Vaccination willingness was high in all countries (69.6%), but the social and psychological factors motivating people to undergo vaccination differed among these countries. The highest vaccination willingness was in the Philippines, followed by Vietnam and Indonesia, whereas the lowest vaccination willingness was in Thailand. Vaccination willingness was affected by not only sociodemographic attributes, but also risk perception and beliefs, which, in turn, were shaped by social factors such as infection trends and vaccine policies. To achieve effective vaccination promotion programs, a system allowing the flexible modification of promotion methods in response to social conditions must be established.Globally, 67% of the population has received at least one COVID-19 vaccine dose, but coverage varies across countries. This study aimed to compare people’s willingness to receive COVID-19 vaccination across Thailand, Indonesia, Philippines, and Vietnam, where vaccination intention tends to be high, to determine factors associated with willingness, and to obtain suggestions for developing strategies. We conducted a secondary data analysis of the Japan International Cooperation Agency survey “Building Resilience: COVID-19 Impact and Responses in Urban Areas—Case of Southeast Asia,” including1842 unvaccinated participants from Thailand ( Considering the characteristics of the COVID-19 virus, including high infectivity and severity, and the impact on daily life resulting from social distancing and business interruption, vaccination is the key. Globally, 67% of the population has received at least one vaccine dose, but coverage varies between countries . AnotherMany factors have been associated with vaccination intention ,9,10,11.To establish an effective strategy, we should consider the factors that influence vaccination behavior and the background that causes these factors as the foundation for developing a tailor-made strategy, which varies from country to country.Therefore, this study conducted a comparative analysis of vaccination willingness and its factors in four Asian countries where vaccination intention tends to be high and to obtain suggestions on how to develop vaccination-promoting strategies.We conducted a secondary data analysis of the Japan International Cooperation Agency (JICA) survey “Building Resilience: COVID-19 Impact and Responses in Urban Areas” , which wRisk perception of the COVID-19 pandemic. The items were subdivided into three components: (a) Confidence in knowledge, (b) Concerns about health risk, and (c) Concerns about economic well-being. Questions were answered using a five-scale method, which was categorized into three to improve the efficiency of the analysis: Strongly and Somewhat likely, Neither Agree nor Disagree, and Strongly and Somewhat agree. Willingness to receive the vaccine. This part was assessed by addressing one question item: “In your current situation, how likely are you to make an appointment, then go and get vaccinated for COVID-19?” Willingness to receive the COVID-19 vaccine was responded to by a five-point scale, which was combined into three categories: Highly and Somewhat likely, Maybe, Somewhat, and Highly unlikely.Reasons (factors) to take the vaccine. The factors were subdivided into positive and negative factors. Respondents were asked to select the top three positive and negative factors that would influence their decision to undergo vaccination. Positive response options comprised 16 items, whereas negative response options comprised 17 items. Survey questionnaire information was collected on participants’ demographic characteristics, socioeconomic status, and occupation. Questions used in the secondary analysis were segregated into the following three parts:The data used in the analysis were categorical variables, which were examined using Pearson’s chi-square test and are expressed as absolute values (percentages).p < 0.05 was considered significant. All statistical data were analyzed using STATA for Windows, Version 17, StataCorp., College Station, TX, USA.The independent predictors of COVID-19 vaccination willingness among people from the four selected Asian countries were evaluated using multivariate logistic regression. A value of The purpose of this study was to perform a comparative analysis of willingness to vaccinate and to determine contributing factors; therefore, the targeted respondents were those who had not yet been vaccinated and would be vaccinated in the future.Of 2684 respondents from the four Asian countries, 1842  were not vaccinated. The sex ratio of this unvaccinated population was closely comparable across these four countries ; the mean ages of this population in Thailand, Indonesia, the Philippines, and Vietnam were 35.6 (SD 10.9), 34.2 (SD 10.9), 32.1 (SD 9.6), and 31.1 (SD 8.7) years, respectively. p < 0.001). Participants from Vietnam were the most confident in their knowledge (88.4%), whereas those from Indonesia tended to be significantly less confident than the other countries  and considering it different from the regular flu (69.2%). All people from all selected countries were aware of the high risks, especially for older relatives and parents; among these countries, Indonesia was the least aware .More than half of all respondents in all countries perceived the risk of COVID-19 death to be high, with Vietnam taking it more seriously .Many participants believed that the world is in serious danger because of COVID-19. In particular, 93.7% of Vietnamese perceived the risk severely. However, despite the COVID-19 risk and the serious situation worldwide, they tended to be less aware of themselves. Vietnam, where the largest number of participants considered the world situation serious, had the highest number of participants who considered themselves safe (52.1%). However, contrary to the trend in other countries, more than half of the participants from Thailand believed that they were unsafe , whereas Indonesia appeared relatively optimistic compared with other countries .More than half of the participants were concerned about the financial crisis and did not feel financially secure. Thailand was the most concerned about these two aspects , as shown in More than half of the unvaccinated participants from all countries expressed willingness to receive the COVID-19 vaccine, with the highest number of willing participants in the Philippines . Other major positive factors included “I am afraid of getting COVID-19,” “Vaccines are safe and effective,” “Experts say it is safe and effective,” and “It’s free”.Apart from “Vaccines will keep my loved ones safe from COVID-19” as the most selected factor, “It’s free” (38.4%) and “Vaccines are safe and effective” (34.3%) were the second and third most selected factors in Thailand; “Experts say it is safe and effective” (32.1%), and “Vaccines are safe and effective” (30.9%) in Indonesia; and “I am afraid of getting COVID-19” (42.0%) and “Experts say it is safe and effective” (38.3%) in the Philippines. Those in Vietnam mostly selected “Vaccines are safe and effective” (52.3%), followed by “I am afraid of getting COVID-19” (52.1%) and “Vaccines will keep my loved ones safe from COVID-19” (44.1%). Overall, the most selected negative factor was “Possible side effects” in all countries . Other major negative factors were “Vaccines are not safe or effective in general,” “Not enough evidence that it prevents COVID-19,” “I do not know when and where to get it,” and “Vaccines are not safe or effective in general.”Regarding the results in each country, in Thailand, the second and third most selected factors were “Vaccines are not safe or effective in general” (62.3%) and “Not enough evidence that it prevents COVID-19” (34.9%). Indonesia and Vietnam showed the same trend, with “I don’t know when and where to get the vaccine”  as the second most selected factor and “Not enough evidence that it prevents COVID-19”  as the third. In the Philippines, “Not enough evidence that it prevents COVID-19” (36.9%) was the second most selected factor, and “Approvals and clinical trials were too fast” (27.9%) was the third. Independent predictors of willingness to receive vaccination were assessed by multivariate analysis. After adjusting for the important covariates, the predictors of vaccination willingness included the index of sociodemographic attributes, risk perception of COVID-19, and beliefs and attitudes toward vaccination. Below are the results of each index.p < 0.05).Indonesia was the only country that regarded (older) age as an increased index for the predictors of vaccination willingness (adjusted odds ratio (AOR), 2.35; 95% confidence interval (CI), 1.20–4.59; p < 0.05);Income in Indonesia  and Indonesia ;(higher) Education in Thailand ;Work style, particularly retired or homemakers in Thailand .Full-time or business owners in Vietnam  were:p < 0.05) and (older) age  in Vietnam were the only decreased indexes. The Philippines did not have any factor affecting vaccination willingness. Conversely, (more) multigenerational living  and “Most concern about older relatives/parents” .In Indonesia, the increased index was health risk perception, including “The world is in serious danger due to the COVID-19”  and “The world is in serious danger due to the COVID-19” , was the increased index. In the Philippines, the health risk perception, including “People of all ages are dying from the COVID-19” , Indonesia , and the Philippines ), whereas “It’s free” was a decreased index , Indonesia , and the Philippines ). Moreover, “Enough time has passed since people started taking it” was a decreased index in Thailand  and Vietnam  but an increased index in Indonesia . The Philippines had a decreased index for “My employer requires me to take it” , which, in other countries, did not affect vaccination willingness. “Experts say it is safe and effective” was a decreased index only in Thailand . In all countries, except Vietnam, “Vaccine will keep my loved ones safe from COVID-19” was an increased index  and the Philippines . Only Vietnam included “It contained human stem cells in its development” as an increased index . “Approvals and clinical trials were too fast”  and “I am concerned it will impact my fertility or pregnancy”  were increased indexes in Thailand. Thailand and the Philippines considered “Not enough evidence that it prevents COVID-19”  and “Vaccines are not safe or effective in general”  as decreased indexes. Vietnam was also the only country that included “Possible side effects” as a decreased index , whereas Indonesia was the only country that included “I do not trust the sites where vaccines are being administered”  as a decreased index. “I do not have the ability to get an appointment” was an increased index in Thailand , similar to previous results that were around 60–70% 9.6%, sim,19. HoweOur analysis of the characteristic trends in social and psychological factors in the Philippines revealed the following: (1) sociodemographic factors did not affect vaccination willingness; (2) a more serious risk perception, including death risk for all generations, made people more willing to be vaccinated; and (3) the abovementioned altruistic factor and the fear of COVID-19 infection were driving the motivation of highly willing people to undergo vaccination. Meanwhile, factors not directly related to vaccine effectiveness, such as cost and employer demands, did not affect highly willing people but affected the unwilling ones. The inability to make an appointment was the only factor demotivating people with high willingness. Alternatively, the lack of evidence supporting the vaccine’s effectiveness was a demotivating factor for unwilling people. People’s vaccination intent being affected by the perceptions of high susceptibility and severity is consistent with the results of previous studies.Second, people from Indonesia perceived that education and decreased income affected their willingness to be vaccinated. According to other studies, people with a bachelor’s degree or higher were more likely to be vaccinated because they understood the vaccine’s efficacy and safety, and those in the middle class were vaccinated to keep working and earn money . Age, edIn Vietnam, the following findings were obtained. First, people with higher incomes and those who worked as full-time employees or business owners were more willing to be vaccinated, whereas multigenerational families were less willing. Second, no sociodemographic factor affected vaccination willingness. Third, concern regarding the use of human stem cells was the only demotivating factor among highly willing people, whereas side effects were only the demotivating factor for the unwilling ones. Only participants in Vietnam considered that the altruistic factor did not affect vaccination willingness, similar to other studies in which such willingness was not influenced by family members, friends, or colleagues . CompareFinally, in Thailand, as reported in other Thai surveys , (1) eduEvaluation of the differences among the countries suggests that the infection status affected the social and psychological factors motivating or demotivating people from receiving the vaccination. The number of infections and the rate of increase were high in the Philippines, whereas the number of infections was stably high with a low rate of increase in Indonesia. Alternatively, the number of infections was low in both Thailand and Vietnam, although the rate of increase was high in Thailand but low in Vietnam . In the Similarly, the trends in Indonesia, where the number of infections was high and the rate of increase was not, differed from the trends in the Philippines. People were becoming more confident that their communities had the infection under control. Concerns about the elderly individuals’ risk of COVID-19 might have reinforced people’s desire for control and motivation for vaccination. The increase in “enough time has passed since the start of vaccination” as a predictor of high willingness to vaccinate might be due to the fact that Indonesia started the COVID-19 vaccination the earliest among the four countries (January 2021), whereas the other three countries started the vaccination in February 2021 or later.In Vietnam, which had the lowest number of infections and the lowest rate of increase, people were not aware that the risk of COVID-19 was a threat and were not in a situation where they were forced to choose their vaccination behavior, which resulted in few factors affecting their willingness of vaccination.In Thailand, the number of infections was as low as that observed in Vietnam, but the rate of increase was higher. It is considered that, unlike in Vietnam, people in Thailand were beginning to feel closer to the threat of COVID-19. Similar to that observed in Vietnam, there were strong safety and efficacy concerns in Thailand, but the increase in infection numbers forced the public to make decisions about their vaccination behavior, resulting in a clear differentiation in the attitudes and beliefs of people who were willing and those who were not willing to vaccinate. The differentiation was reflected in the number of more predictors of willingness to be vaccinated than in Vietnam. Furthermore, the factors that contributed to the high rate of doubts about the safety and efficacy of vaccines among people who were unwilling to vaccinate were identical to those found in the Philippines, where the rate of increase was also high. Thus, even though the threat of infection was close and the sense of fear was amplified, unwilling people perceived more risk for efficacy and safety than for getting infected with COVID-19. Thus, for those with negative intentions towards vaccination, doubts about safety and efficacy might be viewed as a factor that is less susceptible to the infection status. Vaccination willingness was affected not only by sociodemographic attributes, but also by risk perception and beliefs, which, in turn, were shaped by social factors such as daily changing infection trends and vaccine policies. This result might reflect that most risk perceptions and beliefs were susceptible to external and dynamic circumstances. On the other hand, doubts about safety and efficacy were less sensitive to the infection, which indicates that the factors were robust and that resolving concerns and promoting behavioral changes might be quite difficult. Therefore, it is necessary to establish a system that not only evaluates risks from public health and socioeconomic perspectives and allows for flexible changes in promotion methods based on assessment results, but also ensures that information on vaccine safety and efficacy, along with accurate scientific evidence, is disclosed in a stable and consistent manner.Therefore, establishing a system combining flexibility in response to public health and social–economic status and continuous consistency with accurate information on vaccine safety and efficacy will make vaccination-promoting programs effective.First, this is a secondary analysis aimed at analyzing behavior change during the COVID-19 pandemic; hence, a limitation exists in analyzing precisely vaccination willingness. Second, this study involved an online survey by registrants; thus, a bias in the participants is possible, thereby limiting the versatility of the results. Bias factors include education and employment status. Tertiary and above registrants were overwhelmingly higher than the secondary registrants, which did not differ among the countries . Additionally, the rate of part-time or business registrants was higher than the unemployed, retired/homemaker, and part-time registrants , which may be due to the participation of registrants with computer literacy in the online survey. Third, this analysis was aimed at vaccination willingness; hence, only those data from unvaccinated people were selected, resulting in a small number of data being analyzed. Therefore, future studies with a larger sample size should be conducted according to our results, focusing on the relationship between infection status and government COVID-19 measures and vaccination behavior.


Researchers often conduct randomized controlled trials among patient populations that may not reflect the community in which findings will be translated. The University of Florida’s community engagement program HealthStreet provides a diverse sample in which to consider differences between people 65 years of age and older who have seen a physician in the past 12 months and those who have not. This provides a conservative test of potential biases in patient-only samples. Based on a sample of 1,663 people, 65 years of age and older, who were recruited by Community Health Workers in the North Florida region from November 2011 through July 2022, 88% had seen a physician in the past 12 months. Those who had not (12%) were significantly more likely to be non-white than white, to be in good/excellent than fair/poor health, and significantly less likely to have a range of health conditions including high blood pressure, depression, heart conditions, diabetes, a digestive health condition, a dental health condition, or cancer. Yet residents who hadn’t seen a doctor were just as likely to be willing to participate in a future health study (both 94%) that only asked about health, accessed medical records (both 87%) or didn’t provide reimbursement (both 81%), and were not significantly different in attitudes toward participating in research in general. Recruiting of older adults should be conducted in the community, not just in patient populations, which are likely to be less diverse and sicker than those recruited through a community engagement program.


The opioid epidemic is ravaging people, families, and communities in Appalachia. However, limited research has examined how “everyday” people  living in these communities how opioids have impacted their lives.Identify the perception of the opioid epidemic on individuals, families, and communities from people living in region most impacted regions.Patients were recruited at Remote Area Medical clinics throughout Central and Southern Appalachia to complete interviews online (N = 169) or over the phone (N = 26), including one open-ended question about how opioids have impacted their lives.Using the qualitative method content analysis, several themes were identified, including both the positive and negative impact of opioids from the online interviews. Additionally, resiliency was found to be a common theme and a theme not often emphasized by scholars and the media. These themes also highlight the importance of social support in these communities. Further, in the phone interviews, we were able to replicate the themes, and an additional theme was identified: Systemic Cause of Opioids.Opioid intervention must be comprehensive and include the cultural context that recognizes community ties, family and kinship support, resilience, and systemic barriers to addressing the opioid epidemic. Future interventions must harness the existing resiliency and social support in these communities to effectively combat the opioid crisis in Appalachia. Otherwise, opioids will remain the insider and further insulate Appalachian communities from systemic recovery. People who are underserved by health care tend to be lower-income or living in rural areas. These underserved people are affected disproportionately by the contextual factors that affect health, such as the prevalence of food deserts, shortage of healthcare professionals, economic depression, and often high rates of opioid misuse.2Appalachia consists of counties in Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia. Seventy percent of Appalachian counties are health professional shortage areas,6Despite the devastating impacts of opioid misuse and economic downturns, Appalachian people have a strong and proud identification with rural culture. Rural culture is multifaceted and includes variations in demographic, economic, or social factors.Most of the research on the opioid crisis in Appalachia focuses on chronic pain patients or opioid users.High poverty, high drug use, high overdose rates, low education levels, and economic struggles are well-documented circumstances that plague Appalachia.In this study, we sought to understand the impact of the opioid crisis on underserved individuals, families, and communities from the perspective of “everyday people” living in the Appalachian rural, lower-income regions, which have been affected most by the opioid crisis.We’ve asked you a lot of specific questions. But we want to know, in your own words, how have opioids affected you, your family, and your community? There is no wrong answer, we just want to know your experience. A detailed description of the procedures is provided in the Additional Files.Participants were recruited from Remote Area Medical (RAM) clinics across seven clinics in Central and Southern Appalachia. Participants completed surveys over the telephone or online. The online and telephone samples were asked the same stem question: Qualitative survey responses were analyzed using content analysis methods. Two of the authors served as multiple analysts to develop themes; initial coding was done on paper using consensus coding. Content analysis was conducted by pen and paper as the authors were able to spend time together with the data for analysis purposes and combine the online and phone surveys into a paper document. Credibility was established with the triangulation of more than one interview  as well as multiple analysts.23Participants were mostly from rural regions, were mostly white, and about half reported having a high school education or less. A more detailed description of the telephone and online samples are provided in the Additional Files.From the online and telephone data, several themes emerged across varying levels of society: (1) individual impacts of opioids, (2) family impacts of opioids, and (3) community impacts of opioids. Using the content analysis method, three overarching themes were identified in the interview responses: (1) benefits of opioid use, (2) negative impact of opioids, and (3) resiliency. Highlighted within each theme are several subthemes, how themes often span multiple levels of society , and the similarities in the participant’s responses. It is important to note that, at times, responses fell into more than one category.Also using the content analysis, Study 2 identified similar overarching themes with the addition of a fourth theme (Systemic Restrictions and Frustrations). Despite these similarities in theme categories, the telephone interview provided more nuanced detail about the participants’ perspective. This is likely because it is often easier to talk then type responses to open-ended questions. These four themes from the telephone interviews were: (1) benefits of opioid use, (2) negative impacts of opioid use, (3) resiliency, and (4) systemic restrictions and frustration.Through content analysis, several categories emerged across four themes and several subthemes. Rural and underserved participants in this study have a clear awareness of the opioid epidemic in rural areas and the positive and negative impacts at the individual, family, and community levels. They also exhibit several qualities of resilience at the individual and family level with keen observations about the systemic implications in their communities and the nation. Generally, these themes were partially reflected in the previous literature but from a different and important perspective of “everyday” people living in Appalachia rather than from the perspective of chronic pain patients or physicians. One newer theme within the sample was resiliency, which was not frequently highlighted in the previous qualitative literature focusing on medical professionals, individuals using opioids as prescribed, or using it recreationally.The first theme was about the perceived benefits of opioid use. Some participants stated that prescription opioids were beneficial to them and loved ones. Appropriate use of opioids improved participants’ quality of life for those with chronic pain. Within this theme were underlying frustrations with programs and policies that limited their access to opioid prescriptions among the online sample. This underlying frustration has indeed been observed in the literature previously.as a community and as a culture for Appalachia. Previous research has told the contrary story that rurality is more often espoused as a risk factor for opioid misuse and abuse.What has less frequently been discussed in the literature on the opioid epidemic for rural and underserved communities, specifically Appalachia, is resiliency. This concept was present throughout the data and emerged as an important category that informed the theme of resiliency. The qualitative data collection and analysis were essential to building a narrative around the recovery from the opioid epidemic This study is not without limitations. First, the participants in this study were not randomly selected; it was a convenience sample from patients who attended a safety-net clinic. Therefore, the themes identified may be biased by the participants who volunteered for this study. While Remote Area Medical serves the most underserved individuals in the communities it reaches, permission was not given to survey participants on site. Meaning that those who participated had to have access to a telephone to complete this study. This likely means that there was no access to the opinions of the most underserved Remote Area Medical participants, including homeless, individuals without consistent access to telephones, or individuals in the most rural communities without telephone access. However, these findings are a first step in understanding how “everyday” people in Appalachia perceive the impact of the opioid clinic on themselves, their families, and their communities.individual treatment and/or avoidance strategies such as removing children from homes where a parent is abusing opioids. While these strategies are important and necessary, they lack the comprehensive cultural context that recognizes community ties, family and kinship support, resilience, and systemic barriers to addressing the opioid epidemic. Future interventions must take the existing resiliency and social support into account to be effective in combatting the opioid crisis in Appalachia. Otherwise, the opioids will remain the insider and further insulate Appalachian communities from systemic recovery.This research stands to inform future practices for community-level interventions in the opioid epidemic in Appalachia and other rural areas. The media continually emphasizes the statistics of rural poverty, blight, and poor health outcomes.What is already known about this topic? The opioid epidemic is ravaging people, families, and communities in Appalachia. Medical professionals, chronic pain patients, and recovering drug users have been frequently studied in qualitative studies about the impact of the opioid epidemic.What is added by this report? We target “everyday” people to understand their perspective about the impact of the opioid epidemic on their lives, their families’ lives, and broadly the impact on their community. We find that participants see both positive and negative impacts of opioid use and several participants identify resilience.What are the implications for future research? Many opioid interventions lack a comprehensive cultural context that recognizes community ties, family and kinship support, resilience, and systemic barriers to addressing the opioid epidemic. Future interventions must harness the existing resiliency and social support in these communities to effectively combat the opioid crisis in Appalachia. Otherwise, opioids will remain the insider and further insulate Appalachian communities from systemic recovery.There is a substantial body of qualitative research that explores health providers’ perspectives on the impact of the opioid crisis. Many of these studies focus on how the opioid crisis shapes professionals’ prescribing patterns.Most of the research on the opioid crisis in Appalachia focuses chronic pain patients or opioid users. For example, one study, focusing on people who use opioids recreationally, found fears of stigma and law enforcement lead users to change their usage setting to one that increased the risk of overdose.10Quantitative studies of opioid use dominate the research on the impacts of the opioid epidemic. However, qualitative studies are well suited for revealing how circumstances play out in a particular context. In this case, underserved Appalachian culture  is the context for the study, and investigating the phenomenon in this way will provide more depth of understanding.Participants were recruited from RAM clinics across seven clinics in Central and Southern Appalachia. RAM is an organization that has been providing medical, dental, and vision clinics in rural, underserved, and remote areas since 1985. They are headquartered in Appalachia and provide approximately half of their clinics in the Appalachian region. RAM provides a highly valued service – people who would not ordinarily be able to have their teeth repaired or extracted, who may not be able to purchase glasses or who lack access to any preventative care such as mammograms or vaccinations, can get these services with no questions asked. The very poor and uninsured, often immigrants and homeless, wait in line for days to receive these healthcare services. In areas that have been so heavily struck by the opioid epidemic, there are a substantial impact among these, particularly vulnerable patients.We used a convenience sample of RAM clinic participants. During the clinics, as many patients as possible were given postcards with the advertising of the volunteer opportunity to participate in research to better understand the patients who attend RAM clinics. A researcher was stationed in the clinic traffic flow strategically to catch as many patients as possible, but an unknown number of patients may not have been recruited. Patient recruitment was completed at seven clinics across Appalachia between October 2018 and June 2019. Participants could participate in the study if they attended the clinic and were 18 years or older. Upon recruitment, participants were given informed consent. Participants were mailed a $10 gift card after completing the survey. We estimate that approximately 5% of individuals who were given a postcard were recruited into the study and completed the survey; we derived this number by the total number of individuals who completed the survey divided by the total number of postcards given out across the clinics. The postcard asked interested individuals to text or call the research specific phone number within one week of the clinic. Participants who texted the phone number completed the survey and relevant qualitative questions in an online written survey. Participants who called the phone number completed the survey and relevant qualitative questions in an oral telephone interview that was recorded. In total, 189 participants consented and completed all parts of the survey included in this study. Because of the different methods for completing the survey, the set of data will be addressed separately in sequential studies: Study 1 (online interview sample) and study 2 (telephone interview sample). This study was approved by the University of California, Davis Institutional Review Board (IRB).We’ve asked you a lot of specific questions. But we want to know, in your own words, how have opioids affected you, your family, and your community? There is no wrong answer, we just want to know your experience. For the online interviews, there were no follow-up questions due to the nature of the data collection. For the telephone surveys, interviewers were trained to ask follow-up questions to get the participants’ opinions on how opioids had affected all three aspects: themselves, their family, and the community. In addition to demographic questions, participants were asked whether they identified as urban, suburban, or rural. Rurality is defined in the literature in a variety of ways, often based on the zip code where the participant resides. In this case, it is more effective to allow participants to self-identify as rural for several reasons. First, participants in our sample were often transient and may not have a residence or identify with a particular ZIP code. Secondly, while they may have a ZIP code where they currently reside, that residence could be a shelter or staying with a friend in a more urban area that is not consistent with their cultural identity of rural. Rural culture is an important and distinct component of identity, and self-report is the most accurate way of determining rurality in this qualitative study in addition to being an emerging strategy for determining rurality in the literature.11The online and telephone samples were asked the same stem question: Qualitative survey responses were analyzed using content analysis methods. Two of the authors served as multiple analysts to develop themes. Initial coding was done on paper using consensus coding between the authors. Content analysis was conducted by pen and paper as the authors were able to spend time together with the data for analysis purposes and combine the online and phone surveys into a paper document. We established credibility with the triangulation of more than one interview  as well as multiple analysts.14The researcher’s personal goals, previous knowledge, and assumptions can affect the development of the study and the analysis. The first author has a doctoral degree in Child and Family Studies and is currently faculty in a College of Nursing. Family studies researchers typically operate from a systems theory perspective whereby the underlying assumption is that all systems within a community and all individuals within a family are interconnected. This author has volunteered at over 20 Remote Area Medical clinics and is experienced working directly with the population sampled in this study. Further, the majority of this author’s research focuses on underserved communities including low-income and rural families in the Appalachian region. The second author is a master’s level social worker with a doctoral degree in nonprofit and community leadership. Social workers operate from a strengths-based perspective rooted in systems theory. These authors’ areas of interest are in rural health disparities, health and social policy, and community engagement. This author has volunteered at over 15 Remote Area Medical clinics, is very experienced working with the population, and is interested in the topic as a resident of a county bordering Appalachia. The final two authors are trainees of the first author.Undergraduate research assistants transcribed telephone interviews. The online survey responses and telephone transcriptions were put into separate excel databases for coding. Responses were read through in their entirety before coding began.SD = 11.81. range = 18–73). Fifty-nine percent report having some type of health insurance.The online interview sample had 169 participants. Of this sample, 60% of participants reported living in a rural area, 22% in a suburban area, and 17% live in an urban area. The majority reported being a woman (66%) and having children (62%). In terms of race/ethnicity, the vast majority identified as White (89%), followed by 5% who identified as Black, and the remaining 6% identified as another race/ethnicity. In terms of education, 51% reported having a high school education or less, 38% reported having some college, and 11% reported having a college education or a graduate degree. On average, participants were 36.54 years old (SD = 16.64. range = 18–88). Fifty-six percent of these participants reported living in a rural area, 14% in a suburban area, and 31% live in an urban area.For the telephone interviews, 26 individuals participated. The majority of this sample reported having some type of health insurance (72%). The majority of this sample also reported being a woman (73%) ad having children (68%). In terms of race/ethnicity, 89% identified as White, 6% identified as Black, and the remaining 5% identified as another race/ethnicity. In terms of education, 57% reported having a high school education or less, 32% reported having some college, and 11% reported having a college education or a graduate degree. On average participants were 47.17 years old  individual impacts of opioids, (2) family impacts of opioids, and (3) community impacts of opioids. See figure 1 for an overview of themes and subthemes that we discuss more thoroughly in the supplemental file online.Using the content analysis method, we identified three overarching themes in the interview responses. These themes were: (1) Benefits of Opioid Use, (2) Negative Impact of opioids, and (3) Resiliency. Within each theme, we highlighted several subthemes, how themes often span multiple levels of society , and we took note of similarities in the participant’s responses. It is important to note that, at times, responses fell into more than one category.In our first theme, several participants expressed the perception of the impact of opioids on themselves, their family, and their community as positive, despite the current opioid epidemic. Of the 169 participants, 36 participants’ responses fell into this first theme. In the responses, the data showed that some participants believe that, when not abused, opioids can be beneficial to those in severe pain and need. For example, one participant explained how opioids positively impact them and their family:They absolutely helped with headaches. 100% they do. They also cause stomach problems and weight gain…for family, they don’t abuse it, and it really helps them. They don’t have any problems.This participant reported that opioids are not a problem for themself or their family. While they acknowledge adverse side effects that came with using opioids, because they were using responsibly and they were benefiting , they did not see an issue with opioids for them self and their family.The second overarching theme summarized many of the participants’ frustration with the negative impact of opioids in their community, family, and at times themself. Of the 169 participants, 85 participants expressed one subtheme of this theme.the limitation of access to opioids. Some participants explained how systemic changes caused by the opioid epidemic impacts their access to legally prescribed opioids, affecting the quality of life for their loved ones or themself:One subtheme was See, my husband has pain levels of a woman having child-birth 24 hours a day. He was on opium (sic), and they took him off it because of the opioid problem, and they won’t give [him] anything. I think this is a stupid thing. I don’t agree with the opioid problem.This participant’s husband was in an accident in the past and uses a wheelchair and suffers from severe back pain. This participant reported that they were negatively impacted by the opioid epidemic in that they no longer had access to their prescribed opioids. In a similar sentiment, another participant expressed frustration about no longer having access to opioids:Without opioids, I wouldn’t be able to do things for my family. They work. However, I live in an area where they are abused. Because of this, I can’t get them anymore. I have severe sciatic nerve pain. It’s the only thing that had worked for me.This participant evidenced how particular areas are becoming stricter on opioid prescriptions, despite people who were currently using opioids reporting responsible usage. These limitations of legally prescribed opioids appeared to be negatively impacting people’s quality of life.risks and harms of opioid misuse and abuse. While numerous participants explained the utility and importance of opioids, others expressed the danger of opioids. Participants reported that opioids have changed their loved one’s personalities, or they have experienced loss caused by opioids  due to someone misusing or abusing opioids:A second subtheme is the I have a cousin that was in a severe car accident because of opioids, and it destroyed her life... she has a TBI [Traumatic Brain Injury] and needs a walker to walk and get around now, and she thinks a lot differently now... I’ve had many friends that have died due to opioid use too...risks and harms of opioid misuse and abuse indirectly affect them through crime. For instance, one participant explained:This participant explained the extreme risks of opioid misuse have had directly on their loved ones’ physical health and mortality. Other participants report how the I don’t use opioids; no one in my family uses them either. But people in the city I live in do. It drives people to do crazy things. Someone tried to break into my car and apartment, and they were on opioids, at least that’s what the police told me. It was scary.risks and harms of opioid misuse and abuse have negative impacts across multiple levels of society:This participant described how they believe that crime in their community was linked to opioid misuse according to their local law enforcement. There is a stigma that substance use, particularly opioid use, is associated with criminal/violent behavior. However, it is important to recognize that the substance use does not cause criminal/violent behavior; instead, such behavior is more appropriately attributed to the stigmatization and criminalization of substance use disorders as well as the lack of access to substance use interventions, which is particularly true in rural communities (31). This participant’s association between substance use and increased criminal/violent behavior perpetuates the stigma of persons with substance use disorders as “dangerous” and dehumanizes them and reduces the urgency for their need for intervention services. Finally, one participant, who claims to be actively using opioids, summarizes how the Opioids have ruined my life. I was introduced to them by a third party to manipulate me [to] sell. My family is disappointed in me. I’m not a productive member of the community. Opioids have a very strong and negative impact on community.While this participant explained the negative impact, opioids have had on the community, they also underscored how using opioids negatively impacted their life, their family’s life, and strained their family relationships.resiliency. Resilience can defined in many ways, though when expressed as a component of Community Resiliency Theory, Folke and colleaguesresilience is a degree to which the system is capable of self-organization, and the degree to which the system can build capacity for learning and adaptation.resilient can learn and adapt to crisis in a way that allows them to utilize their strengths to maintain a minimum standard of life. Eighteen participants’ responses expressed this overarching theme.The last overarching theme encapsulates many participants’ attempts to avoid opioids and/or recover from opioid addictions through their The first subtheme of resiliency was Physically Moving. Some participants expressed the need or desire to physically move out of communities impacted by opioids to avoid negative impacts of opioid misuse or abuse.Participant 1: I’ve been stolen from. Stole from money from me, personal items, important items. And it’s upset me, and I know they have a problem, so I’ve moved away.Participant 2: My family is fairly responsible with regard to opioid use. I have a nephew who had a serious drug problem, but he has since moved out of the area and is doing well…Both of these participants provided stories about how choosing to leave communities affected by opioid misuse and abuse. While this option is not feasible for everyone, it appears to be a helpful option for these individuals.The second subtheme to resiliency was Active Avoidance. Another way some individuals reported resiliency is by actively avoiding opioids even when prescribed opioids because of witnessing the devastating impact of opioid misuse. For instance, one participant explains their reasoning behind their avoidance:I won’t take opioids even if prescribed. There have been two occasions after surgery that I took a pill or half of a pill...hydrocodone. I didn’t like the way it made me feel. I felt like I was walking sideways. I couldn’t safely walk my dog. I’m also too afraid of becoming addicted. The opioid drug abuse in [state] is the highest in the country… I don’t want to become a slave to a drug. I don’t want to be the person stealing to support a drug habit. So now, I won’t even fill a prescription for an opioid if the doctor writes one. I will tear up the prescription, or I will tell the doctor not to write it.This participant reported actively avoiding opioids to prevent addiction both because they do not like the way it makes them feel and because of the negative consequences they observed in their community.The fourth subtheme was seeking treatment. Many participants who became addicted to opioids in the past reported being resilient by attempting to stop their usage by entering treatment. For example, some participants expressed the following:Participant 3: I had problems in the past. But I overcame the addiction and moved on to a recovery program on my own. I am getting back on track one day at a time.Participant 4: It ruined my life... it sent me into a drug-addicted spiral that was a 15-year blur... I lost my children and still feel like I can’t get on my feet... my family lost trust in me, and they want to do things with me... the loss of my children was a breaking point...to see them with family members breaks my heart... I have been clean for four months, and I’m trying to get back on my feet, but it’s so hard....Participant 5: I was on IV drugs for ten years, current clean and sober four months. It affected my mother badly. It affected my and my child’s life negatively. IV drug use resulted in hepatitis C for me.All of these participants evidenced resiliency by trying to reduce or terminate their opioid misuse or abuse, despite the challenges of treatment and maintenance post-treatment. Several participants explained how their opioid usage negatively impacted them and their family members, and the impact on their family motivated them to enter treatment.Also, using the content analysis, Study 2 identified similar overarching themes with the addition of a fourth theme (Systemic Restrictions and Frustrations). Despite these similarities in theme categories, the telephone interview provided more nuanced detail about the participants’ perspective. This is likely because it is often easier to talk then type responses to open-ended questions. These four themes from the telephone interviews were: (1) Benefits of Opioid Use, (2) Negative Impacts of Opioid Use, (3) Resiliency, and (4) Systemic Restrictions and Frustration. Like with the online interview, within each theme, we highlight several subthemes, how these themes spanned multiple levels of society , and we noted similarities in the participant’s responses. It is important to note that, at times, responses fell into more than one category.Similar to Study 1, some participants expressed how opioids have been beneficial for them, despite the current opioid crisis occurring in their communities. Of the 26 participants that completed the telephone interview, 4 participants’ responses expressed this overarching theme. For instance, one participant explained:Well when we get pain medicine, it helps us improve our quality of life, and to live a little bit less pain-free from the pain we are experiencing, and we can be more productive and be able to do things that we wouldn’t be able to do…But in our community, I guess we’ re, they’re having this big opioid crisis or whatever so I guess it’s getting pretty bad or whatever.Similar to Study 1, this participant expressed the utility of opioids to perform daily functions and improve quality of life. Further, this participant (in addition to others) recognized the opioid crisis occurring in their area despite their responsible usage.The Risks, and Harms of Opioid Misuse and Abuse.Also similar to Study 1, some participants described how opioids have negatively impacted them both indirectly and directly. Twenty-three participants’ responses fell into this theme. However, these participants’ concerns were all categorized into the subtheme, Participants on the phone interview expressed frustration with how opioids misuse and abuse have had negative impacts. For example, participants explained:Participant 6: … It’s raised the crime level. Everything has to do with drugs. If you’ve got a robbery, it’s drugs. If you’ve got a murder, it’s drugs. Most of the traffic things, drugs. My niece’s boyfriend got hit by a car. They arrested him for drugs. I mean, it’s everything…Participant 7: They won’t talk to me…None of my (inaudible) wants to talk to me. My kids, my family, nobody. Because of all them pain pills.Participant 8: …I feel like there’s no economy, so the drug problem is very large. I’ve watched so many people my age die early. I’ve just watched so many become addicted. They have gotten on a lot harder drugs. It just makes me sick. To see what the things that drugs have done to [County name]. I think they’re just must be a better, another, way than drugging everybody. We’ve got to figure out other ways to cope with problems that we’ve got to resolve problems without having to take pills.These participants exemplify the perception of how opioid misuse and abuse has impacted communities at the three levels of society: individual, family, and community. Participant 6 described that opioid misuse is linked to increased crime in their area. Participant 7, who was actively using opioids, reported how their usage negatively impacted their close relationships, presumably with friends or family members. Participant 8 expressed their anger at the severe impact of opioid misuse and death in their community. Further, this participant alluded to the potential cyclical nature of opioid misuse, whereby opioid misuse is linked to community problems but also that community problems  are linked to opioids misuse.Participants in the phone interview also stated ways they are resilient. Three of the 26 participants’ responses fell into this theme. However, most of these examples were under the subtheme’s active avoidance. For example, some participants expressed the following:Participant 9: …But a lot of people make a lot of excuses they think is a good excuse to take it. I believe a lot of people could take Tylenol or Motrin, something like that, stay off the real hard stuff, and real strong stuff. Maybe it would give them a better chance for a better life. Pain medication ain’t good for nobody. Not if they get on it bad enough.Participant 10: I try to avoid them, even if I go to the doctor because I know I have an addictive personality, and that scares me, and I don’t want to go there…All of these participants evidenced resiliency by actively avoiding opioids. Some feared that they will fall victim to addiction, so they chose to not take any opioids, while some, like Participant 9, expressed frustration about why individuals choose to use opioids rather than managing their pain with other, nonpharmacologic, methods. This frustration demonstrated that while some people can actively avoid opioid misuse and addiction, there may be little understanding of how addiction occurs and is maintained within portions of these underserved communities.Unlike Study 1, there was a new theme identified in the phone interviews. The last overarching theme in Study 2 was how participants synthesize why the opioid epidemic has caused systemic restrictions in communities impacted by the opioid crisis. Five of the 26 participants’ responses expressed systemic changes and frustrations. This theme emphasizes how their lives have been negatively impacted by government or larger social systems in ways that are out of their control. For instance, some participants expressed the following:I really wish that health insurance was a lot easier to get, and it was a lot cheaper and easier to get prescriptions instead of how it is done now because of drug addicts who have ruined it. It used to be you could go to a doctor, and they could prescribe medicine or a clinic which could prescribe you pain medicine. Today they have special pain clinics, and you have to pay an exorbitant fee for pain medication, and then it lasts a month, and then you gotta go back again and pay and so it’s made things a lot harder.They took me off of opioids, and the FDA blocked me from any prescription meds period. Cause of some desk jockey in Washington DC, I can’t even get aspirin if I go to the hospital. I can’t even get anything for pain because I’m blocked, and that’s because of the opioid crisis in the state …which is out of hand because of idiots who go to doctors and get prescriptions and sell them on the streets. So it’s affected me that way because I don’t get any pain medication, so I get to suffer 24/7…That’s what happens to people in pain when government decides you don’t get prescription medicine for your pain because other people abused it. That’s how I feel.Both of these participants describe how governmental and industrial systems, including clinics and insurance agencies, have changed as a result of the opioid epidemic. Some individuals that may have been using responsibly are becoming frustrated with these systemwide changes that they perceived have negatively impacted them.Although there is a risk of opioid misuse, it is clear from participants’ perspective that prescribed use of opioids is critical to their own and the family members’ quality of life. Among our telephone sample, this frustration was made clearer with the additional theme of systemic changes and frustrations. This theme discussed frustrations with the barriers to accessing prescribed pain medication and how those barriers were caused by changes in the governmental or larger systemic levels. One possible solution to the frustrations around policy changes and perceived limitation to prescriptions is to enhance medical provider sensitivity and knowledge about patient pain and how prescribed pain medications improve the quality of many patients’ lives. More specifically, providers can enhance patient-centered decision-making by both educating patients and family members about treatment and risk behaviors and training providers to communicate more effectively about pain treatment expectations and alternative options to pain coping .individuals who are in recovery, those seeking recovery or currently using, and those who have been indirectly exposed to the rippling effects of opioid addiction. We must target families to systemically heal ruptured relational bonds, prevent generational trauma caused by addiction, and improve social support for individuals in recovery or seeking treatment. We must target communities as a whole by building or rebuilding healthcare, economic, and safety net infrastructures so that communities can be stronger in the future to withstand the impact of a crisis like the opioid epidemic.The next theme we identified is the negative impact of opioid usage, namely, risks and harms associated with the misuse and abuse of opioids. Some of our participants talked about increased crime and a depressed economy, both perceived to be associated with opioid misuse. 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In the course of service, military members, leaders, and uniformed professionals are at risk of exposure to potentially morally injurious events (PMIEs). Serious mental health consequences including Moral Injury (MI) and Post-traumatic stress disorder (PTSD) can result. Guilt, shame, spiritual/existential conflict, and loss of trust are described as core symptoms of MI. These can overlap with anxiety, anger, re-experiencing, self-harm, and social problems commonly seen in PTSD. The experiences of General (retired) Romeo Dallaire and other international experts who have led in times of crisis can help us better understand MI and recovery.In honor of Dallaire, online opportunities were created for international students and leaders/experts to discuss topics of MI, stigma, and moral codes in times of adversity as well as the moral impact of war. We aimed to (1) better understand MI and moral dilemmas, and (2) identify key insights that could inform prevention of and recovery from MI.Webinars and conversations of 75–90 min duration on MI and recovery were facilitated by Leiden University, the University of Alberta and the Dallaire Institute for Children, Peace and Security between General Dallaire, world experts, and graduate students. Sessions were recorded, transcribed and thematically analyzed with NVivo using standard qualitative methodology.N = 51; female (29), male (22)] from the Netherlands and Canada. Conversations were held with international experts  from North America, Europe, Australia and the global south. Themes included: (1) recognizing the impact of exposure to PMIEs, (2) reducing stigma around MI, and (3) embracing the spiritual depth of humanity.Ninety four participants engaged in conversations. Student engagements were attended by participants [Exposure to PMIEs can have devastating impacts on military members, leaders and other uniformed professionals. This may lead to development of MI and PTSD. Recognizing MI as honorable may reduce stigma and psychological harm, and facilitate help-seeking among uniformed personnel and other trauma-affected populations. Salient efforts to address MI must include use of accurate measurements of MI and integrated holistic therapeutic approaches, inclusive of spiritual and social components. Urgency remains regarding the prediction, identification and treatment of MI. Military leaders and uniformed professionals require moral courage to handle the various types of dilemmas they often face –4. DealiThe toll of moral injury (MI) associated with making difficult moral decisions , 11 is sThe importance of awareness of the current situation is illustrated by a 19.1% prevalence of reporting a mental health problem in service members after returning from deployment to Iraq , and othOne example of how MI can affect the lived experience of a leader is General (retired) Romeo Dallaire, who was the Force Commander of the United Nations Assistance Mission for Rwanda during the 1994 genocide. Military leaders such as General Dallaire are increasingly more likely to be exposed to PMIEs during deployment, as compared to life-threatening situations .We currently lack approaches to tackle these imprints of MI that can serve as chronic drivers for PTSD, depression and also other behavioral problems, including suicidality. Current evidence-based interventions for PTSD focus on fear and emotional dysregulation, but less emphasis is put on factors that comprise the core of the MI, e.g., shame and guilt.In terms of approaches to treatments, North Atlantic Treaty Organization (NATO) partners have been investing resources to develop novel treatment options for service members. Several gaps exist in current care provision for morally injured veterans, including issues related to holistic approaches, spirituality, employment and family functioning, which could ultimately improve veteran well-being . ElucidaThe scope of the present paper is understanding advancements in MI research and recovery. To increase our understanding in this topic area, this effort used online conversations and thematic analyses of qualitative data collected from university students, military leaders and clinical and political experts. They gathered on a series of online webinars and engaged in exploring areas of MI and recovery in uniformed professionals. A total of 11 online conversations were held, centralized around the lived experience of General (retired) Romeo Dallaire who was a thought leader in these discussions. We feel that the lessons from General Dallaire’s lived experience convey a message that extends beyond borders and has relevance for not only military populations but civilians worldwide.n = 48) from the University of Alberta and Leiden University  lens.Qualitative thematic analysis (inductive and deductive) was conducted of transcribed video and audio recordings of General Romeo Dallaire’s discussion with three 75-min online conversations held between April, May, September 14, 2021 with graduate students  were conducted on April 21, May 5 and September 15, 2021 and Critical Conversations (N = 8) on September 22, 29, 30, October 13, 14, 27, 28 and November 10, 2021. Demographic characteristics of student engagement participants (N = 51) and critical conversation participants (N = 43) are presented in n = 29; 56.9%) and male  participants from the Netherlands  and Canada , and affiliated with various health sciences, law, native studies, computational psychiatry and education post-secondary programs, took part in the student engagements. International experts  engaged in the conversation series were from a wide geographic representation and range of sectors, and served in diverse present and past leadership roles at local, national and international levels.A total of 94 participants contributed to the data represented in this thematic analysis. Student engagement sessions  recognizing the impact of exposure to PMIEs, (2) reducing stigma around MI, and (3) embracing the spiritual depth of humanity. These themes, associated sub-themes are summarized in PMIEs can have disastrous effects on a personal, social, and spiritual level. Sub-themes that were recognized include: “facing PMIEs and ambiguity of moral dilemmas” and “feeling the impact of a disrupted moral compass.”Leaders are often faced with various types of moral dilemmas. On the military side, leaders experience tension between carrying out a mission and priorities about “[T]he people you are trying to protect” (SE 2). Limited resources can further complicate situations where leaders have to make moral decisions: “That’s what ultimately happened to us, is that we got a mandate on the [inaudible] there was no money and nobody was really interested in coming.” (SE 2). In some cases, choosing not to engage may be the best option: “[T]his was the example of my colleague in the United Kingdom, who could simply not accept that her advice on the legality on the use of force in the case of Iraq in 2003, was not followed. She found this unacceptable, and she had such strong feelings about this that her inner voice told her, “I need to resign, I cannot accept this.”” (CC 3). At the end of the day, it comes down to balancing the potential cost with the potential benefit: “I’d like to finish with a quote from former Head of the Department of Peacekeeping Operations, Under-Secretary General Jean-Marie Guéhenno. And he said, “In peacekeeping, you have a dilemma: To look the other way and have to live the rest of your life with maybe the notion that if you had moved in, you may have made a difference. Or, to move in, maybe with the risk of failure.”” (CC 1).The consequences of facing moral dilemmas can be “[A] terminal injury, suicides were happening, families were being destroyed, women were being beaten, men were drinking, they were losing careers, they were in the streets. It was- it was quite, quite catastrophic.” (SE 1). The effects of dilemmas can have lasting effects as well: “[Y]ou’ll never erase the blood off your hands. It’ll, it’ll be hidden in the pores of your hands for life.” (SE 3). Part of the complexity of this lasting effect may be attributed to a deeper and more spiritual element that is affected with moral dilemmas: “Someone else is in pain, and we caused that pain, or we were unable to do something about it. What follows are tremendous feelings of guilt and shame and anger. What we call Moral Injury.” (CC 5).A need is expressed for a culture change to more effectively recognize and address psychological injuries, such as PTSD and MI, to overcome stigma as well as to move toward recognizing honorable injuries. Sub-themes include: “breaking out of “old think”, “moving toward treating with urgency,” and “framing the injury as honorable (overcoming stigma).”It is imperative that all serving members affected by PMIEs be able to recognize their inner struggles and identify self-stigma that may impede/paralyze them in their ability to seek help. At its core, “Stigma creates holes in our life narrative. It makes us not understand how we got from there to here, and we don’t know how to get back.” (CC 6). The tone that leaders set in a community can open the door to reconciliation and healing: “I just wanted to comment, to be sure that we captured the important role of leadership in this task. That leaders establish the tone of communities, they say what is acceptable, and they also provide forgiveness.” (CC 6). For this reason, it is important to create a structure, organization, and society that is able to question non-inclusive practices: “That should never be. It should never be that we wait until an example of a human being or a system has failed – like terribly, that has turned into a crisis – in order for all of us to give us the capacity to question.” (CC 7). Traditions in a structure, organization, society should be critically evaluated because “Traditions are a value when they continue to assist humanity. When they are a constraint to human beings, no matter what group they are, they are of no use for the society. And that takes guts to do that.” (SE 1).A culture shift in moving toward treating moral injuries with urgency requires leaders who say “[I]ndividual justice depends to a huge extent on cultural justice. And that’s where moral leadership, I think, is absolutely essential, because in order to move communities toward those kinds of healing stances and actions, we need moral leaders to stand up to the flow in the other direction and say, “No, no. That’s justice, in that direction.”” (CC 5). One of the precursors to having leaders be more attuned to cultural issues is understanding that “[I]f they’re human, then fundamentally there’s equality. There may be nuances to it, and so on, and frictions. But they’re all human.” (CC 1). Once it is understood that all humans are humans, it bolsters the efforts to “[B]ring operational stress injuries into an honorable injury to be treated honorably and with the same urgency with physical injuries” (SE 2).Overcoming stigma has multiple components associated: “So in order to deal with stigma, which is so prominent, I think we’re going to have to attack it in each one of these boxes. We’re going to have to attack the individual level, the cultural level, the systems level. We’re going to have to deal with how we stigmatize.” (CC 6). In terms of current efforts made, the framing of injuries as “operational stress injury” positively changed the help-seeking behavior in veterans: “When we called it an operational stress injury, and it was honorable to be injured in that way, it changed totally their philosophy in regards to getting help and support and so on” (SE 1). As well, tangible things, such as awards, have been a positive step forward in recognizing honorable injuries: “Tangible things like our Sacrifice Medal, where, if somebody has a psychological injury, they’re entitled to the Canadian purple heart because of this injury. So any opportunities we had to tangibly recognize these as injuries, I think it’s gone a long way. We’ve put in systems where we think about the multimodal way of treating this (…)” (CC 6).Integration of social and spiritual components need to continue to be bolstered in therapeutic approaches. Sub-themes include: “fostering resilience and interconnectedness” and “bolstering holistic approaches” and “leaving no one behind.”Open dialogue with individuals and communities that have been psychologically injured, such as some refugees and, globally, Indigenous communities, is an important preliminary step to healing: “But what we really need to do is to be having these open conversations, and this dialogue, with all of our non-indigenous communities and allies. So that we can all start to heal from the intergenerational traumas that continue to haunt our communities. Because wahkôhtowin. If we’re all related, then maybe what’s happening to me, is also happening to you.” (CC 3). It is crucial to inspire people to care about issues such as residential schools and the effects of moral injury as well as trauma: “Imagine what it is like for the parents who lost their children to [North American] residential schools. Imagine what it was like for the children who went to those schools to have lost their childhood.” (CC 8). One of the ways to move toward understanding and ultimately building resilience is having a spiritual depth: “The first is that there’s a lack of spirituality in humanity now. I speak not necessarily being focused on the religion but on a sense of inner spirituality of what the human being is. Because its not touched upon, its not nurtured, its not even spoken of, when you face these extraordinary challenges to every fiber of your being you realize that there’s nothing there behind you to be able to refer to re-establish a balance if you don’t have some sort of spiritual ability to communicate.” (SE 2).The role of the spiritual dimension needs to be further bolstered since “Most of our empirically-supported treatments offer guidance for transforming painful states of anger, shame and guilt into more adaptive ones. Yet, for many persons around the world, forgiveness is intricately tied with spiritual beliefs, practices, and relationships.” (CC 5) and “[I]t’s widening the set of Best Practices that we truly need, to address Moral Injury.” (CC 5). The rationale for including spiritual dimensions for a biopsychosocial-spiritual approach is because love creates a spiritual depth that can alleviate destructive tendencies: “Only when you find some other human who can receive that can you alleviate that incredible destructive force that eating away at you year after year after year and making you worse” (SE 2). From a systems perspective, systemic barriers to health care access need to be addressed: “Just as mental health professionals too often exclude spiritual components of culture and intersectionality, systemic barriers to this type of community engagement too often limit our ability to address social and communal dimensions of moral repair. (…) We are at a point now where we need to better understand, access, and possibly enhance the healing potential of our patients’ social environments, and communities of choice. Without doing so, we risk perpetuating Moral Injury and not being as helpful as we possibly could be, as clinicians and researchers.” (CC 3).No one can do it alone. Recognizing the need for formal therapy can help in the process of moral injury and PTSD recovery: “So in order to pursue with that it, it takes help. You won’t be able to do it alone. You need formal therapy to set up some parameters to help you both psychiatrists and psychologists who don’t always get along together.” (SE 1). Relationships can also be the motivating factor in a pathway to recovery: “So ultimately you know what saved me? I discovered love. I’ve finally found a higher calling in life. An actual loving of another human being and that love between my wife and I have now and myself was an element of backdrop to which all this other stuff could be adjusted.” (SE 2). The keys to effective peer support involve someone such as “[A] uncle a friend a colleague that’s willing to just keep their mouth shut and listen and let you empty 4 h worth of pain, that is an extraordinary tool.” (SE 2) as well as “[T]o just keep showing up, and to check in regularly, to keep showing up. And don’t underestimate the power of a compassionate, non-reactive presence in people’s lives.” (CC 5).This paper uniquely engaged a convenience sample of international scholars, subject matter experts, leaders, and graduate students to engage in conversations on the topics of moral injury and repair. Romeo Dallaire’s experiences as a thought leader laid the foundations for these discussions. The impact of PMIEs was considered from a variety of perspectives and the need for further scientific research into MI was identified , 33, 34.Recognizing the impact of exposure to PMIEs, its relation to PTSD and the process by which MI occurs was one of the key focuses of the conversations. Current findings in literature and recent studies provide evidence that events can be simultaneously morally injurious, traumatic and life threatening –37. MoreAs shown in our analyses, students and clinical experts accentuated the importance of advancing our understanding and assessment of MI. Access to assessment measures of PMIEs and MI was found to be essential. Various MI assessment tools to date have been developed [e.g., the Moral Injury Questionnaire–Military version (MIQ-M) , Moral IReducing stigma around moral injury was also a prominent theme. This further complements literature reporting negative health outcomes associated with self-stigma such as PTSD . DallairThe conversations also emphasized the need for targeted, evidence-based MI interventions. Use of psychotherapeutic approaches to MI by mental health professionals hold promise for improving the lives of many past and present military members. Our theme, “embracing the spiritual depth of humanity,” highlights the need for interventions from a holistic perspective. We see that addressing trauma among veterans and uniformed personnel has traditionally included front-line Cognitive Behavioral Therapy (CBT), Cognitive Processing Therapy (CPT), and Prolonged Exposure (PE) treatment . HoweverWe recognize opportunities for MI that may be applicable to other populations outside of the military  –81. The This paper has some limitations. We believe that the people interviewed were carefully selected as they represented broad groups ranging from the military, mental health professions, legal domains, educators and academics. It is important to understand, however, that our sample is not representative of all veterans’ lived experience, since this population is highly heterogeneous, and the findings must not be overgeneralized. The student population was also not reflective of students across all academic faculties and departments. Yet, we believe that the unique nature of the present sample, including across generations of students and scholars, is inclusive of a range of areas of expertise.We feel the MI literature is rich and evolving and encourages conversations in this area. There is more to learn from global leaders who have faced PMIEs. Their insights can help us better understand MI and PTSD, identify preventative and treatment approaches, and means by which to destigmatize psychological injuries. The unique findings presented in this paper identify a number of important considerations. Future research would benefit from investigation of assessment and treatment approaches from a holistic and cross-cultural perspective. Inclusion of third wave behavioral and spirituality-integrated therapies is warranted. Our findings will inform key areas for future policy and practice recommendations, as well as directions for future research.This paper presents a unique series of conversations between graduate students and world experts around topics of MI and recovery. The results of these conversations may serve to forward the discourse surrounding PTSD and MI. Based on findings from a qualitative thematic analysis, it is evident that leaders often experience psychological injuries as a result of being placed in situations with moral dilemmas. The stigma associated with psychological injuries contributes to challenges with help-seeking among military members and veterans, and positive treatment outcomes. Recent efforts to expand more holistic, personalized and culturally-sensitive therapies to strengthen efforts in MI recovery have been encouraging. Urgency remains regarding the prediction, identification and treatment of MI.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.SB-P and EV conceived, designed, and conducted the manuscript. JJ and KW conducted the analysis. All authors drafted, revised, and approved the final manuscript submitted for publication.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.