not have access to kitchen scales to weigh ingredients and had to rely on handy measures. HCPs in the Philippines reported that readymade supplements were freely available in their hospital. However, the pharmacy would buy a three-month supply and would not be able to purchase more in between so occasionally stocks would run out. Patients reported a variable experience of having supplements. One patient reported, “I have lost my appetite” and when asked if they had been given supplements said, “not yet” (P-Pt7). Whereas another patient who had lost their appetite said they had been given, “milk called Boost Optimum that was prescribed to me” (P-Pt9).In all countries, there was a particular problem for patients accessing oral supplements outside the hospital, as they need to buy them, and the cost was prohibitive for most. Nevertheless, patients in the Philippines mentioned being given cartons of oral supplements. As one said, “I was given [oral supplement] but I left it at our place” (P-Pt1) and another commented, “we were visited by…officials. They gave out [oral supplement] to the elderly” (P-Pt10). However, it does not seem to have been either a consistent supply or consistently taken by the patients. There were also barriers for patients accessing appropriate advice as outpatients as access to nutritionists was limited for patients in the community. HCPs in the Philippines said that patients could be referred to a dietitian as an outpatient. However, patients could have to travel long distances to come to the hospital. They would not want to come only for nutritional assessment and monitoring. If they were at the hospital, patients did not want to wait to see the dietitian if the queue was long.Although there were many barriers, there were circumstances that could be leveraged to facilitate good nutritional care, such as the training and level of knowledge of the HCPs. For example, the dietitians in Ghana were aware of how to undertake assessments and prepare supplements. They would do so if the resources were in place. They were also keen to research their practice to improve outcomes for patients; a nutritionist said, “I would love to do more research on what we are preparing and if it really meets the standards for protein, carbohydrates and whatever” (G-HCP3). HCPs in other countries also demonstrated their knowledge of nutritional assessment. The surgeons in India discussed the importance of weighing patients and HCPs in India and the Philippines commented on the value and use of screening tools. Therefore, although physical resources could be scarce, intellectual and knowledge resources were available, without which nutritional assessment is not feasible. The other asset that some HCPs reported were the systems that were in place in their hospitals, which facilitated nutritional care. For example, as noted above, a surgeon in India commented that there were mechanisms to ensure that patients were weighed, as patients were weighed both on admission by the nursing staff and by the anaesthesiologist. In the Philippines, there was a system for filling out the screening tools. Although there were current problems with it being carried out, the training and infrastructure were in place to be built on. Having systems and protocols in place is a more efficient way to ensure that patients are not missed and that the scarce resources are used appropriately.In this study, we explored nutritional assessment and support on surgical cancer wards in LMICs. We found that the knowledge of nutritional assessment amongst HCPs was high. However, there was a continuum of care moving from individual assessment using only clinical judgement, to subjective assessment and objective assessment, and finally, to a system approach employing screening tools.The continuum of care from clinical judgment to a systems approach seemed to be fuelled by availability of resources. Clinicians only used clinical judgement if they did not have access to weighing scales, and as physical resources increased, there was also an increase in systems for assessing nutritional status, with hospitals having protocols for weighing patients and the use of screening tools. In our study, only HCPs in the Philippines working in a University hospital setting reported that they had a system in place for using screening tools. Screening a patient’s nutritional status on admission is an effective and efficient way of identifying malnourished patients . TraininPart of the screening process is finding out whether patients have lost weight in preceding months, and in some LMICs people would not routinely measure their weight, as discussed by HCPs in this study. In these circumstances, HCPs use surrogate measures to assess patients’ weight loss, such as whether their clothes have become looser. Researchers have suggested that screening tools are modified to incorporate such measures . This woFood first is recommended for nutritional support in many countries . TherefoA strength of the current study is that HCPs from four different countries were involved, providing a broad picture of nutritional assessment and support across a range of LMICs. A further strength is that patients were also interviewed in the Philippines, which corroborated the observations of the HCPs and provided the unique patient perspective on the topic. They provided triangulation of data, where data is drawn from different sources, and as such were playing a supportive, but not essential role . TherefoThe study has identified variability in the practices of HCPs and resources in LMICs. Further work needs to be carried out in addressing malnutrition for cancer patients in these settings. However, the identification of low resources and high costs could lead to the development of local products and protocols. Some researchers have investigated the use of cost-effective, locally manufactured supplements ,34. ThisIn conclusion, nutritional management of surgical cancer patients in LMICs could be improved by moving from individual case management to a system-based approach, where nutrition support management is integrated into routine hospital policies and procedures. The challenges of implementation in low-income settings should not be underestimated. The development of a more robust evidence base relating to the effectiveness of nutritional supplementation for patients having surgery for cancer is required to influence policies and justify increased resource allocation within healthcare systems in LMICs.