Ongoing demographic change is leading to an increasingly older society and a rising proportion of people in need of care in the German population. Therefore, the professional group of outpatient caregivers is highly relevant. Their work is characterised not only by interacting with patients in a mobile setting but also by working in shifts. Health behaviour under these specific working conditions is crucial for ensuring long-term work ability and performance. Little is known about the health behaviour of German outpatient caregivers and its potential impact on their work. The aims of the study were (1) to examine health behavioural patterns  of outpatient caregivers, (2) to illuminate their personal health-promoting behaviours, and (3) to identify potential work-related factors influencing their health behaviour. Fifteen problem-centred interviews were conducted with outpatient caregivers working in Northern Germany in the period January–April 2020. Interviews were analysed by using qualitative content analysis. Outpatient caregivers reported improvable nutrition and hydration, with simultaneous high coffee consumption, low physical activity, poor regeneration , and good personal health-promoting behaviour , although the majority were smokers. Barriers to the implementation of health-promoting behaviours were a high perception of stress due to increased workload and time pressure, while aids to better health-promoting behaviour were described as being social support and personal resources. The respondents perceived their working conditions as potentially influencing their health behaviour. On the basis of their descriptions, various practice-relevant strategies were derived. The data explore a potential need for outpatient care services to develop interventions on behavioural and structural levels that can help create healthier working conditions for their employees so these caregivers can adopt better health behaviours. In Germany, a demographic change is being recorded. In the population, the group of people 60 years old or older is constantly increasing and will increase to nearly half of Germany’s total population (40%). Getting older raises the risk of being in need of care someday (see ). At theBy 2018, among German employees, higher rates of incapacity to work were found among the nursing professions compared with other occupational groups . A high Because the number of outpatient caregivers is increasing , it has Health behaviour can be divided in health-promoting  and health-impairing  behavioural patterns ,23. In tOrganisational structure and conditions in the care sector workplace can have a negative impact on the health behaviour of employees . To promThere are already several studies focusing on nurses’ health behaviour, although the majority of the participants were from the inpatient care sector  , nurses (n = 471) showed a healthy diet in terms of their fruit/vegetable intake  Yes, exactly. When I’ve somehow finished with a patient or when I see that I’m well on time, then I can stop briefly in the parking lot when I’m with the next patient and then have a quick breakfast. But actually it’s always during the ride, yes.” (Interviewee #5)Food choices varied among the respondents. In part, a (ready-made) salad was consumed in order to eat healthily or to reduce weight. Some outpatient caregivers did resort to vegetables, fruit , and smoothies as well as home cooking , or they paid attention to having a sufficient protein intake (shakes or bars). Most of them, however, ate ready-made meals to heat up (on the go during or after work). Pizza, burgers, chips, and especially baked goods  were increasingly on the menu. In addition, many reported regular consumption of chocolate, sweets, cakes, or crisps. In contrast, fewer opted for nuts to chew on during work.“Well, in the morning I have something sweet from the bakery or something, right? Maybe a piece of fruit, which would actually be healthy, but rather rarely.” (Interviewee #2)The time pressure at work favoured the choice of snacks in between. However, some respondents said that they snacked on fruit  or vegetables (such as carrots) while at work. The majority, however, liked to snack on sweets in between meals, e.g., in the form of cakes or chocolate/chocolate bars. Nuts or muesli bars were snacked on less frequently.“Yes, if there are sweets lying there, they are mine. They will be gone to 100%. So I grab them, because anything that’s edible and I can grab it while I’m doing something, it’s gone. The first thing I did this morning was grab a cake, because it was sweet.” (Interviewee # 6)Moreover, outpatient caregivers reported a general impact of their job activity on their eating behaviour. The sudden irregularity of individual meal taking was most frequently emphasised. For example, in this context, the outpatient caregivers stated that they could not eat in peace during work. According to the respondents, a more balanced diet was more possible on days off. Overall, the consumption of sweets and fast food had increased.“Changed, changed. Yes, this irregular eating, right? Before, you had a schedule, so you could divide it up a bit. Breakfast in the morning, then lunch at noon. Evening meal, not necessarily, but so that you paid attention to it. And so, yes, I would say it changed. Because I can’t do it in the morning either, or I don’t have breakfast before work, a black coffee is enough for me and then, yes, depending.” (Interviewee #4)Ultimately, the majority of outpatient caregivers expressed the desire for a healthier diet. However, in this context, they faced some challenges in being able to implement a healthier diet. On the one hand, the lack of time in everyday life was put in the foreground, so that organisation and the motivation to cook healthy food were impaired. In turn, time constraints at work, which could also sometimes lead to missed breaks, meant that they did not have time to pick up food and then eat it. The high responsibility towards patients was mentioned as one of the reasons. Thus, something was usually eaten in the car; the spatial possibilities on tour are limited. For some, the early shift was also too early to eat something beforehand.“Yeah, sure, I mean healthier is always possible. Why not.” (Interviewee #12)“We don’t take a break, and when we do, I always have to make something or take a bite somewhere in between. So it’s really always just one bite and then it continues. There is no regularity.” (Interviewee #11)In addition, stress and hectic pace encouraged the choice of unhealthier foods among the respondents. Therefore, sweets would be consumed more frequently by the outpatient caregivers when there was less time. However, loss of appetite was also mentioned.“Yes, when I’m stressed at work, I feel like eating sweets.” (Interviewee #7)Interviewed outpatient caregivers talked about their drinking behaviour regarding beverage choice, how much they drank, and when it was possible for them to drink. Influence and challenges through work were also mentioned. Other than water, the beverage choice of the surveyed outpatient caregivers was varied. Most of them stated that they drank coffee every day, which was either sweetened (sugar or sweeteners), black, or with milk. Many of the respondents drank tea every day, whether with sugar, honey, or lemon. Juices, soft drinks, or wine were drunk less frequently. The amount of fluid intake varied. While some felt they were drinking enough (1.5–3 L/day), some other outpatient caregivers described their daily drinking amount as insufficient (0.5–1 L/day).“I drink my coffee in the morning when I start and I take a bottle, because we also have free water here, free drinks, and then I take a bottle of water with me and just drive off.” (Interviewee #8)“Well, I always have to force myself to drink a lot, so I always try to get to a litre during the shift.” (Interviewee #5)Most of the respondents also stated that drinking between activities during their work was generally always possible. Several times the car or the office were mentioned as places where they could drink.“In the car and accordingly also when I say there is no eating in my car, but I can at least always have a sip in the meantime before I start, so to speak, to take another two, two sips, to drive to the next customer.” (Interviewee #9)The outpatient caregivers highlighted some of the challenges regarding daily hydration. In addition, they mentioned that more can be drunk on days off compared to workdays. A large number of the respondents highlighted that during outpatient care work, the possibilities to visit a toilet are very limited. Therefore, less drinking was done in advance. Sometimes there are no drinks available, and there are no refilling possibilities. The experience of stress and time pressure during work were mentioned as reasons that strongly favour forgetting to drink.“Well, sure, I take something with me. That’s quite clear, it’s just always the same with going to the toilet, because of course you can’t go everywhere. So I already have my route that I take, where you know where you can go and where not. And of course you always have to look a bit. I always plan to drink a 0.7 bottle of water, but that often doesn’t work.” (Interviewee #1)“So two litres a day in any case. But that’s also a problem because of the work, because we have to go to the toilet a lot and that’s also difficult. That is the disadvantage of outpatient care. And if I don’t drink enough, I have a headache, that’s also a disadvantage then, that’s why/the distances also increase sometimes, often I come to the office. I don’t like to go out somewhere. Well then, that’s just the way it is. A bit stressful over time.” (Interviewee #7)The interviewed outpatient caregivers reported on their physical activity during and after work or in their free time, mentioning also potential barriers regarding their physical activity. According to their own statements, most outpatient caregivers reported being very active during work due to their job itself. Some of them travelled to their patients by bicycle as opposed to driving a car, so they were basically additionally active. Furthermore, it should be emphasised that many outpatient caregivers take care of patients who live on upper floors, and not all houses have lifts. If lifts are available, the preference varies; the stairs are taken by most respondents up to the fifth floor, for example. Furthermore, one interviewee emphasised that she takes 7000 steps in an early shift (measured with her own pedometer).“So that’s/you’re from one patient to the next, stairs up, stairs down, sometimes without lifts. There is a lot of movement. Getting patients out of bed, putting on compression stockings, etcetera pp, that’s already/I measured once, I don’t know, I think it was 7000 steps in the early shift.” (Interviewee #11)Their physical activity in their free time varied. Only a few outpatient caregivers reported participating in regular sports, such as jogging or sports courses. More of them liked to go cycling, swimming, or hiking in their free time. Home training or going to the gym was less common. Although some of them did yoga or Pilates, a large part of the respondents also stated that they were physically active irregularly or not at all.“I go to the gym twice a week. That’s all I can do.” (Interviewee #2)Most of the outpatient caregivers interviewed expressed a desire to become more physically active in general. In this context, however, many respondents reported that since they started working in outpatient care, their physical activity in their free time had been considerably reduced. In the course of this, they mentioned some challenges from their work activities. Most outpatient caregivers do not have the energy to do physical activity after work. In contrast, many of them lack the necessary time after or before work, which is limited by shift work. Others, on the other hand, said they were too lazy and did not feel like it. Private reasons  as well as stress or pain also played a role for those respondents whose physical activity was too low.“Yes, I think that being a/really physically very demanding/at least for me I can say that I don’t necessarily feel like it and I’m just very tired when I’m at home. And then going to the gym somehow, I did that for a while, but it’s not really what fulfils me. I’m simply exhausted, no, I’m happy when I have my peace and quiet and can sit, at least for a while, I mean, you don’t sit at home straight away, but in that respect you do. It’s just not an office job.” (Interviewee #10)Many of the outpatient caregivers interviewed were smokers and used cigarettes regularly. One respondent even replaced cigarettes with nicotine spray before the interview. Many outpatient caregivers stated that the need to smoke was especially increased when their individual stress level at work was higher. For some of them, time pressure also played a favourable role. Many of them did not feel like using tobacco at certain times but said that they would do so every few hours in between. Many mentioned that they would smoke during their break. It was striking that one respondent said that they smoked only at work and barely when they were at home.“When I’m stressed, I smoke a cigarette.” (Interviewee #14)In this context, the influence of the work activity of outpatient care on the respective smokers became clear: it was mentioned several times that constantly being on the move at work favours smoking. Furthermore, it was emphasised that individually perceived work stress and time pressure led to increased smoking. One interviewee had stopped smoking but started smoking again after starting work as an outpatient caregiver.“Well, I don’t smoke at home as a general rule, and if I do, it’s only at work. (…) I even started again at work.” (Interviewee #2)Nevertheless, some interviewed outpatient caregivers reported that they had the intention to quit smoking. However, they also reported that work activities  present counteracting challenges.“((laughs)) Yes, if it were that easy, then, then I would like to stop.” (Interviewee #10)Breaks during working hours were perceived as recreation by the interviewed outpatient caregivers. The frequency of the breaks depends on the respective shifts. Most of the interviewees reported that they are entitled to a break of 1 × 30 min during a full shift. It was often emphasised that shorter breaks were taken more often instead of a long break, since they can get more rest in between or because it is hardly possible due to the tour planning. The part-time workers stated that they did not have a break. Furthermore, one interviewee who used to work in inpatient care emphasised that breaks were always possible during inpatient care work, in contrast to outpatient care work.“Well, I have a set half hour a day. And then, as I said, always in between, as it suits me. If, let’s say, I finished a patient a bit quicker or the next patient is half an hour later or something, then I try to sit down again for a short while and have a drink. Yes, always in between, when it suits the time and during my break.” (Interviewee #13)The outpatient caregivers’ break arrangements varied. The majority of them spent their break in the break room (if available) alone or with colleagues who also took their break. Others could take their breaks in the office, where they could sit down and have something to eat or drink. A few respondents reported taking their break on a bicycle to the next patient. The outpatient caregivers who smoked associated their break with tobacco use.“I sit, I smoke, I drink coffee. I don’t answer the phone. I chat ((laughs)).” (Interviewee #6)Lastly, the majority of the interviewed outpatient caregivers mentioned break failure. This inability or reluctance to take a break was evident in almost all respondents. Reasons for not taking a break were mostly, e.g., lack of time, tight tour planning, experiencing stress, and unforeseen extra work.“To be honest, I can’t take this break at all like this, because we have planned a travel time of five minutes between two patients and you can’t even make it from one patient to the next in five minutes.” (Interviewee #4)Regeneration after work was described by the respondents in terms of available recreational opportunities and individual sleep. Recreational opportunities varied according to individual preferences. For many of them, physical activity or sporting activities was a strategy for recovery. However, most of the interviewees also reported that reading a book, going out for a meal or a drink, and simply taking a nap or doing nothing were perceived as ways to relax. However, some also mentioned spending time with family or pets or watching television in this context. Less frequently, mental hygiene, photography, or gardening were mentioned.“I have this routine that I come home. I now have a cosy sitting area in my kitchen where I first relax, have another drink. Maybe I have another short chat with my daughter or prepare dinner or whatever. Or simply come home and turn on the TV and say, I’m going to let myself be entertained for a while.” (Interviewee #9)The respondents described their nightly regeneration through sleep differently. Most of them regularly slept less than 6 h. However, almost all of them mentioned that they slept more on days off. In this context, the outpatient caregivers described some negative influences on their sleep quality that were the result of their work activities. Sad images from the work activity, e.g., when patients are very ill, which causes pity, were mentioned as a cause. Other reasons were perceived work stress in general. Shift changes and especially early duty were mentioned as the most common factors affecting personal sleep quality.“Well, it has the effect that I’m exhilarated, that I can’t sleep because there are images running through my head. (...) There are also things that get to you. Really bad things. We also often get short admissions, people who are discharged from hospital and then come home to die or have really bad things that heal, but still/it is also rare, but there are also things that already/so rarely/actually almost always have someone where one now also has pity, right? So now beyond the professional then.” (Interviewee #1)“For example, when I’m on early duty/I can’t fall asleep so quickly. That’s why I always go to bed late. And then I get up early, which is different from when I’m on late duty, because when I’m on late duty I’m home at about 12 o’clock at night. Then I go straight to sleep when I get home. And then I sleep until nine or ten. I find it very different from early duty, somehow.” (Interviewee #14)The surveyed outpatient caregivers reported that their personal health-promoting behaviours differed based on whether or not they were working. During work, most respondents implemented back-friendly work to protect their own health. In addition, many regularly disinfected and/or washed their hands. Wearing personal protective equipment (PPE), such as face masks, gloves, and gowns when interacting directly with patients, was also mentioned in this context. Voluntary cycling during work to keep moving and staying calm as well as driving carefully were also reported. Only one interviewee mentioned taking breaks.“(…) Even when putting on compression stockings, I try to maintain the correct posture and not bend over too much or slouch, because it also kind of affects my back. (…), sometimes you have to go through it even if you already have severe pain in your back, working in a bent position or on your knees, so to speak, because the home environment and conditions of the patients do not allow it. (…) you have to make sure that you work healthily and gently for yourself.” (Interviewee #4)Finally, personal health-promoting behaviours related to private life were described in terms of sport and exercise, massages , and time with family and friends. Most, however, emphasised healthy eating in this context.“I try to eat healthy as much as possible. Yes. Maybe I should go cycling or something more often in my private life. So I don’t really do that much.” (Interviewee #10)Almost all respondents described that they perceive stress at work on a daily basis. In this context, the outpatient caregivers reported several demands they faced during their work, which are explained in the following.All interviewed outpatient caregivers agreed on the issue of time constraints. According to the respondents, the tours are planned too tightly. Staying longer with patients was unavoidable. Overall, the time allowed by the health insurance companies was too unrealistic and not feasible in practice. In addition, traffic-related challenges, such as traffic jams or road works, led to delays and thus caused time constraints. In this context, many respondents emphasised the constant search for parking spaces which caused time delays. Furthermore, some respondents felt that the physical exertion during their work was stressful. Many also mentioned not knowing whether or not their patients’ health had deteriorated in the meantime or even whether a patient had died. Many of the interviewees also complained about a lack of support in the team or existing hierarchies between superiors and employees in the care service. Unclear responsibilities/competences, no help from colleagues in the immediate vicinity, and on-call duty were also named. One interviewee reported on the demands resulting from an empty tank of a shared car. Some outpatient caregivers also found sick leave from colleagues to be stressful as it resulted in a higher workload.“Yes, at most it would be when you have unexpected things like traffic jams and traffic and not being able to find a parking space. Those are the kind of things that just stress you out and get on your nerves, yes. Or lifts are broken and then you have to go to the 16th floor and [I: 16th really?] Mhm, that also happens sometimes, yes. Then it’s ((laughs)) hard.” (Interviewee #5)Coping strategies were described on the one hand for work and on the other hand in the private lives of the outpatient caregivers. During their shift, most respondents told us that they would try to calm themselves down. In this setting, they would take deep breaths to calm down. A very large proportion of respondents would go out for a cigarette to compensate for perceived stress. However, a few also reported that they would accept the situation or avoid the stressful experience. Some outpatient caregivers also mentioned snacking on sweets as a coping strategy during work. A few respondents reported that they curse while driving and swear at other road users.“Yes, when I was stressed, I smoked more.” (Interviewee #1)During their free time, the outpatient caregivers partly resorted to other coping strategies. Communication with family, partners, and friends was mentioned most frequently. Going for a walk, doing sports, or simply keeping moving were also mentioned by the respondents. In this context, those owning a dog used the daily walk with their dogs as a coping strategy. Some of them talked about relaxation techniques, such as yoga or progressive muscle relaxation or about sleeping the stress off. Listening to music, reading, or doing handicrafts as well as watching TV were also described as strategies for coping with everyday stress.“Staying at home, watching a bit of TV. Or, when I’m really stressed, I call a friend. And then everything is gone.” (Interviewee #7)Existing support when it comes to advice or assistance was reported on a private level and on a workplace level by the outpatient caregivers. Regarding support by employer or institution, the interviewed outpatient caregivers experienced internal work-related support mainly from their team, either through colleagues or their management. The respondents described external support in terms of labour law, the Federal Association of Private Providers of Social Services, and the VERDI trade union. However, some outpatient caregivers also mentioned that support from employers was completely lacking because the boss does not want to be disturbed.“They’ll take over a patient if I’m too stressed. They can do that. Yes, once a patient is off the schedule, so to speak, then everything is fine again.” (Interviewee #14)Moreover, outpatient caregivers received private support mainly from their families. Family members and partners but also children were mentioned by the respondents. In this context, most outpatient caregivers referred to private support from friends who, for example, worked in care as well or simply had an open ear. A few emphasised that they would not receive any private support. In general, however, they reported that they did not like to mix their private lives with matters from their jobs.“Yes, I have a friend who is also a nurse. She understands this quite well. But she is an inpatient nurse. With the—of course—family, but you always try to do that a bit/work is work and private is private.” (Interviewee #2)A summary of the results regarding the health behaviour of the interviewed outpatient caregivers and their described barriers and aids regarding the implementation in practice is shown in This is the first study to apply qualitative methods to a comprehensive examination of the health behaviour and health behaviour-influencing factors of outpatient caregivers in Germany. Important insights into the working conditions and the associated health behavioural patterns were gained. Outpatient caregivers have a special work setting with certain stressors which could have a negative impact on adopting health-promoting behaviour. Interviewed outpatient caregivers showed different diets as well as different drinking patterns. Even though there was a desire for a healthier diet or increased fluid intake, the respondents faced many challenges. While the work activity itself provided sufficient physical activity during the shift, in most cases it prevented physical activity during leisure time. Many outpatient caregivers smoked when they were stressed or when taking a break. However, the interviewees’ statements emphasized that the opportunities for breaks during work were sometimes limited. The regeneration behaviour of the interviewed outpatient caregivers consisted of their sleeping behaviour and also restorative activities. In addition to the differentiated health behaviours suggested above, we were also able to examine health-promoting behaviours, such as the use of PPE or disinfectants, from the perspective of outpatient caregivers. Most of the interviewees talked about a high perception of stress during their daily work life due to specific job-related demands, such as time pressure and a constant high workload. To cope with the stress at work, a lot of outpatient caregivers mentioned smoking or snacking. Supportive factors were communication in the team or private support from family members or friends.In the course of their nutrition, the interviewed outpatient caregivers showed different behaviours. It is generally assumed that human beings prefer foods that provide a high energy intake  at minimal cost  and at the same time require little effort  . In thisThe drinking behaviour of the outpatient caregivers was similarly reported by the interviewees. Our study results highlight that without exception, all outpatient caregivers surveyed consumed coffee in large quantities on a daily basis, especially during their work shift. Considering research results, inpatient nurses and midwives show increased coffee consumption, especially when working shifts ,56,109. In the present study, the outpatient caregivers interviewed described what they considered to be sufficient physical activity during their work activities, for example, by constantly climbing the stairs to the patients or cycling the tour. However, during their free time, only a few respondents reported physical activity on a regular basis. This is also reflected in other study results: Compared with inpatient nurses and educators, geriatric nurses showed the lowest physical activity according to Wirth et al. , which wMost of the outpatient caregivers interviewed were in agreement with regard to behaviour that impairs health. Many of our interviewed outpatient caregivers were smokers. There are first indications that the adults of Germany’ population are smoking less overall: 26.6% of women and 35.0% of men have stopped smoking based on the data of the GEDA 2014/2015-EHIS study  . Accordin = 1003, of which n = 685 nurses and n = 318 geriatric nurses) were interviewed regarding the reasons for constantly not taking breaks, strong time and performance pressure emerged as the biggest factor. This led to physical discomfort but also to emotional exhaustion and increased night-time sleep disturbances [The respondents described their break behaviour or rather the use of breaks as difficult. Regarding rest during working hours, the majority of our respondents reported a complete absence of breaks even though the German Working Hours Act (ArbZG) stipulates minimum breaks . Main reurbances . Other rurbances ,66. Undeurbances . Ultimaturbances ,115.The regeneration behaviour after work was particularly evident in the sleep behaviour and respectively in the quality of the interviewed outpatient caregivers from our study. Most of them slept fewer than 6 h at night. In most cases, shift work and type of the shift, the poorer health status of patients, or work-related stress were reasons for a negative influence on sleep behaviour. The influence of shift work and shift type on sleep behaviour and quantity is also known from studies on inpatient nurses and midwives, e.g., ,116,117),117116,1In the context of personal health-promoting behaviour during work, the outpatient caregivers interviewed emphasised back-friendly work, regular hand hygiene, and wearing PPE while working. Regular hand hygiene, i.e., washing or disinfecting hands, is already widespread among healthcare workers (see. ) and alsPersonal health-promoting behaviour in leisure time was reported by our interviewees in terms of exercise and maintaining a healthy diet. However, the majority of respondents highlighted decreased health-promoting behavioural patterns in general since working in the outpatient care setting. This could be explained by their working conditions, which can be straining  . This exAdditional factors were reported by outpatient caregivers interviewed that were perceived as impairing the implementation of health-promoting behaviours. In particular, time pressure and delays due to constant searching for parking spaces and lack of on-site support from colleagues were mentioned. Ultimately all of the factors led to an increased perception of stress in general. This is also shown by results from inpatient geriatric care, e.g., ,128,129),129128,1A strength of this study is that we were able to recruit several outpatient caregivers from different care services of different city districts from Hamburg, Germany. Participants had a variety of socio-demographic characteristics, e.g., differences in age, length of work experience as well as working hours per week. Recruitment took place in a short period of time. Ultimately, we were able to establish a broad picture of health behaviour patterns of German outpatient caregivers, which has not yet been examined. To increase the trustworthiness of our findings, we employed rich descriptions of our results and displayed many direct quotes from the interviewees . FurtherHowever, there are limitations which need to be noted. Firstly, our findings are not based on a random sample. Since participants were partly chosen via snowballing technique an increased risk of self-selection cannot be excluded. For example, people who are more interested in one topic are more likely to participate in a study. Moreover, only three of our interviewees were male. However, female nurses tend to participate in studies more often than male nurses ,142,143.At this point, it must be emphasised that part of the interviews were conducted during the early outbreak of the COVID-19 pandemic . This maAnother limitation can be the relatively small sample size. The results therefore must be reviewed in terms of transferability or generalisation ,152. AllSince outpatient caregivers represent a special group of employees, as they are always on the run to their patients, further research studies with larger sample sizes are needed. Especially since it is assumed that because of their special work activity in the field, the conduct of healthy behavioural patterns might be hindered . In suchImplications for further practice could be divided into two sections. On the one hand, behavioural  measures could be carried out, and on the other hand, structural  prevention measures could be carried out ,154,155.Sufficient nutrition and hydration ensure that the body’s functionality remains unimpaired . OutpatiOn the structural level it is also important to create eating possibilities for outpatient caregivers (see ). Since In the future, efforts should be made to introduce higher-level health-promoting processes in outpatient care as well, which could facilitate healthy eating (see ). Since In the future, attention should also be paid at the political level to the healthy working arrangements of people in caring professions, and their good health should be set as a widespread goal (see ), not neThe present study focused on the health behaviour of outpatient caregivers, a yet unexplored field. The statements of the interviewees provide a highly differentiated insight into the individual experience and implementation of health behaviours of outpatient caregivers. Respondents in our study reported a variety of factors individually experienced in their working activity that had an impact on their individual health-related behaviours. Subjectively perceived barriers to adopting health-promoting behaviours illustrate the relevance of changing the way outpatient care work is organized in the future. Creating health-promoting working conditions and focusing on the personal empowerment of outpatient caregivers could help encourage health-promoting behaviours cf. ,26. Desp


In their commentary, Macnamara and Hambrick  accused my colleagues and me of systematically changing the definition of the concept of deliberate practice. Deliberate practice was the result of a search for characteristics of effective practice in the laboratory that was shown to improve expert professional performance in domains, such as music. In this reply, I will first describe five different criteria that defined the original concept of deliberate practice and each of them is presented with directly supporting quotes from Ericsson, Krampe, and Tesch-Römer  paper. Unfortunately, Macnamara, Hambrick, and Oswald  misinterpreted our concept of deliberate practice, and defined it much more broadly: “as engagement in structured activities created specifically to improve performance in a domain” (p. 914). This definition led them to include activities, such as attending lectures, studying alone by students, and group activities led by a coach, where each activity does not meet one or more of our criteria for deliberate practice. In this commentary, I will argue that Macnamara and Hambrick (2020) became aware of some of the original criteria for deliberate practice, such as the role of individualized training by a teacher, and these discoveries misled them to assume that we had changed our definition. The intended meaning of sentences that Macnamara and Hambrick (2020) had carefully selected is shown to have an appropriate interpretation in Standard English that is consistent with our original definition of deliberate practice. In conclusion, I will give a proposal for how the different perspectives can be reconciled. In their commentary, Macnamara and Hambrick  generousTo address their criticism, I will first document and describe our original definition of deliberate practice published in 1993 . These criteria were explicitly described in my immediate unpublished response Ericsson  to Macnadeliberate practice” .After a search for activities meeting the 5 criteria among domains of expertise with centuries of experience of successfully training individuals to attain reproducibly superior (expert) performance, Ericsson et al.  focused all the criteria for deliberate practice.” . Similarly, in the same edited volume, Ericsson et al. , they intended to say “some of the criteria” and definitely not “all of the criteria”. I agree that this sentence would have removed any ambiguity if it had included “some of”, but Macnamara and Hambrick’s claim that it implicitly says “all of” is not accurate given that no reference to these criteria had been made earlier in this chapter, the use of the definite article, “the” has no known referent and, thus, can refer to any combinations of criteria for deliberate practice.When a practice activity meets all of the five external conditions (criteria) we referred to it as deliberate practice. Ericsson et al.  also disn et al.  referredbest met the theoretical description of deliberate practice” . Consequently, Moxley et al.  was collected, with reference in the study report to at least one publication on deliberate practice by Ericsson et al.” . This activity is clearly structured and led by a teacher. The lecture is designed by a teacher to improve the students’ performance. This activity, however, does not meet the criteria requiring individualized assessment of each students’ current performance and the individualized design of appropriate practice activities for each student, nor would the lecture typically include practice activities that can be repeatedly performed with clear goals and immediate actionable feedback. Other structured practice activities included in their meta-analysis involve watching games relevant to their sport on tv  came from studies that never used the term “deliberate practice” anywhere in the text of their articles. Their only mention of deliberate practice was in the reference section as part of the title of Plant, Ericsson, Hill and Asberg’s  paper. TAnother argument that Macnamara & Hambrick  might maIn a recent effort to explicate consequences of conducting a meta-analysis of the relation to achievement based on different definitions of accumulated structured versus deliberate and purposeful practice, Ericsson & Harwell  examinedPsychological Science, appeared as Chapter 6 in Macnamara’s  “as engagement in structured activities created specifically to improve performance in a domain”  with attained performance. However, future research is likely to allow descriptions of the longitudinal development in terms of each of the individuals’ practice sessions and the attained performance improvements. With these refined descriptions, it should be possible in the future to identify more of the contributions of practice to final level of achievement . When I read this sentence, I am reminded of a similar conclusion in Ericsson et al.’s . I look forward to new and further refined definitions and associated measures of amount and quality of different kinds of practice, that will take us beyond distinctions between naïve, purposeful, structured and deliberate practice and hopefully uncovering practice activities that will more effectively improve particular types of performance. This would allow the steady accumulation of empirical evidence to identify the best predictors of attained performance and performance improvements as I proposed in the final paragraph in Ericsson (Macnamara and Hambrick , p. 5 suet al.’s , p. 400 Ericsson , p. 535:


When such conditions are not met, the system most often converges towards mutually detrimental equilibria.The ability to learn from others  is often deemed a cause of human species success. But if social learning is indeed more efficient (whether less costly or more accurate) than individual learning, it raises the question of why would anyone engage in individual information seeking, which is a necessary condition for social learning’s efficacy. We propose an evolutionary model solving this paradox, provided agents (i) aim not only at information quality but also vie for audience and prestige, and (ii) do not only value accuracy but also reward originality—allowing them to alleviate herding effects. We find that under some conditions (large enough success rate of informed agents and intermediate taste for popularity), both social learning’s higher accuracy and the taste for original opinions are evolutionarily-stable, within a mutually beneficial  As the group size increases, the average prediction can even approach perfect accuracy, provided that individual predictions are unbiased. Empirically, this phenomenon was famously illustrated by Galton’s “Vox populi” paper2: when he gathered the estimates of an ox weight from 787 participants, the average opinion was just one pound away from reality.In 1785, Condorcet proved that aggregating predictions can be much more accurate than individuals’ predictions3: if, as often assumed, the price of an asset aggregates all available information, then there is no reason to gather information, which makes it absurd that the price reflects anything to begin with.Yet, the very fact that the aggregate prediction is better than individual ones creates a tension: why would anyone make up his/her mind independently when he/she would be better off sampling around and simply endorsing the majority opinion? A very close analogy can be found in the Grossman-Stiglitz paradox in financial economicsasocial learning) refers to learning by oneself, usually by trial and error, without any input from others5. In this context, the aforementioned efficiency of socially adopting the majority opinion implies that a population where all agents learn independently would swiftly be invaded by a “conformist” strategy , as long as the sample size is greater than one, or if there is some information cost. This creates what Boyd, Richerson and Henrich7 called a conformist bias  that populations should be a smear of ideas, beliefs, values and behaviours, and that group differences should only reflect local environmental differences.”From an evolutionary perspective, this parallels the question of the evolution of social and individual learning strategies. Social learning refers to learning in interaction with another individual, whereas individual learning (which we employ here as synonymous to 9). This independence breakdown has consequences—at some point, opinions are so tightly correlated that the accuracy achieved by imitation collapses, as individuals agree more with one another than with reality. The snake bites its own tail: the increase of accuracy achieved by sampling the opinion of others triggers a spread of imitators, which continues until all anchor to “truth” has disappeared. Social learners are ‘information scroungers”, whose spread is reminiscent of Rogers’ paradox10. However, the paradox we study is different: In Rogers’, social learners spread because they do not pay information search cost, whereas this rationale holds even if information is free, and comes from the fact that social learners are more accurate.This rationale brings however an internal tension within Condorcet’s jury theorem, which rests on a crucial assumption: that opinion are somewhat independent in the probabilistic sense. But when allowing imitation, the theorem jeopardises the very independence it is assuming: if most of the population imitates others, opinions are no longer independent, but converge towards one another 7). This conclusion can be understood from Fig. the vast majority of agents imitate, so that virtually every agent holds the same belief 10 . A study trying to measure within- and between-group cultural variation incidentally found the first component to be the larger than the second19. Furthermore, humans are found to use individual learning quite often22 and to under-use social information23, a phenomenon known as “egocentric discounting”24, which leads to a sub-optimal situation in terms of belief accuracy, both at the individual22 and collective25 levels. Also, the very tendency to conformism is disputed18: minorities seem to have a literally disproportionate social influence, greater than their share in the population26.Second, there is usually a substantial in-group heterogeneity in people’s beliefs . Similarly, financial analysts who produce “bold forecasts” tend to be preferentially heeded35. Agents seem to be intuitively aware of the danger of blindly following the “crowd”.This is a feature that should be incorporated in theoretical models. Previous studies implicitly assume that agents listen to randomly chosen other agents. Instead, we propose that agents can develop a “taste for originality”, implemented as a preferential attachment to individuals displaying deviant opinions, in a dynamic network representing who listens to whom. This taste for originality is not only normatively warranted, but also empirically reasonable. Several studies have found that individuals having atypical opinions were rated as more likeable, courageous or admirableinteresting–because unexpected–opinions, likely to be listened to. This could be the primary goal of certain individuals36. In current evolutionary models, fitness is proxied by belief accuracy, which means that humans are assumed to be accuracy-maximizers. Here, we propose that humans also care about their social influence . The dynamic network representing who listens to whom allows one to do so in a simple way: agents simply maximize a combination of their opinion accuracy and the number of people who listen to them.Being independent-minded generates To sum up, we introduce two novel assumptions: (i) agents have an incentive to be listened to, and (ii) agents can choose to listen to deviant opinions in order to benefit from the diversity effect. This framework allows us to shed a new light on individual learning: although it is sub-optimal in terms of accuracy, it is a way to signal independent mindedness, which makes one worthy to be listened to. It leads to a kind of division of labour equilibrium: as they do not benefit from the wisdom of crowds effect, individual learners achieve lower accuracy, which is offset by the reward they get from being listened to. Such reward may be prestige, influence, or more concretely university positions, consulting fees, copyright, etc. Our scenario is consistent with the empirical findings we mentioned: (i) the effectiveness of the wisdom of crowds effect despite widespread social learning, (ii) a stable non-zero degree of within-group cultural diversity, and (iii) an over-reliance on individual learning, with respect to what accuracy-maximisation would require.The paper is organised as follows. In Sect. 11 considers a population of agents making a binary forecast for the next time step. Table I) or being “follower” (F) and relying on others. These two strategies correspond to what is usually called respectively individual and social learning in cultural evolution. An agent playing the I strategy has a probability (i)F randomly initialize their opinion, with a 1/2 probability of being right: they have no private information, and thus a neutral prior.All agents playing (ii)m individuals, and endorses the majority opinion among them .One of them, randomly chosen, observes a random sample of (iii)Step (ii) is repeated a large number of times until the proportion of followers holding the right opinion converges to a value Unlike the I strategy, the F accuracy depends on the fraction z of followers in a non-trivial way, see Fig. z, there is only one attractive fixed point p, which means that herding is efficient. This is simply the Condorcet theorem mechanism at play: aggregating information yields more accurate predictions. Furthermore, the performance of followers increases at first with their number, as the probability to sample from an accurate follower increases, thereby improving sample quality. Notwithstanding, above a critical value The seminal model of Curty & Marsilientclass1pt{minimaz) that, due to initial conditions, followers trap themselves in the wrong self-reinforcing forecast. When z becomes very large, these two fixed point are close to 0 and 1, the followers basically reach a consensus. This is a herding phenomenon: when imitation is too frequent, followers are mostly imitating one another and no longer aggregating genuine information. It is possible to compute analytically 11, which gives the bell-shaped blue dotted curve shown in Fig. More intuitively, there is for entclass1pt{minimaq has to fall towards 1/2 as Under the hood, this is due to the fact that the more numerous the followers, the less independent their opinions. As we mentioned in the Introduction, the super-accuracy of followers relies on independence: if all individuals agree, aggregating opinions has no effect. Worse still: as followers have no information of their own but rely on others to make up their mind, a population made of 100% followers would decide purely by chance, which means that 10–see Sect. 38.The message of the model is twofold. First, the equilibrium of the game is the point where, even though most people learn from others, learning offers no longer any gain of accuracy .This model shares the basic features and conclusions of the conformist transmission literature. In Fig. i is a node. A link i listens to j when he/she makes up his/her mind. The network follows the following rules.i initializes its network m agents in the population.Each agent j was right at time t, 0 otherwise. The score thus reflects the accuracy record of an agent, with an emphasis on the recent past. Each member i drops the lowest performer At each time step, For the moment, we keep the strategies (I and F) fixed and exogenous, and observe the phenomenology of the model; we shall in a second stage let the strategies evolve depending on their respective payoffs. Henceforth, we choose z (the fraction of agents playing F) close to 1, and One of the limitations of the Curty-Marsili framework is the assumption that followers sample randomly their consociates to make up their mind, thereby neglecting all possible effects of reputation, trust, and epistemic links between agents. In order to represent the fact that agents often rely on a network of people they know and trust, we embed the game in a dynamic directed graph, where each agent q now drops below p, and settles around 1/2  evolves dynamically. Quite interestingly, we find that the in-degrees distribution develops a power law tail, see Fig. k, with an exponent that depends on the parameters of the model (see e.g.40).In our network, the out-degrees (the number of agents a given agent is listening to) are all fixed to q is close to 1/2, any follower would benefit from listening to an informed instead of a follower. This is an assortment failure, and the situation described above is only an equilibrium because our assumptions prevent efficient assortment.The results of the previous section are somewhat unsatisfying. In the situation where I or F) are not directly observable, opinions are public and may be used to infer the underlying strategies. But as we repeatedly pointed out, at equilibrium informed agents cannot be identified by their accuracy , whereas this quantity is close to one for followers. This distinctive feature can plausibly be observed by followers, and be used to identify potentially informed sources and listen preferentially to them. More mundanely, agents with original opinions are often deemed competent .Instead, the most distinctive feature of i between the forecast of an agent j in originality over accuracy.This intuition can be formalized by introducing a proxy of originality, which we define to be the distance observed by agent In information-theoretic terms, given the opinion of an original agent, the opinion of another randomly drawn unoriginal one has a null Shannon entropy. Conversely, the opinion of an original agent has a constant positive Shannon entropy, irrespective of the opinions that have been already voiced, since the random variable representing his/her opinion is independent from all other opinions. In other words, listening to an original agent is a way to diversify information sources, whereas listening to a consensus-follower is a waste of time. Hence, listening to original agents can actually be seen as a form of protection against group-think, which agents are arguably wary of. We start by fixing q is non-monotonic. As q reaches a maximum beyond which it decays.Figure z was found to have a bell-shaped effect on q. In the present framework, the informed audience share s in the network  somehow plays the role of z in Curty & Marsili’s model. There needs to be an optimal fraction of informed agents in the network in order to maximize the wisdom of crowds. It is due to the fact that when In order to understand why this is the case, recall that in Fig. This result is striking. Intuitively, social learners should preferentially seek to copy individual learners, who supposedly possess high quality information. Here, at some point, social learners are so good at detecting individual learners that listening to social learners instead becomes a better option. Analogously, reading a meta-analysis instead of primary literature is a good idea as long at the meta-analysis is filled with primary literature.From the group point of view, the optimal situation should correspond to a “pyramidal” organisation with some individual learners at its base, originality-oriented social learners in the middle (who aggregate the information produced by the base) and pure social learners at the top. But if agents aimed to be right as often as possible, such a pyramid would be doubly unstable: the base would have an incentive to switch to social learning, and the middle would gain from listening to social learners instead. However, this organisation can be stable when agents do not have accuracy as only goal. This is what we explore in the following section.I agents have massive in-degrees, but numerical results are, again, counter-intuitive. The higher the Finally, increasing Our exploratory results so far have shown that there exists an optimal positive value of the taste for originality In addition, we have so far worked with an exogenous proportion of informed agents. But if agents try to maximize their accuracy by changing strategies, this proportion should spontaneously decrease as soon as c are information costs, and that the profit of followers is simply q. Then one can have Within our framework, the only way to produce a situation where z and Thus, neither the taste for originality nor the survival of informed agents can be taken for granted at this point. We need to investigate these issues in a dynamical setting, i.e. by making both At this point, analytical computations of an evolutionary equilibrium appear out of reach. We thus choose a dynamical mutation-selection algorithm, which allows us to find the equilibrium numerically, and a possible description of how the psychological traits we study evolved biologically. To do so, we need two ingredients: genes (the endogenous part of the model) and a fitness formula (maximized by evolution).(i)I) and follower (F)The strategy gene, which has two alleles: informed ((ii)The originality gene, with also two alleles: Note that henceforth the taste for originality is no longer continuous, but instead binary (We assume that agents have two genes: (i)Followers preferring originality, thereafter called “dandies”. (ii)Followers without this taste, or “conformists”(iii)Informed The natural selection dynamics is implemented in a Wright-Fisher fashion41. At each time step, a uniformly drawn individual is killed, and replaced by a clone of some agent chosen with a probability proportional to fitness, defined below. At each time step, each gene has also a small probability Three phenotypes can then be distinguished: In addition to the obvious aim of agents, which is to make the right forecast as often as possible, we add two further sources of costs and benefits . First, information seeking has a cost. Second, we assume that being listened to has benefits. It can represent an analyst fee, university wage or simply the prestige or the power reaped from being influential.(i)i was right at time t and 0 otherwise.A measure of an agent’s forecast performance, (ii)The cost of information ((iii)A measure of an agent’s audience/prestige proxied by its in-degree The fitness formula, in its simplest linear form, writes:Formally, we introduce the fitness of an individual q increases rapidly with Figure In order to explain this result, we plot the frequencies of types in the population Fig. b. We seeThe bell-shaped effect on informed agents then follows naturally. We suggested in Sect. (i)q to fall to 1/2, as no one in the network has any information any longer.Small (ii)High (iii)Intermediate The last regime is especially interesting and is that which we are looking for. We can describe it as a mutually beneficial “division of labour”: informed agents do the hard work and collect reliable information, dandies listen to them to form more accurate opinions , whereas conformists listen to a mix of conformists and dandies . The taste for originality is now stable, as the lower in-degrees of dandies is offset by their higher accuracy. The presence of an informed minority is also stable, as their lower accuracy is offset by their high in-degrees.To sum up, we find three distinct regimes: One can also analyse these results in terms of opinion diversity. Such diversity can be thought of as the average size of the minority group. One finds (not shown) that it follows very closely the prevalence of dandies. Thus, allowing for originality somehow solves the paradox we started from: the wisdom of crowds can work while maintaining opinion diversity.8 nor homogenous. Instead, there is a clear majority, but also a substantial residual heterogeneity, which is endogenous and evolutionary stable.In the labour division equilibrium, the population is neither a “smear of ideas”43 in their models of social imitation—models that posit some inherent heterogeneities, for a review see44.So, how can we position the agents in terms of conformism? Similarly to Fig. mentclass2pt{minimmentclass2pt{minimq  is a strictly increasing function of opinion diversity, in line with Pages’s “Diversity Prediction Theorem”27: the amount by which the crowd outpredicts its average member increases as the crowd becomes more diverse. As noted in45 such a situation also prevents large opinion swings (or “crashes”) when external conditions slowly evolve.Intuitively, agents are only cautiously influenced by the majority: they aggregate information while remaining wary of herding. Also, we can note that q is larger than p, we are still in the bi-stable region of Fig. Note however that although the average value of 46. Furthermore, originality is simple enough to produce: an agent can choose opinions randomly, or sample around and adopt the minority opinion. Therefore, the above scenario is possibly vulnerable to an invasion by parasitic behaviour mimicking originality, thus scrounging the prestige of genuinely informed agents.The line of arguments developed above still has a loophole. If originality in itself is used by agents to detect the sources of genuine information, then original agents benefit from this signal by getting prestige in return. Thus, a social learner could benefit from being artificially original: he/she would be considered by others as a good source without paying the price of information search—just like in Batesian mimicry, where the palatable species gains protection from predators without paying the cost of being toxicanti-conformism, consisting in sampling around, and endorsing the minority opinion. If such a behaviour spreads in the population, it challenges the very credibility of our scenario, as an original agent is no longer necessarily a source of reliable information. To do so, we include a third binary gene, whose possession of the positive allele coupled with the follower one leads to anti-conformism. Like the other genes, it evolves by mutation and selection. Now, if we re-run the simulations of Fig. It thus makes sense to include a fourth strategy: At this point, one could conclude that our scenario producing worse than random . We can think of p as the easiness to forecast the topic in question. For instance, p would be higher in meteorology than in finance, as the predictive power is (nowadays) stronger in the former case. So, it would make sense that the lower the p, the more anti-conformism can spread in the population. Put differently, the more unpredictable a subject is, the harder it is to detect con artists. Thus, the virtuous equilibrium described in Sect. p is sufficiently high to detect counterfeits; (ii) The magnitude of this effect is controlled by the probability p. As shown in Fig. p and intermediate This scenario is indeed confirmed numerically cf. Fig. a: the \dpolarisation: the average size of the minority group is close to 50%, i.e. the population is evenly split, as would indeed be expected for an anti-conformist bias , the phase where anti-conformists are present not only produces heterogeneity, but also see Fig. : if the 1, together with empirical data22, shows that aggregating others’ opinions often allows one to form more accurate opinions than relying on individual learning. If this is the case, individuals should rely on “wisdom of crowds” heuristics, and there is indeed evidence that they do34. However, as agents form their opinions based on the views of others, the diversity of opinions in the group diminishes. This undermines a necessary condition ensuring the very effectiveness of the wisdom of crowds in the first place, namely the independent formation of aggregated opinions.We started this paper with an apparent paradox. Condorcet’s theorem11, even though (ii) this strategy, based on the wisdom of crowds effect, is not more effective than individual learning11.As a result, and as previous models suggest, we should end up in an apparently paradoxical equilibrium in which (i) the vast majority of agents adopt such a social learning strategy, leading to a large within-group homogeneity of opinions27, it is beneficial for individuals to listen preferentially to original opinions. Second, by assuming that individuals benefit not only from being well informed, but also from being listened to, the preference of social learners for original opinions endogenously creates an incentive to be independent-minded.Our model offers a way to solve this apparent paradox and generate endogenous heterogeneity. First, because listening to diverse opinions increases the efficiency of information aggregationThus, as individuals have an extra-epistemic incentive to be listened to, some individual learning can endure despite the more efficient character of information aggregation. Importantly, the very persistence of individual learning guarantees the efficiency of social learning, as it introduces some diversity and independence in the opinions that the social learners gather—a necessary condition for the wisdom of crowds to work.Rogers’ paradox The paradox of the wisdom of crowd shares some similarities with Rogers’ paradox10, and can thus be relevant to its resolution as well. In Rogers’ influential model, social learning is initially more efficient because it allows, in a varying environment, to avoid to cost of trial-and-error exploration. However, as social learners massively spread in the population, genuine information search get rarer. Social learning thus becomes less and less efficient, as the probability to copy an outdated belief or behaviour increases. Because of this negative prevalence dependence, social learning’s fitness then collapses until being, at equilibrium, equal to the one of individual learning. Consequently, the mean fitness in such a group ends up being equal to what it would be in an “acultural” population, where everyone learns individually. In other words, culture  would be, in the end, inevitable but useless. When compared to apparently massive contribution of social transmission to the ecological success of the human species48, this result seemed somewhat paradoxical.49 proposed “selective learning”, where individuals try to learn individually first, then learn socially if the first trial was inconclusive. It allows to imitate opportunistically, only when needed, and predicts a fitness gain for the group at equilibrium. Enquist et al.50 proposed the reverse: “critical learning”, consisting in learning socially first, then individually if the socially acquired strategy proved unsatisfactory.Several solutions were proposed to solve Rogers’ paradox, mostly involving hybrid strategies. Boyd & Richerson’sOur model provides an alternative to solve the conundrum. Under the hood, Rogers’ result comes from the prevalence-independence of the fitness of individual learning strategies. Since by definition strategies have identical fitness at equilibrium, the system is bound to have the same fitness as an asocial learners population. In Boyd & Richerson’s model, this issue is bypassed by the assumption that the strategy consists in setting a threshold of self-confidence under which one learns socially, which means that the less one learns a-socially, the more one is demanding, hence the better its outcome. In our model, the positive prevalence-dependence of individual learners’ payoff is quite natural: their opinions are sought for, so the rarer they are, the more they attract an audience.ex post . Second, and more importantly, it solves an extended version of the paradox: if we allow individuals to aggregate information, then social learning is not only less costly but also more accurate than individual learning, because of a “wisdom of crowds” effect. This setting precludes Boyd & Richerson’s explanation, where individual learners are the ones who achieved the highest accuracy.It would be dubious to argue that our scenario is simpler than the existing ones. However, it has two merits. First, it is robust to a situation where a belief’s quality can only be assessed In addition to offering a solution to the above paradoxes, our model generates several predictions allowing one to explain some already known phenomena and possibly stimulate further empirical research.51. However, somewhat unexpectedly, experimental evidence from social psychology, cultural evolution and experimental economics consistently shows that humans typically under-use social information, by placing an unjustified weight on their own opinions relative to others’ .Social learning seems to contribute to our species ecological success, and many models of its evolution showed its great adaptive benefits24—is not easily explained within existing frameworks (see23). By contrast, it is a natural consequence of our model. As social learners need to diversify their pool of opinion, individual learners, although informationally worse off, get social benefits from being listened to, that out-weight the costs of belief inaccuracy. In other words, a sub-optimal reliance on social learning with respect to belief accuracy is compensated by extra-epistemic benefits brought by social influence.This sub-optimal under-reliance on social information—often called “egocentric discounting”53.In this perspective, egocentric discounting is explained by a mutually beneficial equilibrium, in which individual learners exchange, with social learners, original information for status. Such a division of labour equilibrium is consistent with the documented substantial inter-individual variation in the propensity to individually vs. socially learnThe same model also predict that (i) social learning is assorted to a taste for originality rewarding the independent-minded individual learners, and that (ii) individual learners, in exchange, gain social status or reputation benefits from their independent-mindedness. The next sub-sections successively examine these two points.A taste for originality, by which people would put more weight on independent-minded individuals’ opinions, has, to our knowledge, never been tested—and could form the basis of future studies.54 might however be a manifestation of such a phenomenon. In opposition to what a pure conformist bias would predict7, minorities have indeed frequently been found to have a disproportionate social influence relative to their size in the population55. Again, this kind of phenomena emerge straightforwardly from the model: the taste for originality makes agents holding frequently deviant opinions more influential, and, as a result, the influence of a rare opinion is higher than its share in the population , others individuals will pay deference to gain access to them in order to imitate the best available models. It is akin to the way informed agents get prestige in our model, by centralizing attention in the network. Note however that this analogy is somewhat misleading. Indeed, at variance with our model, the informed agents are indeed informationally better off in such a story. By contrast, in our virtuous equilibrium, informed agents are in fact the worst forecasters as they do not benefit from the Condorcet effect. But although their opinion is less accurate, it is  more informative about the state of the world, as it is not correlated to the opinion of the crowd. This extends Henrich & Gil-White’s logic: when sampling several models, it can make sense to pay a deferential cost even to someone who is not particularly competent, as long as his/her opinion is original.First, researchers long argued that prestige might be gained by providing others with social information58. Gaining extra social status could be the compensation that allows individual learning to endure, or as Dessalles puts it: communication of information is part of a kind of unconscious trade in which status is the payment. Furthermore, he remarks that people often have a hard time being heard and making their point instead of being asked for information, which would be expected for an altruistic act. Humans seem to be willing not only to share information, but to strive to make others hear their point of view and recognize their authorship of new ideas59, which suggests that being heard is indeed profitable. Also in line with this idea, prosocial individuals tend to spend more effort on individual learning21.Second, some dimensions of communication suggest that it involves a form of reciprocal trade of information for status benefits. As argued by Dessalles, learning individually is costly and sharing the obtained information benefits its receiver, so doing it without compensation would amount to altruism3. In particular, our distinction between information seekers , followers and anti-conformists is a relatively faithful description of the ecology of financial markets. .Finally, as noted in the introduction, our story shares some similarities with, and offers some original insights on, the “impossibility of efficient markets” paradox discussed by Grossman & Stiglitz in their seminal workp of the informed is very close to 1/2. As we have pointed out in Sect. after informed traders can give rise to bubbles that further decouple market prices from ground truth.Financial markets are notoriously difficult to predict, meaning, in our language, that the probability of success within a factor of 2 of fundamental prices61: only when mispricing becomes large enough will p differ sufficiently from 1/2, allowing true information to reveal itself and reinstate the power of Condorcet’s aggregation theorem. In fact, since p becomes itself endogenous in this case, financial markets are presumably prone to predictivity cycles: p close to 1/2 disfavours informed trading, which generates mispricing and, in turn, larger values of p, favouring informed trading, etc. For some empirical signatures of such cycles, see63.Hence we are less optimistic than Grossman & Stiglitz who propose that financial markets are close to efficiency, with a small residual error allowing information seekers to cover their costs while allowing the aggregation process to perform its task. We rather believe in Black’s picture, where market prices are quality of these opinions ex post, when it is too late to change opinion. In other words, agents can measure the past accuracy of an information source, but know nothing else of the current advice he is proposing. Thus, our model was not designed to study a cultural item like canoe building techniques, where the quality of a technique can be inferred through the quality of the produced canoes. This allows more elaborate strategies, such as the critical learning50 we mentioned, or a prestige bias56 . As these were not central to the contribution of the model, we chose not to include competence heterogeneity and prestige-biased transmission, although these are clearly major forces in cultural evolution. Our model seems at first sight more suited to analyse beliefs such as forecasts. Indeed, it is impossible to compare the qualities of different forecasts before the event realization, and too late to change them afterward, which makes the two aforementioned solutions unworkable. We see however no fundamental reason why our model would not apply to technological cultural items: individual learning  is a sine qua non condition for the cumulative process to take place, and should at first sight be counter-selected if the aggregate opinion is of high quality. The endogenous generation of cultural diversity through individual learning may also have interesting implications regarding the dynamics of cumulative technological evolution. Researchers have indeed suggested that increasing the independence of individuals’ exploration strategies can decrease the probability of populations getting “stuck” in local optima, by making them explore different cultural possibilities64.We should nevertheless highlight a number of limitations of our model, which might help to delineate its domain of validity. For example, our model treats beliefs as perishable instead of cumulative: agents start searching from scratch at each iteration instead of taking their previous opinion as a starting point, and search to improve it. Also, the model implicitly assumes that agents can observe the opinions of their neighbours, but can only assess directly the 65). In line with this idea, studies suggests that IQ and self-confidence negatively predict reliance on social learning65. This idea, however, assumes that it is because competent individuals are informationally better off that they rely on individual learning (because they are “wiser” than the crowd). This, however, seems not to be the case. Throughout the experimental literature in social psychology, cultural evolution and experimental economics, individual learners’ independent mindedness appears as informationally sub-optimal: they are found to under-use social information relative to what an accuracy-maximization imperative would warrant23. Furthermore, Mesoudi22 found that the subjects who used social learning the most were also above-average individual learners.Other mechanisms could also be invoked to justify the persistence of some individual learning (and the resulting preservation of some opinion diversity), despite social learning’s efficiency. A possibility would be for more competent or knowledgeable individuals to discount the opinion of others in forming their own (see, e.g.,Finally, our model neglects possible conflicts of interest or strategic interaction: agents ignore the influence they have on others. In reality, information transmission has no reason to always be benevolent, but can lead to manipulation, against which individual learning is a way to hedge oneself.


The aim was to systematically assess the evidence on whether cultural safety affects breast cancer outcomes with regards to care for Indigenous women in high income countries. We conducted a systematic review in accordance with PRISMA guidelines of peer-reviewed articles in Medline, EMBASE, CINAHL, Scopus, Web of Science, Proquest Sociology and Informit Rural health database and Indigenous collection databases. Key inclusion criteria were: adult female patients with breast cancer; high income country setting; outcome measure, including screening, diagnosis, treatment and follow up care. A total of 15 were selected. We developed a Community Engagement assessment tool in consultation with aboriginal researchers, based on the National Health and Medical Research Councils’ community engagement guidelines, against which studies were appraised. This novel element allowed us to evaluate the literature from a new and highly relevant perspective. Thematic analysis of all 15 studies was also undertaken. Despite limited literature there are evidence-based strategies that are likely to improve outcomes for Indigenous women with breast cancer in high income countries and indicate that culture makes a positive difference. It is also clear that strong Indigenous community leadership and governance at all stages of the research including design is an imperative for feasibility. Breast cancer is the most commonly diagnosed cancer in Australia, representing 28% of all cancer incidence in women and the second highest number of deaths . MortaliUptake of screening has increased over time among both non-Indigenous and Indigenous populations in Australia, however a significant gap remains. Australia’s national population-based screening program BreastScreen offers free 2-yearly mammograms targeting women aged 50–74 years. In 2019, 41% of Aboriginal and Torres Strait Islander women in this age group participated compared with 54% of non-Indigenous women [While age is the greatest risk factor for breast cancer, Aboriginal women are more likely to be younger than non-Aboriginal women at the time of diagnosis . AborigiThere is evidently a demonstrable need for improved screening, diagnostic and care pathways for Aboriginal women in Australia . The litAn environment that is safe for people: where there is no assault, challenge or denial of their identity, of who they are and what they need. It is about shared respect, shared meaning, shared knowledge and experience, of learning, living and working together with dignity and truly listening” [Overwhelmingly, contributing factors are related to the lack of cultural safety within health services. Cultural safety has been defined as “stening” . Aborigistening” . FurtherThere is a body of evidence surrounding initiatives aimed at increasing breast screening among Aboriginal women which indicates that success is highest where there are partnerships with Aboriginal community-controlled organisations . These iThis review aims primarily to examine the role of culture when it comes to improving Indigenous women’s health outcomes, and secondarily to elucidate factors predicting success, and barriers to success of programs.This study is a systematic review of peer-reviewed literature and is reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines . The stuPopulation: Indigenous women in the US, Canada, Australia, New Zealand, Norway and Japan participating in breast screening, diagnosis, treatment and follow up Intervention: Prevention, Screening, Diagnosis, Follow Up. Comparator: Non-Indigenous women in high income countries, as defined by the WHO. Outcome: Mortality, participation rates, adherence to guidelines, cultural safety (was any provided and did it make a difference?)Seven online databases were searched: MEDLINE, EMBASE, Scopus, Web of Science, Proquest Sociology, Cinahl and Aboriginal and Torres Strait Islander Health Informit database.The strategy had three main concepts relating to: (1) Indigenous populations around the world in Australia, New Zealand, USA, Canada, Japan and Norway and related terms, (2) Breast cancer and related terms and (3) Culturally appropriate and related terms.The search terms were:  AND ) OR culture) AND ((cancer OR tumo?r* OR neoplasm*)))The terms were combined with limitations on human studies only and language was limited to English. Eligible studies were limited to journal articles, observational studies, clinical studies, and clinical trials. The search terms were adapted for use with other bibliographic databases in combination with database-specific filters, where these are available.Following duplicate removal, the first author screened all studies retrieved using the search strategy and any additional sources using the title and/or abstract to determine inclusion based on the criteria outlined above. The full text of these articles was then independently assessed for eligibility by the first author and discrepancies were resolved by consensus between the first and Senior authors. This review applied the National Health and Medical Research Council (NHMRC) community engagement guidelines  and assiAll final 15 studies selected for community engagement assessment underwent a thematic analysis. Each of the studies was analysed against these categories and evidence of themes was recorded. If a theme emerged in two or more papers, it was considered ‘strong’. The thematic analysis was conducted by one researcher (VC) and reviewed by a second (KG). The researchers reached consensus through discussion and subsequently sent to entire author team.General characteristics of the article, participants, interventions, study outcomes and measures were extracted by the first author using a purpose designed form. The first author then compared the results of the community engagement scores with the Thematic analysis.The initial search yielded 1714 records. After removing 701 duplicates 1013 records remained. During the title review 699 were excluded as they were either: biomedical, focused on complementary medicines and spirituality, not wealthy countries, animal studies, not in English language, males only, limited to other individual bodily system, regarding youth only. Thus 314 articles remained, which were then subjected to an abstract review, with further exclusions made: focused on family experience only, studies including non-Indigenous population groups, related to clinical trials only, discussion of HPV/Cervical cancer only, speaker abstracts, conference abstracts, PhD dissertations, prevention focus only, service provider focus, systematic reviews, reviews, no outcome data, all cancers, men and women, specific cancer(not breast) only, regarding challenges within the health system but not for community, format(such as book excerpt) or because they did not use primary data sources or were about cancer in general. 15 remained and were subject to the community engagement tool and a thematic analysis. This is shown in All 15 papers were assessed using the community engagement tool we developed based on the NHMRC Community engagement guidelines. The studies fell across the spectrum in community engagement scores. One study scored 5, eight scored 4, two scored 3, one scored 2 and the remaining three scored 0. The community engagement factors that were reported in the majority of studies were Cultural consideration (x/15) in design and Respecting community difference (y/15). The community engagement factor least likely to be reported was Issue identified by community (z/15). reported details of community engagement despite this being a key component of successful study design with Indigenous communities.Besides the eight studies which scored between 4 and 5, two of the remaining papers scored 3, one scored 1 and 3 scored 0. This implies that, while the majority of projects have used community engagement as a focus of research, others may not have taken it into account at all. When looking at the studies that scored 0 it was notable that none explicitly mentioned Indigenous researchers working on the study and nor did they view this as a limitation of their studies ,33,37. IFour themes emerged strongly in the thematic analysis, these were: (1) Silence; (2) Service Access; (3) Cultural conception of cancer; and (4) Family and community support. The presence of the theme is shown in the most successful and effective programs were those developed with input from the population and tailored to meet the needs of the region and specific tribes” [This novel study demonstrates that if researchers, clinicians and community members work together, solutions exist for complex health issues like breast cancer prevention and treatment. Despite the small number of relevant studies in the review, the principles of co-design, including community engagement, community governance and capacity building are central to effective research with Indigenous communities ,39. In a tribes” .With an underlying framework of respect and communication, diverse skills and knowledge, a coalition was formed between community and external programs to guide the project and ensure that the community had ownership of both the problems and the solutions” [The involvement of community representatives, working alongside researchers, in baseline survey planning, helped assure the survey was acceptable to the participants and the community as a whole” [The goal of Talking Circles is to make one’s self into a vessel to receive spirit through a series of processes, for example, purification of place, self, and community. The cultural and spiritual experience changes a person’s sensory and self-awareness [While only one of the studies scored five on the tool, a further eight scored four, indicating the importance of community engagement in doing publishable research with Indigenous peoples. The top scoring study attributed the success of the research to the focus on community engagement, stating that “lutions” . One of a whole” . When obwareness . This spwas assumed to be a goal in itself, separate from programmatic objectives to improve screening rates” [An integral element of community engagement is capacity building. Not only does it engage the community and help to build a culturally safe protocol, it also helps to ensure sustainability and increase health literacy. The top scoring study attributed a good deal of its success to the fact that capacity building was a focus of every part of the project, claiming that it “g rates” .is no word for cancer” [inviting it into the community [cultural views tend to discourage open verbal discussion about negative health topics because it is believed that talking and thinking about these topics in first-person rather than third-person, may bring disease or illness upon the person speaking” [The thematic analysis revealed four themes across the literature included in this study. The first theme, Silence, remains a theme that needs further investigation as it appeared to sit across all the other themes, and not squarely in one. Silence appears both from the person with cancer and also those supporting them. In fact, in some Indigenous cultures there “ cancer” . While sommunity ; or “culpeaking” . SilenceMany Navajo women avoid mammography screening, due in part, to a lack of knowledge and a sense of hopelessness associated with cancer” [lack of trust in their providers and in Western Medicine made them not want to get screened at all” [Preventive care is considered of tertiary priority and is available if there is money left over after other services are covered. In addition, patients do not often use available preventive services or come in when they are symptomatic from an illness” [Theme number two, Service Access, is much more easily delineated. There were several emerging sub-themes, such as specific barriers to access or delivery. One sub-there identified was a lack of appropriate education around the disease, one study stating that “ cancer” . Another cancer” . Another at all” . The barillness”  due to tWomen articulated a conception of how cancer works, describing cancer as threatening and damaging, often final. Some saw cancer as worsening their economic and mental state of wellbeing” [participants emphasized that many older Native women did not feel that they were even at risk for cancer, and they did not seek preventive testing” [punishment for one’s own actions or those of a family member, (or that) one needs to “wear the pain” of cancer to protect their community, cancer is a natural part of one’s path, cancer results from a curse or a personal violation of tribal mores, and there is a contagious “cancer spirit” [Theme number three, Cultural conception of cancer, covered a range of beliefs about and attitudes towards the disease and identified that beliefs about cancer can directly prevent women seeking screening, diagnosis or treatment . While tllbeing”  where astesting” . Other s spirit” . In one  spirit”  speakingencouragement from significant others, particularly family, friends, elders, and health providers, who either advised keeping the scheduled women’s health exams and the mammography referral appointment or counselled keeping oneself healthy” [participants were comfortable in making an oral commitment to the family and community to engage in screening behaviors” and that this knowledge added to the researchers’ understanding and “provided more depth related to family involvement; women brought children, aunts, mothers, grandmothers, and spouses” [as a barrier to breast self-care” [Theme number four, Family and community support, contained several sub-themes, including lack of proper dissemination of information, family and community support encouraging positive or change of behaviour and a general understanding of community of the difference between survival and non-survival. One study identified the motivator to screen as “healthy”  and anotspouses”  to assisspouses” ,28. Altelf-care” .Cancer isn’t about me. It’s about us. Families and communities are affected, too” [A key driver for engagement in breast screening was the perception of investing in health for the sake of the next generation” [Family and community not only offer the support but are also affected by the disease. One participant in a study said “ed, too” . and a deration” . The expOnce the themes had been established, the first author looked at whether there was a correlation between the community engagement score and the thematic analysis. Not being able to find a clear one, the first author looked at the studies that were high scoring in community engagement to distil the elements these studies had in common; inferring the factors that were reported as having an impact. This is shown in When poor experiences with mammography were discussed, not up to date women focused more on cultural insensitivity and lack of respect than the mammogram itself” [Increases in screening participation must be matched by culturally appropriate programs that deal with abnormal findings and facilitate Aboriginal women’s pathway through cancer treatment services. Only then will earlier detection of breast cancer translate into better outcomes” [Overwhelmingly the literature finds that culture makes a real difference to Indigenous women when it comes to the breast cancer journey. Many studies found that women fared better when culture was incorporated into the screening, diagnosis, treatment and follow up care. Further, none of the literature claimed there was no relationship between culture and health. One study found that “ itself”  indicatiutcomes” .sparked an interest in gaining more information about treatment options and reduced anxiety related to the treatment process” [Much of the literature found that the use of Indigenous methodologies  and Indiprocess” . A limitprocess”  and furtThis literature in this review found that culture makes a significant difference to Indigenous peoples in wealthy countries when it comes to cancer in general. When looking specifically at breast cancer for Indigenous women in high income countries, much the same message emerges on a smaller scale. The literature that is available about breast cancer overwhelmingly emerges from the US and Canada, compared with a relative paucity from the Australasian nations included in the search, however the concepts are the same.From this review, it is clear that there needs to be more research about capacity building, culturally safe services and building health literacy. Based on this study we can infer that the impact of these elements is vast, but it is not clear just how integral they are to the success of services for Indigenous women with breast cancer.The literature provides evidence-based strategies that are likely to improve outcomes for Indigenous women with breast cancer in wealthy countries. It is also clear that strong Indigenous community leadership and governance at all stages of the research including design is an imperative for feasibility.