Parental mental illness is a major international public health concern given its implications for whole families, including children. Family-focused practice (FFP), an approach that emphasises a “whole-family” approach to care, provides an opportunity to mitigate the significant risks associated with parental mental health difficulties. The positive benefits associated with FFP have led to a shift in policy and practice towards prioritising FFP within adult mental health services. However, evidence suggests that FFP remains scarce and is not routine. Research has identified the important role of practitioners in facilitating FFP. The current review identified, synthesised and appraised the international qualitative literature examining adult mental health practitioners’ implementation experiences of FFP. It aimed to provide an evidence-informed account of practitioner experiences of FFP delivery and to identify key recommendations to enhance future FFP outcomes in AMHS. Ovid Medline, PsycInfo, CINAHL plus, EMBASE and Web of Science Core Collection were searched systematically, in line with PRISMA guidance, up to January 2022. The Critical Appraisal Skills Programme (CASP) was used to undertake the quality appraisal prior to a thematic synthesis being conducted. The review was registered on PROSPERO. Nineteen papers, spanning 17 years of research with 469 practitioners, were included. Three main themes and 14 subthemes were developed, representing different aspects of practitioner experiences of FFP delivery. Practitioners’ approach to FFP was variable and influenced by their beliefs about FFP, perceived roles and responsibilities, competence, service setting, and personal parenting status. Practitioners engaged in a balancing act to maintain a dual focus on their service-users and their children, to navigate powerful emotions, and consider multiple perspectives in a biomedical organisational structure that advocates individualised treatment. Although working together unified teams, a greater need for external interagency collaboration was identified. The use of strength-based approaches with clients and dedicated staff resources, within clear guidelines and frameworks, was reported to be necessary to maximise FFP delivery. This review proposes a complex FFP dynamic whereby practitioners engage in a constant balancing act between FFP stakeholders to achieve meaningful FFP outcomes for service-users and their families. Service recommendations are provided. Parental mental illness is a major international public health concern given its implications for whole families, including dependent children  emphasises a “whole-family” approach to care .The Sample, Phenomenon of Interest, Design, Evaluation, Research Type (SPIDER) tool  participants were adult mental health practitioners who worked in AMHS, (2) studies included data on views and experiences of FFP as well as perceived barriers and facilitators, (3) studies using qualitative methods of data collection and analysis, (4) studies were written in English or German in peer-reviewed journals. Papers were excluded if: (1) participants were mental health practitioners working in child services, substance use or physical healthcare roles, or occupying a solely managerial, non-clinical position, (2) studies centred on FFP-specific interventions or projects, such as family-based interventions or any family-specific therapies , (3) the focus of the study was not exclusively on professionals’ FFP delivery and (4) the study was a review or did not present empirical data, such as theses, opinion pieces and audits. Mixed sample studies  and mixed-method papers were included if practitioner data were presented independently but excluded if data were combined. Similarly, mixed-method papers were included if their qualitative data were distinct from the quantitative findings.https://casp-uk.net), a widely used quality assessment tool for assessing qualitative research  checklist for qualitative studies , the UK (n = 3), Norway (n = 3), Sweden (n = 3), Ireland (n = 2), Germany (n = 1) or New Zealand (n = 1). Recruitment settings for the studies included: Community Mental Health Services (n = 5), Inpatient Mental Health Services (n = 6), Outpatient Services (n = 1) and mixed samples of Inpatient, Outpatient and Community Mental Health Services (n = 7). Samples ranged from 6 to 219 participants, with a combined sample of 496. Tchernegovski et al.,  and Interpretive Phenomenological Analysis (n = 3), Phenomenographic Analysis (n = 1), Content Analysis (n = 1), Framework Analysis (n = 1) and Pattern Coding (n = 1)  or moderate (n = 2). Detailed quality appraisal ratings are shown in Table The methodological quality of all included studies was appraised and deemed as high ((1) A Variable Approach, (2) A Balancing Act and (3) What Works? Table A Variable Approach included the following subthemes: “practitioners’ beliefs about FFP” (e.g., see Beliefs about FFP column in Table A Balancing Act highlights the key simultaneous demands that practitioners had to balance and navigate with service-users, families and service contexts, which requires consistent negotiation and consideration throughout the delivery of FFP. Subthemes included: “the dual focus: difficulties keeping children and parents in mind”, “What Works? offers strategies that support practitioners FFP delivery endeavours. Subthemes included: “guidelines and regulatory frameworks”, “Three main themes were developed representing different aspect of practitioners’ experience of FFP delivery: This theme encompasses factors associated with practitioners and includes their beliefs about FFP, their perceived FFP roles and responsibilities, competence and confidence, service settings and parenting status. These factors appeared to contribute to the variability in the delivery of FFP. Five subthemes were included in the analysis.There is no one anywhere, no matter what their title or role in the organization, that doesn’t support the notion that families should be supported and that a child perspective is important: there is no one that opposes that. (Strand & Rudolfsson, We all know that if you don’t engage the family meaningfully, people’s recoveries are limited. (Ward et al., This subtheme illustrates that practitioner’s beliefs about FFP impacted their practice. Practitioners, in principle, acknowledged the importance of considering wider family, including children, in their service-users’ care (Grant et al., Most respondents emphasised their need for adequate time to perform additional duties. (Lauritzen & Reedtz, Now we’re working with the child’s perspective in addition to our real job, and it just becomes an extra task like everything else. (Strand & Rudolfsson, Despite reflections of FFP as important, most practitioners believed FFP was an additional duty and extension to their routine practice requiring more time and resources (Grant & Reupert, It was noted that considering wider family was somewhat new practice and unfamiliar terrain (Skundberg-Kletthagen et al., The subtheme captures how the extent to which practitioners viewed FFP as part of their role varied widely. Many practitioners supported the notion that FFP was their role and responsibility (Foster & Isobel, I don’t think looking at the children is a key priority. The priority is to get the person well and recovered unless there is a clear history of abuse or serious harm to that child. (Pfeiffenberger et al., They’re with us with a view to help them address their symptoms and be able to recover so their primary need is to get well and obviously we expect that if we achieve that, they will be able to parent their children successfully. (Radley et al., Conversely, some participants did not believe FFP to be within their role and that working with children was outside the remit of an adult mental health practitioner (Foster & Isobel, Some practitioners indicated uncertainty with regard to the boundaries of their role (Foster & Isobel, …they are our clients, they’re the ones in hospital and they’re the ones that we are first and foremost accountable to, so we have to put our client first. (Maddocks et al., There is nothing in place in acute wards that allows for the protection of these children … or to minimize the risk involved. (O’Brien et al., This subtheme shows how the service setting might impact FFP, There seemed to be disparity as to whether service setting impacted on FFP delivery. Some practitioners in acute inpatient services adopted a “narrower focus” (Grant et al., Conversely, Foster and Isobel  commenteThis subtheme related to practitioners’ fundamental competence and confidence in delivery FFP, and this led to variability in practice efforts. Across the studies, practitioners expressed that they lacked in competence, knowledge and confidence to deliver FFP and to meet the expectations of service-users and their wider families (Foster & Isobel, I’m not confident at it because I am not trained in it. I’m not qualified to give family-centred care. (Maddocks et al., We need information about building competency to manage complex family and parenting issues, how to put the family at the centre of care and recovery and how to refer to family services and how to utilize voluntary sector support. (Grant & Reupert, Furthermore, participants who had undergone training in formal family interventions also commented on their lack of confidence to deliver these interventions in “real-world clinical practice” (Hjärthag et al., How practitioners’ parenting status impacted their delivery of FFP was outlined within this subtheme. Practitioners identified that their personal experience of caring for their own children increased their awareness, skills and knowledge of service-users’ needs as parents and the needs of a child (Foster & Isobel, Despite the recognition of the value of FFP across most studies, a lack of role clarity and clear responsibilities, coupled with feelings of incompetence and insufficient resources, meant that FFP varied considerably across practitioners. The diversity of practitioners’ personal parenting experience also contributed to this variability.This theme highlights the interrelationships of practitioners with service-users, families and services, resulting in an ongoing balancing act in the delivery of FFP. The need to hold service-users and children in mind was expressed as a core challenge. The powerful feelings that FFP evoked in practitioners in combination with the emotions of service-users required balance, as did the key tension between the “person-centred” model of AMHS delivery and FFP.This subtheme outlines practitioners’ experiences of having to balance and hold in mind both parents and children. Keeping both parents and children in mind was a key challenge for practitioners, particularly balancing alliance with the parent service-user with the needs of children (Leenman & Arblaster, You’re trying to find that balance all the time between acting safely and not overly sort of escalating things because even if it’s intended to be protective, it can really increase anxiety levels. (Radley et al., I used to find it quite difficult because you are with your client and you want to support them but you have to think about the child, you have to think about their safety, their future and their emotional needs as well.... (Maddocks et al., Some practitioners described an “impartiality”(Maddocks et al., Family caregivers have a lot of knowledge, through a long life, which can be important to us… they are a great resource, they are in the same house and are present round the clock, and they can observe changes. (Sunde et al., I also think that relatives greatly need to get an explanation as to what happened and why and be able to reduce the shame and guilt. (Hjärthag et al., The subtheme captures how FFP requires practitioners to draw together and balance a range of perspectives from service-users and family members, which are not necessarily harmonised or consistent. A key task of a practitioner is to reflect and balance these multiple perspectives in their actions and care planning. This can be a challenge and a “dilemma” (Sunde et al., You can’t work with parents unless you’ve an emotional connection with them and there’s a downside to having it [emotional connection]. I don’t think that’s appreciated and it would be better for us as professionals if it was acknowledged by the organization. (Grant & Reupert, It’s so hard and frustrating. I had a mother of five children where I made home visits, so I met the kids because they were also at home. One day I had to be there when the police took her and her new-born baby because she was totally insane, so terrible . . . I just went home and cried for days [cries]. (Strand & Rudolfsson, I don’t have the time, I constantly feel guilty because I don’t have the time for it, and yes it feels terrible. (Strand & Rudolfsson, It gives you a few sleepless nights because you wonder what the impact will be on the parents. (Tchernegovski et al., The presence of heightened emotion from all stakeholders involved in the delivery of FFP defined this subtheme. Practitioners described the emotional cost of FFP when working with parents and children (Grant & Reupert, I know I certainly can think of a number of parents who feel incredibly guilty and actually largely this guilt is of not being able to do the parenting role as well as they would like to. (Radley et al., Practitioners had to balance their own emotional responses with the emotions of their service-users. In particular, service-users’ expressions of guilt and shame in relation to their parenting responsibilities (Leenman & Arblaster, They are afraid of being accused of not being a good parent, and then be the cause of the son or daughter’s mental health problems. (Skundberg-Kletthagen et al., Family members were described as experiencing shame, guilt and stigmatisation (Foster & Isobel, Practitioners navigated a plethora of emotions when delivering FFP and had to be attuned to their own emotional experiences and that of others which was described as a “balancing art” (Skundberg-Kletthagen et al., If funding went to a family rather than just the individual, that would be one of the biggest changes in the current system. (Pfeiffenberger et al., Conventionally, AMHS have adopted a “problem-focused” (Grant & Reupert, This theme brings together the potentially modifiable factors that could encourage adoption of and facilitate the delivery of FFP and foster a service ethos vested in FFP.This subtheme is characterised by the impact of guidance and regulatory frameworks on the delivery of FFP. Practitioners reflected that there was a lack of FFP guidance or an unawareness of guidance in countries where FFP was a part of service policy (Foster & Isobel, It was easier when the child’s perspective developers were here and you could receive guidance and raise questions, it was a natural source of help. Although I’m not completely alone now, there’s no one to seek guidance from, no one to lean on in difficult decisions. (Strand & Rudolffson, The subtheme captures the need for dedicated resources in order to effectively deliver FFP. Additional “concrete resources” (Grant & Reupert, The subtheme related to how the engagement approach that practitioners’ adopted impacted service-users’ and families’ responsiveness to FFP. Practitioners noted that seeing strengths and focusing on “potential and possibility” (Tchernegovski et al., This subtheme underscores the importance of staff teams working collaboratively to deliver FFP. Working together was seen to enhance FFP and facilitate “supportive and unified teams” (Leenman & Arblaster, The role of inter-agency working in order to deliver FFP and improve outcomes for service-users and families was highlighted in this subtheme. Practitioners identified a need for enhanced cooperation and collaboration with relevant external agencies to improve service integration (Grant & Reupert, This systematic literature review of 19 studies based on 17 samples provides a comprehensive synthesis of the experience of adult mental practitioners in delivering FFP. The aims of the review were fully met, and our findings resulted in the identification of key themes. Practitioners’ approach to FFP was reported to be “variable” and influenced by their beliefs in FFP, perceived FFP roles and responsibilities, competence in FFP delivery, service setting, and personal parenting status. Practitioners had to engage in a “balancing act” to navigate powerful emotions, maintain a “dual focus” on parents and children, whilst considering multiple perspectives in an organisational structure that advocates biomedical individualised treatment approaches. The studies helped to identify “what works” to enhance FFP. Although working together supported unified teams internally, a need for interagency collaboration development was identified. The use of strength-based approaches with clients and dedicated staff resource, within clear guidelines and frameworks, was necessary to maximise FFP delivery. Whilst corroborating and extending the findings of Gregg et al. , Shah-AnBeliefs about FFP and perceptions of roles and responsibilities influenced FFP delivery. This finding supports previous research findings (Gregg et al., The impact of practitioners’ perceived competence and confidence on the delivery of FFP has been consistently demonstrated in the previous research (Grant et al., Comparably to Gregg et al. , there dThis current review highlights the interrelationship of practitioners with other FFP stakeholders. Although there has been recognition for the significant role of the “dual focus” and “seeing double” (Allchin et al., This finding contradicts the linear proposition presented by Maybery and Reupert . The linSeveral facilitators of FFP were identified by practitioners. Whilst lack of resources was ubiquitous (Maybery & Reupert, Although the recommendations in this study are necessary and provide a starting point for FFP, they are not sufficient in isolation. In line with findings by Eassom et al.  and AllcGiven that the search was limited to studies written in English or German and those published in peer-reviewed journals, publication and language biases are acknowledged. The language selection was based on expertise within the research team and due to a lack of funding for translation services. However, the search did not identify any non-English papers. In addition, a variety of studies from different countries and cultures were identified and included, albeit largely countries from the anglosphere, which raises the question as to how FFP is interpreted and delivered cross-culturally (Sin et al., This review is the largest and most comprehensive review of the qualitative literature pertaining to adult mental health practitioners’ experiences of FFP to date. The findings provided an evidence-informed account of factors that influence their practice. We demonstrated that practitioners were involved in a complex and persistent navigation between FFP stakeholders in which required a ‘balancing act’ to achieve meaningful FFP outcomes. In the light of the findings, important considerations for service development are highlighted to improve implementation of FFP in AMHS to support practitioners in this “balancing act”. Key recommendations include the implementation of policy to set out roles and practitioners’ expectations of FFP, the provision of “real-world” FFP training, the development and protection of team-working forums, the provision of dedicated FFP staff and the development of interagency awareness and pathways for integrated care structures. Overall, a “whole-team”, “whole-service” approach to FFP is advocated by this review to signify that “family matters” and to lead to long-lasting changes for our service-users and their families.


In study 2, using a sample of individuals from 18 to 45 years old, two Exploratory Factor Analyses (EFA) were conducted separately for sexual minority (n = 167) and heterosexual persons (n = 198), and a Confirmatory Factor Analysis (CFA) was conducted for heterosexual persons (n = 176). Results showed underscored the importance of families of origin independent of sexual orientation. Different factorial structures for sexual minority and heterosexual persons were observed. Among sexual minority persons, the role of stigma was also highlighted. Implications for practice and research are discussed.The coparenting relationship begins with a process of planning and negotiation about having children. Available psychological instruments have not been adapted to sexual minority people, which compromises their ecological validity. This mixed method study aimed to adapt and validate a prospective version of the Co-Parenting Relationship Scale in a Portuguese sample of sexual minority and heterosexual adults who did not have children and who were in a dyadic relationship. In study 1, cognitive interviews were used to gather participants’ reflections about the original items and the role played by the family of origin and anticipated stigma in coparenting ( Coparenting concerns the act of both members of the couple sharing family management, division of domestic labor, agreement on child education, and mutual support on parenting ,2,3,4. HThe quality of the coparenting relationship is associated with marital adjustment  and chilThe coparenting relationship does not simply begin with the birth of children given that a process of planning and negotiation usually takes place before ,6. In faCoparenting  among seThe parenting experience, including the prospective one, which comprises the planning and negotiation about parenting and the way future parents think about their future coparenting relationship ,6, also Thus, the aim of this study was to validate an existing instrument measuring the prospective coparenting relationship ,12, withCoparenting relationships have been conceptualized in different ways . In FeinFeinberg  proposedSocial support is linked to the quality of the coparenting relationship both directly and indirectly in several ways ,15,30,31In addition, because families are embedded in social contexts, broader legal and cultural aspects also influence parenting. In the case of families headed by same-gender parents, the absence of legal recognition impacts both prospective ,22,23,35One of the most used multidimensional psychological instruments to assess the coparenting relationship is the Coparenting Relationship Scale (CRS) . This inIn the present study, we aimed to adapt and validate a prospective version of the Co-Parenting Relationship Scale , specifiThree scales assessing the perception of coparenting relationship were already adapted to Portuguese language: authored by Carvalho et al. , Lamela Our convenience sample was recruited from the personal network of the first author and through the snowball technique. To be congruent with the criteria used to answer the instrument, participants must be in a committed relationship without children. To assure face validity, we recruited participants diverse in sexual orientation, gender, educational level, and age. Participants were asked to inspect the adequacy of the items of the CRS-PV  with regSociodemographic Questionnaire. Participants were asked about their age, ethnicity, gender identity, gender expression, sexual identity, educational attainment, relationship status, type of geographic location, and employment status. Completion of this questionnaire took no longer than five minutes.The Coparenting Relationship Scale—Prenatal Version (CRS-PV) . This scCognitive Interviewing . The adeSexual minority people had a specific section of questions to be answered. First, they were asked if any questions raised difficulty for them in conjunction with their sexual orientation. Then, they were instructed “When we plan parenthood there are some challenges and questions that we anticipate and think about before achieving our parenting plans. Specifically, considering your sexual identity, what questions and challenges do you anticipate that might influence your coparenting relationship and that would not exist if you identified as heterosexual?”.This study was approved by the Ethic Committee of the host institution. Participants were asked to participate in an individual interview; three participants asked to be interviewed in a locality of their choosing and three were interviewed on the premises of the host institution. At the beginning of each interview, the researcher provided complete information about the study regarding all ethical issues, namely confidentiality, anonymity, the possibility to withdraw at any moment, and discussed how the data would be used. Subsequently, a written consent was read and signed by the participant, who also authorized the audio recording of the interview. There was no financial compensation for participation.At the beginning of the interview, all participants were asked to answer the sociodemographic questionnaire and then the CRS-PV . Then, cInterviews were first transcribed verbatim and checked for accuracy. To understand the participants’ reports, we decided to allow themes to emerge from the data. This procedure ensured the facial validity of the data ,27,45. AFollowed Braun and Clarke’s  six-stepAll participants suggested changes throughout the instrument, but no participants suggested the removal of any item. Globally, participants considered that many items were stated in a negative way and that this made their interpretation difficult. Furthermore, participants found it difficult to prospect some aspects of the coparenting relationship . Several suggestions were made on item content and changes were made throughout the instrument. First, one participant suggested an introductory item to inspect to what extent the participants desired to have children. However, this item was not added as this question was already part of the larger research protocol. Second, because the instrument raises different questions about conflicts, one participant suggested the introduction of daily scenarios to facilitate the items’ interpretation. In this regard, another participant considered that the couples’ communication about problems might be an important dimension to be included in this instrument. Furthermore, two participants considered that the first item of the scale (“I believe my partner will be a good parent”), should be changed to other position given its confrontational content; then, participants suggested that item 25 should be presented first (“Parenting will give us a focus for the future”). Thus, item 1 and item 25 were switched. Item 3 raised some doubts among the participants because of its length; authors rearranged this item as follows: “My partner will ask my opinion about parenting issues”. The language used on item 5 was also considered confusing, and the item was changed to “My partner will like to play with our child and then he/she will leave the dirty work to me.” Concerning item 18, one participant, who had the lowest educational level, did not understand how to “compete for the child’s attention” could be considered a negative aspect. So, authors further emphasized the negative content of the item and changed it to “When all three of us will be together, my partner sometimes will want all our child’s attention for him/herself.” Regarding item 26, three participants considered that jokes and sarcasm might be a positive personal strategy to deal with challenges. Thus, this item was changed to “Sometimes, I will find myself in a mildly tense or sarcastic interchange with my partner”. Item 28 used the term “discuss” which raised some questions among four participants who had considered that this was not necessarily negative. Considering this, the item was changed to “We will argue about our relationship or marital issues unrelated to our child, in the child’s presence”. Three participants considered that items 26 to 30 shared a negative approach that may influence the interpretation of participants once the items were presented together. To overcome this difficulty, the items were distributed along the instrument. Although two participants mentioned that the use of gender inclusive pronouns could complicate the reading level of the items, authors decided to maintain this in compliance with the suggestions of the 7th edition of the Publication Manual of the American Psychology Association  and the Thirty-four excerpts of the interviews were coded by the first author together with second and third author and with a master’s student. An inter-rater agreement of 94.12% was obtained. The coding process allowed the researchers to discuss, compare, and contrast their thematic coding, agreeing upon a final set of themes/categories . At the Socioeconomic Contexts. The first emergent category was the socioeconomic contexts. This category includes the economic variables that might be a barrier to achieve parenthood. The economic situation was referenced three times by two participants “For me, the major challenge is the economic situation […] and because of our economic situation, I have to work, my partner has to work, and we would need someone’s support” . Also, a heterosexual man raised this question: “We need somebody to help us monetarily” .Families of Origin. The second category, families of origin, encompassed two subcategories, namely, support, and (re)adjustment of family relations, both within the couple and with the respective families of origin. The subcategory support consisted in the valorization, anticipation, or desire to receive emotional support from both families of origin. This theme was mentioned seven times by four participants, who raised some important questions, “I can consider parenthood because my mother-in-law is available to take care of the child” ; “I have seen several persons postponing the decision of having children because they do not have enough social support” ; “There is a lot of things that I will always need: advice, tips, and having the family support is an added value” . The second subcategory, (re)adjustment of relations, was mentioned four times by two participants: “But if we had a child my relationship with my partner will need adjustment” ; “When you have a difficult relationship with your family of origin or with your partner’s family of origin, you fear to deal with them, because probably bring you with more contact with family, and not everyone is willing to do that” .Anticipation of Stigma Upon Sexual Minority Parenting. The third category, anticipation of stigma upon sexual minority parenting, includes five subcategories, namely, (i) internalization of stigma; (ii) dyadic problems; (iii) families of origin; (iv) legal structures; and (v) social challenges. The first subcategory, (i) internalization of stigma, concerns the process through which the person internalizes the stigma that they had suffered. This category was mentioned twice by one participant “As a gay couple, some situations might happen and I won’t feel so comfortable to handle them; and I can miss having a female partner in the relationship [to deflect attention]” ; “I already had relationships with persons who had not their sexual orientation well-established neither with themselves nor with the family” . The second subcategory, (ii) dyadic problems, considered the influence that stigma related to sexual minority parenting could have on the couple’s relationship. Dyadic problems were mentioned four times by two participants, “The prejudice and discrimination which will pour over the couple could, obviously, influence the dyadic relationship” , “It could wear out a relationship. It could cause a big distress. Either people get closer together at a difficult time and try to overcome it together or it can act to wear down the relationship a lot.” .The third subcategory, family of origin (iii), concerned all situations where families of origin were mentioned as sources of discrimination, which was mentioned ten times across all of the sexual minority identified participants: “I have heterosexual people in my family (…) and other family members are always asking them when a child will come, and for me, even though they know that I am in a relationship (…) that question is not mentioned” ; “A question like this [having children] countering that is difficult (…) it’s difficult to start on that point [having no family support upon parenthood], starting right there” ; “I imagine that my family would give us more support than my partner’s family and I need to be understanding about that” .The fourth subcategory, (iv) structural challenges concerning disparities in services and laws on parenting in terms of parents’ sexual orientation. Structural challenges were mentioned one five occasions by two participants: “Even when starting finding health professionals, finding people who we can talk to, without being afraid to talk about this… we never know how the doctor will answer” ; “The bureaucracy (…) I have the view that this is a more difficult pathway (…) from the initial information given about the process and throughout the process itself” . Lastly, the fifth subcategory referred to the (v) social stigma surrounding sexual minority parents and was mentioned twice by two participants: “As if it was a bigger expectation (…) due to the fact that I am homosexual and I do not have access to biological parenting, so I have to become an exemplary father” ; “All the comments we hear from people around, all their prejudices saying that is not the same thing (…) or that the children will learn a divergent sexuality.” .Scale Reconstruction. From out thematic analysis  above anThe subscale concerning the challenges faced by sexual minority persons is composed of 11 items, namely: (i) It will be difficult for my partner to speak out in public about our family”; (ii) “My partner will have difficulty coping with our child experiencing discrimination due to our sexual orientation”; (iii) “Having a child will make us more visible targets of prejudice”; (iv) “My partner will have doubts about how to be a parent because of our sexual orientation”; (v) “My partner will be less comfortable in raising our child because of not having a woman/man as a role model at home”; (vi) “It will be harder to become parents if our family does not support our sexual orientation”; (vii) After having a child, our family will support us as parents”; (viii) “Because our parents are not expecting us to have a child, they will provide us with less support”; (ix) “It will be easy to find a school which accepts all types of family”; (x) “It will be easy to find health professionals who do not discriminate LGBT families”; (xi) “It will be easy to teach our child how to deal with prejudice”.This study encompassed 535 participants using a non-probabilistic snowball sampling in a committed relationship aged between 18 and 45 years old. We considered the limit of 45 years as a useful threshold for parenthood in the Portuguese context because (i) the age limit for access to assisted reproduction techniques (ART) funded by the Portuguese National Health Service is 42 years old, with a legally established upper age limit of 50 years old; and (ii) in Portugal, people older than 45 years seldom present themselves as candidates to adopt . To condThe sexual minority sample encompassed in total 167 participants, whose age ranged from 18 to 45 years old . Regarding their sexual orientation, 40 participants identified as lesbian women, 50 as gay men, 63 as bisexual, 13 as pansexual and one as asexual. Concerning gender, 61.1% identified as women, 33.5% as men, and 5.4% as non-binary. Most participants (84.4%) lived in an urban area, 50.9% had a full-time job, and 71.9% had a university degree.n = 176) used in CFA ranged from 18 to 45 , and 72.2% lived in an urban area, 44.3% had a full-time job, 72.2% had university degree, and 88.6% identified themselves as cisgender women, and those remaining as cisgender men.The heterosexual sample used to perform a separate EFA was composed of 198 persons whose age ranged from 18 to 45 years old , and 65.6% lived in an urban area, 54.7% had a full-time job, 80.2% had university degree, 90.6% identified themselves as women, and those remaining as men. Lastly, the separate heterosexual sample  and was advertised on-line in websites, social media and LGBT+ organizations. The confidentiality of the collected dataset was ensured, with the survey link being accessed only via a secure university service. Completing the questionnaire took approximately than 15–20 min.Participants were asked to fill in the Coparenting Relationship Scale—Prenatal Version  with the2 (666) = 2798.6 p < 0.001). Then, considering the factor structure proposed by Pinto and colleagues [To assess the suitability of the sample data for EFA, the Kaiser-Meyer-Olkin (KMO) Measure of Sampling Adequacy , and Barlleagues , plus thlleagues .To assess the final structure of each factor, the component matrix with PCA was analyzed and items eliminated if they had either (i) lower loadings; (ii) a difference between factors lower than 0.100; (iii) or low contribution to factor . Considen = 4) and lack of coparenting support subscales (n = 1). Factor 3 was named Conflict regarding Families of Origin and comprised four items generated in Study 1, described in the present paper. Factor 4 included two items which belonged to the subscale lack of coparenting support in Pinto et al. [o et al. . Howevero et al. , these tn = 176 of the heterosexual participants in study 2, using the AMOS software, version 27. Multivariate outliers were sought using the Mahalanobis squared distance (D2) (p1 and p2 < 0.001) and the highest six outliers were eliminated [2 (201) = 281.5, p < 0.001; CFI = 0.940; RMSEA = 0.048; TLI = 0.931), with factor loadings ranging from 0.27 to 0.84. The final model of PCRS is represented in In a second stage of the analysis, the factorial validity of the structure yielded by the EFA was established through CFA with iminated . Six iteiminated . Lastly,iminated . Overall2 (1128) = 3695.1, p < 0.001). In this EFA, six factors were extracted: the five factors previously established in the heterosexual sample by EFA and CFA plus the specific dimension for sexual minority persons of anticipated stigma upon parenting generated in study 1. Principal Component Analysis (PCA) was used to determine factor extraction, analyzed by the Varimax rotation with Kaiser normalization. After conducting a PCA, the model with six factors explained 46.99% of total explained variance with all eigenvalues higher than 1 [Concerning the sexual minority subsample, neither the Coparenting Relationship Scale  nor the r than 1 .Concerning the analysis of communalities, five items were eliminated because of low communality values , namely:To assess the final structure of each factor, the component matrix using PCA was analyzed using the previously established criteria  and fiveAs can be observed on The aim of the present study was to refine the previous adaptation of Pinto and colleagues  of FeinbConcerning the heterosexual sample, the original subscale Undermining ,12 was dNevertheless, in our studies there were common points among sexual minority and heterosexual participants concerning prospective coparenting. It is interesting to note that coparenting support was the most important subscale for all participants, regardless of the individual’s sexual orientation, as the support dimension accounted for the highest portion of explained variance in both analyses. In fact, coparenting support promotes parental psychological well-being as the sexual minority participants in the qualitative component of the study noted, a strong dyadic relationship might be essential to overcome the difficulties inherent to the lack of family and social support ,3,9.Both heterosexual and sexual minority participants in our psychometric analyses of the CRS-PV highlighted the role of families of origin. In our qualitative thematic analysis of the interviews, the values associated with familism  were often mentioned ,24,25,29Both groups of participants had considered the negative interference of families of origin on their own dyadic relationship after parenthood, probably because each generation tend to construct their own parenting behaviors differently to at least some existent compared with their family of origin . This paThe importance of institutional support in prospective coparenting relationship emerged only among sexual minority participants. In fact, interactions with professionals in care settings and school environments have been identified as a common source of concern for prospective sexual minority parents ,70. In PSurprisingly, the dimension closeness did not form a coherent factor in the analysis of scores on the CRS-PV among sexual minority people, whereas it did coalesce into a factor when we consider the scores of heterosexual participants. For some sexual minority people, just becoming a parent is difficult, this might be a postponed life project for many same-gender couples . ConsequThe present study is a contribution to the validation of an instrument to assess prospective coparenting relationship, considering the sexual orientation of participants, and the relationship with families of origin. In spite of its pioneering contribution, some limitations of the present study should be addressed. First, considering that this is the first study exploring the prospective coparenting relationship among both heterosexual and sexual minority persons, larger samples will be needed to confirm the structure of CRS—PV. Given the low internal consistency of the dimension Disagreement among sexual minority people  this facThe results of the present study have highlighted the importance of considering the sexual orientation of participants when we are inspecting the prospective coparenting relationships. The different profile of prospective coparenting for sexual minority groups compared to their heterosexual peers in terms of the role of anticipated stigma has indicated the need to enhance resilience in the face of social prejudice against sexual minority parents. In this regard, therapists should consider the role of internalized discrimination  in cliniLastly, and considering the importance of sources of support in transition to parenthood among sexual minority persons ,21 studiThis section is not mandatory but may be added if there are patents resulting from the work reported in this manuscript.


Implementing practices adapted to patient health literacy (HL) is a promising avenue for improving their outcomes in the context of cardiovascular diseases (CVD). The health communication skills of healthcare professionals (HCPs) and the quality of information provided are essential for low-HL patients. We aimed to explore HCP knowledge about HL, patients’ and HCPs’ views on current practices regarding low-HL patients, and facilitators and barriers to adapting communication to patients’ HL level, in order to prepare the implementation of a complex intervention dedicated to improve CVD management for low-HL patients.We conducted face-to-face semi-structured interviews with HCPs practicing in cardiology units and patients hospitalized for CVD. The study design and analysis were based on the Theory of Planned Behavior for HCPs and on the framework of Health Literacy and Health Action for patients. Deductive and inductive thematic analysis were used. Barriers and facilitators were structured into an Ishikawa fishbone diagram and implementation strategies were selected to address resulting themes from the Expert Recommendations for Implementing Change (ERIC).Fifteen patients and 14 HCPs were interviewed. HCPs had partial knowledge of HL dimensions. Perceptions of HCPs and patients were not congruent regarding HCP-patient interactions and information provided by hospital and community HCPs. HCPs perceived they lacked validated tools and skills, and declared they adapted spontaneously their communication when interacting with low-HL patients. Patients expressed unmet needs regarding communication during hospital discharge and at return to home.To implement HL-tailored practices in this setting, our results suggest that several implementation strategies will be valuable at individual (engaging patients and their family), interactional (educating and training of HCPs about HL), and organizational levels (creating a multidisciplinary HCP interest group dedicated to HL).ClinicalTrials.gov, (NCT number) NCT03949309, May 10, 2019.The online version contains supplementary material available at 10.1186/s12913-022-08455-8. And these patients are among the people with low literacy skills.” WHP13Sometimes the patients’ ethnic background was considered by HCPs to be a proxy of their HL level."There is another population there... I'm going to talk about the Mediterranean people, Spain, Italy, and Portugal, but we also have a lot of North African patients who are alone here, and these North African patients have very big problems of understanding and putting into practice...." MHP1Patients’ limited communication skills and reluctant attitudes regarding patient-provider interactions were also associated with low HL level.“he doesn't communicate, he doesn't answer questions, or he may be aggressive and always in denial. [...] Some people don't want to talk. A low level of literacy?“WHP13HCPs also estimated the HL level of their patients according to their behaviors or attitudes.“It can be precisely in relation to a question that the person has already asked me 4 times, and to which I have already answered 4 times, so I say to myself that either the question is not the right one that he wants to ask me, or the answer is not the right one that he wants to hear.” WHP3Among HCPs, the level of knowledge about HL was heterogeneous, as 5/14 HCPs were not able to provide a definition of HL. Other HCPs gave partial definitions that suggested links to one or more of Nutbeam et al.’s  dimensioHCPs reported they dealt with low-HL patients by adapting their behaviors when recognizing difficulties in patients. Most interviewed HCPs (12/14) declared that they changed their behaviors when communicating with patients for whom the difficulties are apparent.They stated that they provided patients with simplified explanations, using layman’s language and/or illustrations.“Indeed, we’re going to use simpler terms it's obvious... and then uh... we're going to ... so I'm simplifying... [...] or I'm going to explain to them what this term means, in a visual way, I try to put into images what I’m explaining. I sometimes have, we have teaching aids, we have a little plastic heart.” WHP5They also mentioned the importance of time: taking the time to let the patient ask questions and above all, taking the time to re-explain.“Well, we take maybe more time with him [...] to explain things at greater length, maybe, repeat things to him because he hasn't understood everything.” WHP10In order to appraise the effects of their adjustment to low HL level, HCPs said they observed patients’ health behaviors over time. They got more confident in their effectiveness if they found that after their visit, patients took their treatment better or attended more regularly medical follow-up visits.“I think it's really from the beginning, the first time you take the patients in charge, that you have to get into that sphere, to measure their literacy, in order to really have an impact. Afterwards, if they don't hear it from the start, they will actually come back [to the hospital]... “ WHP13In-hospital HCPs also emphasized that their goal was that patients get enough information and understanding to ensure their safety and self-care once returned home.“what is important is that at the end of the hospital stay, the patient knows about the disease, the treatment, knows what to take, how to take it, how to adapt to the treatments” MHP1Despite the efforts described above by hospital HCPs to adapt their communication, patients reported hospital discharge as a challenging time. Some patients (4/15) said information was missing or that explanations about treatment were not sufficient.“I need someone to explain to me, to tell me, there you go, you've done that, the treatment corresponds to what you have, you are going to be fine. You don't just let people go out like that, without...” LWPA7They deplored having received information only from junior physicians, and 3/15 patients stated that they had not seen any senior physician to prepare their discharge. Conversely 2/15 said they received too much information or advice and they experienced it as a mental burden.“They put too much information in my head, you have to be rigorous, you have to take your treatment properly, you should absolutely not smoke, you shouldn’t use illicit products, drugs, all that, I don't use drugs. Be careful; eat a balanced diet, not too rich.”LMPA9Regarding information transmission between in-hospital and community doctors, most of the time, the information given to patients was consistent between hospital and general practitioners. However, 5/15 patients stated their general practitioner did not get information about their hospital stay from the hospital staff.“I went to see my general practitioner yesterday, he was not aware of it, he told me, I had no feedback about what happened to you. [...] I didn't get the scanner, the hospitalization; I got nothing, no information.” LWPA7In addition, relationships between patients and community HCPs did not always appear to be good and could constitute an additional barrier to the transmission of information.“She [the nurse] comes once a week. She measures my blood pressure. [...] They [nurse and GP] have no clue [about the HF follow up process]. My GP, it's the same thing. The first time, I went to see him about it, the second time, I said, it's not even worth it. He doesn't even seem to care at all. I thought they didn't know enough about it.” AMPA10Finally, some patients (4/15) expressed a need for more tailored information beyond the general information provided. For instance, they requested referral to other professionals depending on their needs, for follow-up by a psychologist, a tobacco specialist, or for obtaining daily help.“I would have liked to see someone who's accredited, a psychologist, so that I could talk about it, about what I've been through, what I've had. Well, no, I didn't receive any guidance.”LWPA7Adapting one’s behavior to patients experiencing comprehension difficulties requires adaptation and training. Even though most of the hospital HCPs interviewed were considering themselves as taking the necessary time to do so, we identified four types of barriers that may influence HL-tailored communication practices: beliefs of HCPs, the place of caregivers, inappropriate documentation, and organization .HCP individual belief about patients’ competencies were directly associated with a feeling of low self-efficacy:“There is also the investment of the person... The fact of thinking “well, I'll get “nothing more” [from this patient] anyway” WHP3We also identified challenges related to informal caregivers. Some patients’ relatives took an overwhelming place in the patient-provider relationship and communication, preventing the professional from communicating directly with the patient, especially in case patients did not speak French.“I don't like having to go through someone else, it's a third party, it's an intermediary and uh the biggest problem is that, from time to time, I know a little bit of the language, and well the interpreter will change what I said.” MHP2The available documentation that HCPs may use to support their statement or to convey information to patients did not always fit the needs of patients. It may be at the same time insufficient and too detailed.“(we need) simple things, otherwise they don't read long blocks, some read but others tell us frankly I didn't read, or else they prefer an explanation as well.” WHP4Some HCPs (8/14) pointed out a significant lack of time or a lack of staff at the hospital to properly inform and educate patients before discharge. They also pointed out challenges in care continuity with a lack of post-hospital follow-up and a lack of communication between the medico-social and hospital domains that act like silos.“I would need an outside network that provides us with what we don't know how to do in the hospital, which is to go into patients’ homes, which is to develop relationships with nurses in private practice, which is to have a coordinator in the network, or support platforms" WHP7These barriers were described differently depending on the profession of HCPs. Nurses put forward the lack of communication and the informal transfer of tasks from the physician to the nurse as challenging in daily practice.“nurses often find themselves in the situation where they have to rephrase the diagnosis [...] and then the patient bursts into tears because they knew how to say the words and the patient understood, and actually for the patient, it’s as if it was the first announcement, and then they’re in trouble because normally it's the physician who has to make the announcement.” WHP7A similar vision was shared by the assistant nurse who pointed out a lack of physician interaction.“Because often when we go behind them [doctors] they [patients] say “they gave me the prescription but I didn't understand anything” (laughs). I think they don’t bother the doctors because they think that the doctors don’t have time but we may have more time I think. They must think like that the patients. ( … ) Because often behind the nurse re-explains the treatments.” WHP10However, a supportive interaction was reported between different professions i.e. between residents and assistant nurses for communication with patients.“ they [assistant nurses] talk to each other to see how they can make things easier. I’ve had quite a few assistant nurses who have helped me explain to patients what their pathology is, what treatment we’re going to give them, and everything.” WHP11Other facilitators that HCPs reported were related to the patients’ side and how they are engaged in their care.“If the patient has, let’s say, understood, and finally he/she becomes an actor ... necessarily he/she will take better care of himself/herself but ... it's like for everything else, one must understand why do things … ” MHP8Facilitators could also relate to community care, which was considered as more individually adapted to patients’ needs. For instance, interviewees declared that home care nurses and community pharmacists might take more time with the patient, in particular to explain the prescriptions.“ … the second help that we will be able to have outside the hospital it will be the pharmacist, the one who will deliver the medicines to the patients who will show him the boxes, who will show him the tablets who will tell him how he must take them....”MHP1The main barriers to a satisfying hospital discharge for patients were the lack of follow-up and continuity of care at home. Some patients reported a need for support once they returned home (6/14), while others did not declare any specific needs or issues. However, problems related to information and communication were reported. Some patients found it difficult to ask questions to their physician because of fear of judgment, or fear of disturbing (7/14).“Sometimes, I don't tell all my problems. I don't dare.” LWPA13Patients also reported a lack of opportunity to clarify and deal with the information they received in depth.“I had a very important question to ask them, they inserted me a stent and I wanted to know if the rest of the arteries were damaged or not. That's something I don't know anything about. So I would have liked to know if the rest of the arteries were okay. If I've got one that's got a stent and I've got one next to it that's damaged, it would be nice to know.” LMPA2Patients reported the fact that nurses and assistant nurses were more present and engaging ininteractions than physicians during the hospitalization period. Patients were sometimes dissatisfied with not knowing the different roles and profession of the care team members.“When I was there, I saw mostly residents and people, and by the way I got angry because I didn't have any communication about what was going on ... I knew what I wanted to know when I saw the physician between two doors, he talked to me in the hallway.” AMPA6Thus, nurses and assistant nurses were a source of support for patients, in addition to informal caregivers  who were identified by patients as being their main social support.“At least I'm seeing someone, that's good. She measures my blood pressure, she weighs me...” AMPA6Contrary to the sometimes overwhelming presence of caregivers mentioned by HCPs, patients perceived them differently as very helpful. Patients used material support tools to improve their self-management capabilities, such as pillboxes to organize their treatments, and caregivers or community nurses often managed these for patients who needed it.“ They are the ones who manage the pillbox, they are the ones who manage everything”  Daughter of LWPA1The available discharge programs, although very scarce, were appreciated by the few interviewed patients who were included in such programs. For instance, “PRADO”  was reported to provide more regular follow-up and social support.Overall, the findings of the present study highlighted the gap between the perceptions of patients and HCPs regarding the adaptation of practices to the HL level at each step of the patient care pathway. This qualitative study provided insights into the perspectives of patients and HCPs regarding the barriers and facilitators to implement HL-tailored communication for the management of CVD. We proposed individual, interactional, and organizational strategies that may be effective in improving the uptake of evidence-based HL-tailored practices, and the access to care and health outcomes for low-HL patients Fig. . These ret al. [Even though HCPs expressed their intention to tailor their communication according to patient difficulties, the complete definition of HL was not clear to them, and they expressed a lack of tools  to identet al. . When thet al. . Still, et al. .et al. [Interactions between patients and HCPs constitute a challenging issue to overcome. Indeed, most HCPs rely on patient commitment to express their needs, while low-HL patients can either hide their misunderstanding behind the existing communication difficulties or fear the stigma attached to them . HCPs maet al.  that conet al. . The suret al. . Upgradiet al. , 10, 43.Moreover, both patients and HCPs pointed out a gap in the transition between hospital and community care. In community care, low-HL patients’ difficulties to communicate with HCPs may persist with their general practitioner (GP). Communication with the GP regarding hospital stay was occasionally reported as limited. This point has to be improved since the transmission of hospital stay information cannot only rely on patients’ ability to summarize their situation and represents an unnecessary responsibility for patients. A quality improvement study has demonstrated how educational sessions can improve discharge summaries and communication with primary care .et al. have showed a good coordination in the management of HF patients improved health outcomes [Regarding organizational challenges at the hospital, both patients and HCPs underlined staff shortages, which may limit interactions between senior physicians and patients. A lack of patient empathy and confidence towards residents in patient centered care and communication has also been reported . This iloutcomes .As hospital discharge constitutes such a defining step for patient care, in addition to the strategies discussed above, further solutions need to be implemented to establish a link between hospital and community care. Once again, on a relational level, other key players such as the pairing of the nurse/care assistant or the community pharmacist may contribute to a successful discharge . Additioeducating and training HCPs about HL is a prerequisite. Nowadays, in France, HL and its related issues are not part of neither the regular medical education curriculum nor continuous education. Teaching HL within medical education should ensure all HCPs share the same core knowledge on HL, better understand the challenges related to low HL level, and develop skills to identify and communicate with low-HL patients.Considering these results, we identified several implementation strategies that might drive the translation into practice of evidence-based HL-tailored communication strategies , improvecreating a multidisciplinary HCP interest group dedicated to HL might promote best practices for low-HL patients and induce peer-to-peer exchange at the organizational level [creating a HL improvement plan constituted of short and long-term goals for addressing HL challenges in the context of CVD care.Second, al level , 35. The, engaging patients and their family would also encourage HCPs to move evidence into practice [patient participation in the HL-interest group, patient involvement in designing the HL plan, and setting-up a systematic patient experience feedback process (patient experience survey for instance). This could enable HCPs to identify patients’ needs and priorities and confirm communication improvements and successes with low-HL patients [Thirdpractice , 35. Thipatients .inking patients to additional non-medical support, such as a community-based network or support by expert-patients may also help address patients’ issues during care transitions.Fourth, regarding the gap perceived by patients between hospital and ambulatory community setting, involving GPs and pharmacists alongside patients and families may help to design innovative solutions to share information, or introduce new professions such as coordinating nurse  or case Our study has some limitations. First, the interviewed patients were not followed directly by the HCPs interviewed, hence we cannot directly link the two perspectives. This may have hindered the possibility to explore whether individual strategies of HCPs were effective from their patients’ perspectives, and identify how HCPs directly adapt to specific patient situations. However, structural determinants, such as the location of the interview or the department from which the HCPs originated did not influenced the results. We may hypothesize that HCPs share the same education, training and sensitization to HL. Indeed, all interviewed patients were hospitalized in a unit where interviewed HCPs practiced, and all HCPs worked with patients with HF and MU, and were therefore able to answer our questions. This also allowed each of the participants to be neutral and free to answer as they wished. Moreover, interviewing HCPs and their patients to compare their views would have biased discourses towards an evaluation or satisfaction interview, and induce a social desirability bias. Second, for patients with communication or interactive HL difficulties, the expression of their issues may have been hindered by the fact that the interviews were not conducted in a neutral place but at the hospital. However, this risk was reduced by the attitude and profession of the interviewer (AP), who is not a HCP. The hospital where patients were recruited is a large hospital that covers a large population and geographical area, so it was not possible for us to go to the patients’ home, and a place different from the hospital while attending an encounter was not convenient for patients. However, patients were interviewed in the outpatient clinical and not in the inpatient ward; this may have reduced the psychological impact and the influence of the place where the interviews took place on patient discourse. Outpatient clinic is more neutral since the interviews targeted the hospital stay, hospital discharge, and return home.The HCPs interviewed were volunteers and made themselves available to participate in the study, which probably biased towards the inclusion of the participants who were more aware of the concept of HL and interested in the topic, especially since some were recruited through colleagues or superiors involved in health education approaches that were closely related to HL. However, for feasibility reasons, it was not possible to adopt other sampling strategies of recruitment, and circumventing the volunteer bias is very challenging especially for qualitative research. However, our results showed that, despite this potential bias, HCPs’ knowledge regarding HL remains partial, illustrating that it is essential to implement interventions to promote good communication practices.Finally, we are aware that the tool chosen to measure patient HL does not reflect all aspects of HL and remains a subjective tool. However, we needed this tool to be administered to all patients in the quantitative P-ILIADE study to categorize patients and identify the barriers specific to the patients presenting more difficulty in the present qualitative portion of the study.The exploration of the perceptions of HCPs and patients regarding their interactions at discharge showed both commonalities and differences regarding the care pathway. Our study provides useful information on which implementation techniques at individual (educating and training of HCPs about HL), interactional (patient participation in the HL interest group), and organizational level (creating a multidisciplinary HCP interest group dedicated to HL) can be built. These may be effective to improve communication with low-HL CVD patients in order to improve discharge planning. Involving hospital and community HCPs, patients, and family members within a co-construction strategy will be one of our future goals to operationalize our results in the development and implementation of the CVD management intervention regarding discharge.Additional file 1.


But he would have probably never imagined that we, who know him well, actually do spot the pink elephant in the classroom. It is the lecturer.Juanjo is the incarnation of an outlier, a personality that lies at an abnormal distance from other researchers in a random sample of academics in Spain, in Europe, and worldwide. It is difficult to summarize the merit and life of such an extraordinary scholar in a few paragraphs, so we hope he will forgive us if we fall short.Juanjo Dolado, JD, would have had the best initial conditions for becoming a disc jockey, all he had to have done was switch his initials to DJ. He started flirting with this idea early in life, but then tradition led him to study to the Universidad Complutense de Madrid, where he completed his B.A. in Economics in 1977 and in Mathematics in 1979.Madrid was great at the time, but could not be compared to London, which was really the place to be! The year 1979 marked the beginning of several trends in music. Electropop was one of them, quickly reaching the top of the British charts. It was time to move there. In 1978 Juanjo and his classmate Rafael Repullo were granted the Bank of Spain scholarship for graduate studies abroad and were admitted to the MSc in Econometrics and Mathematical Economics at the LSE. Two notable classmates in their cohort were John Moore (who did not know any economics and was not afraid of asking) and Dilip Mookherjee (who instead knew everything). The teachers in the program were also outstanding: George Akerlof, Partha Dasgupta, Amartya Sen, Douglas Gale, Chris Pissarides, Steve Nickell, David Hendry, Denis Sargan, and Ken Binmore, among others. But, at least in Juanjo’s mind, this was nothing compared to the number of concerts taking place in London and its surroundings at the time. Between September 1979 and June 1980, while in the first year of the program, Juanjo attended, according to his own recollection, 65 concerts, more than twice in a week. The list of rock stars was also impressive: The Clash, Sex Pistols, Police, Slits, Chic, Jab Jab, Elvis Costello, Richard Hell, John Cooper, UFO, Liar, Osmonds and Frank Zappa, among others.Rafa and Juanjo shared a room in a nice street in Chelsea, the best thing about it being that it was close to a good record store. On the way to the tube station, Juanjo bought a single almost every day, to break the monotony of the long hours of study. They also shared the record player: 1 h of classical music (Rafa) and 1 h of pop (Juanjo). As the English of both flat mates was not great, they gave some of the most remarkable seminar presentations in the history of the LSE. In a memorable one, Juanjo discussed the consequences of “changing tastes” , pronouncing ‘’tastes’’ as “testes” (meaning testicles in English). The Brits were polite, but the seminar stuck with them for a while.“Tainted Love”, by Soft Cell. The opening of the song describes very precisely Juanjo’s feelings during that period. “Sometimes I feel, I've got to run away, I've got to get away…” Contrary to Rafa, who stayed on for the PhD, Juanjo went back to Madrid to become an employee at the Bank of Spain, despite having admission and funding from the LSE.It was prophetic that one of the top hits of 1981 was During these golden years at the Bank, he was offered to give a number of lectures to executives, and this kept him entertained. 1983 was both a revelation and a decisive year in his life. While teaching an Econometrics course, he met Samuel Bentolila, who was finishing his undergraduate studies. Juanjo asked Samuel to send him his thesis, he read it right away and gave him comments the very next day. Samuel was amazed. They have been friends ever since. At the European meeting of the Econometric Society in Pisa, he met a couple of young academics, Olympia Bover and Manuel Arellano, another long-lasting pillar in Juanjo’s life.“The Hunter” on his desk, a concept album based on the theme of "searching, hunting, or pursuing one's own Mt. Everest." With this soundtrack, he identified young and beautiful Carmen Contreras as his Everest. She was brought to his apartment by one of his flat mates, who was also attending his course. Carmen was planning to informally attend the course as well and has been by his side ever since.1983 was ending and Juanjo kept a copy of Blondie’s How could Juanjo have escaped his deserved academic destiny in this network of young and promising Spanish academics? In 1985 both Olympia and Manuel took jobs at Oxford. The instigator of this move was Steve Nickell, Olympia's PhD advisor at the LSE and Manuel's mentor, who had also moved from LSE to Oxford the year prior. Juanjo and Carmen followed them that same year, and Juanjo started a PhD at Oxford with David F. Hendry and Steve Nickell as advisors.“Happy Mondays,” “Gang of Four”—or six, if one includes Anindya Banerjee and Antonio Villar, also PhD students at Oxford at the time—Oxford “Culture Clubs” and outings. Life was “Simply Red” and Juanjo had time to “Talk Talk” for the following 5 years. He built his econometrics and economics skills in the post-punk New Wave era. He had been extremely productive. Life at Oxford “Spined Him Round (Like a Record)" and, before he even realized it, he became a father: In December 1987, Laura Dolado Contreras was born at the John Radcliffe Hospital and spent the first moments of her life surrounded by millions of records, loose papers with mathematical proofs and the tender love of her parents. The thesis entitled "Modelling Employment, Inventories and Wages in U.K. Manufacturing Sector: A Cointegration Approach" was defended in 1988 and, after that, Juanjo became a lecturer at Oxford for two more years.From then on, there were only “Englishman in Madrid”.The UK chapter ended in 1990 when the Dolado-Contreras family moved back to Madrid. Juanjo came back to Spain, as an Another five years passed. By then, Juanjo had become a CEPR research fellow, a member of the Economic Policy Panel and Associate Editor of the Revista Española de Economía. He had published 25 academic articles in Spanish and 31 articles in English, together with a number of policy reports. During those years he published some of his most influential econometrics papers: "The Power of Cointegration Tests," (1992) with N.R. Ericsson and J.J.M. Kremers, “Co-integration, error correction, and the econometric analysis of non-stationary data,” (1993) with A. Banerjee, J.W. Galbraith, and D. Hendry, “Cointegration and unit roots,” (1990) with T. Jenkinson and S. Sosvilla, and “Making Wald tests work for cointegrated VAR systems,” (1996) with H. Lütkepohl.Jewel was singing at that time, "Foolish Games" were over and Juanjo was meant for UC3M.This academic success, however, failed to impress some of the Bank’s highly ranked staff. So Juanjo left the Bank for CEMFI with a leave of absence in 1996. This year was another benchmark year for many reasons: Most importantly Atletico Madrid finally won the League after a dry spell of 19 years. Secondly, Juanjo found at CEMFI a friendly environment, accompanied by his best friends Manuel, Samuel and Rafa. After two years there, Rafa made him an offer to stay permanently but fate had a different destiny for Juanjo. The offer from CEMFI never materialized. Instead, an offer from UC3M arrived, with Juan Urrutia pulling the strings; both CEMFI and the Bank lost out, Madrid’s Carlos III gaining an excellent academic in 1998. As While all these changes undoubtedly constituted a headache for Juanjo at the time, they were a stroke of luck for one of the authors here, who was looking for a thesis supervisor at the precise moment that Juanjo landed his new destination. She could not have wished for a better mentor. Juanjo’s arrival at Carlos III was also a breath of fresh air for everybody there. And Getafe’s atmosphere probably also inspired Juanjo, who remained faithful to his relentless productivity (41 research articles and 6 book contributions), besides being head of the Department of Economics (1998–2001), writing music reviews for Expansion y RockdeLux and recommending films and records left and right. He also began then his fruitful collaboration with Jesús Gonzalo and started a tradition: publishing in Econometrica shortly after joining that University . As was reflected in the panel discussion and in Juanjo’s speech during the conference organized in his honor, youth unemployment is a major challenge for the Spanish economy and more research and effort should be dedicated to address it. In this paper the authors estimate the effects for college-educated workers of entering the job market in a recession. In “The internship contracts in Spain: a stepping stone or a hurdle towards job stability?” Lucía Gorjón and Sara de la Rica evaluate the impact of the internship contract (IC), which was originally designed to promote an appropriate transition for young people with higher education from their formative years to their working lives. “Temping Fates in Spain: Hours and Employment during the ‘Great Recession’ and Covid-19” by Cristina Lafuente Martinez, Raul Santaeulalia-Llopis and Ludo Visschers studies the behavior of the number of hours worked in Spain in the most recent recessions while “So different yet so alike: micro and macro labour market outcomes in Germany and Spain”, by Maia Guell, Cristina Lafuente, Manuel Sanchez and Helene Turon documents differences in unstable labor market spells across these two countries. These last two papers are very closely related to Juanjo’s research agenda, see Dolado, García-Serrano and Jimeno (2002) and Booth et al.  knowledge of the intricacies of Atletico de Madrid was severely lacking. It was not easy for the faculty either. No one was used to daily visits to discuss the royal family gossip from “Hola” extracts, new movies being released, football scores or Champion League highlights. But above all no one was prepared to cope with the avalanche of CDs and the newcomer’s insistence of having them played immediately.A new chapter in Juanjo’s life started in January 2014 when he decided it was about time to get “From He-Cession to She-Stimulus? The Labor Market Impact of Fiscal Policy across Gender”, Alica Ida Bonk and Laure Simon analyze the differential effects of fiscal policy on female labor market outcomes. The authors find that the effects of fiscal policy shocks on labor market outcomes depend on the type of public expenditure. Many of the results of this research were discussed in the benches of “Mago Balducci” bar in the neighborhood of “Le Cure,” or in car drives from downtown Florence to Fiesole. Some of these rides were tough. Juanjo can get carried away when discussing economics and music. He pines for people to appreciate the songs he enjoys and so, while driving, he typically switches frantically from one CD to the next, playing half a song from each, making you wonder if you will survive the ride. Could this be the reason why “Automation and Sectoral Reallocation” of Dennis Hutschenreiter, Tommaso Santini and Eugenia Vella talks about automation? Regardless, we are all hopeful that AI will someday help Juanjo change the CDs in his car. Eugenia and her coauthors show that in theory the reduction in manufacturing employment can be offset by the increase in service employment and for that reason the industrial robot adoption might not affect aggregate employment as it happened in Germany. “Primary elections and electoral outcomes: Evidence from the Spanish Socialist Party” by Ricardo Ciacci, Jorge García Hombrados, Laura Gismera, Antonio Nuñez Partido is also related to Juanjo’s years in the EUI, the contributor Riccardo Ciacci being Juanjo’s PhD student in Florence. This paper studies the causal impact of holding primary elections on electoral outcomes.Juanjo soon realized that EUI’s treasure is its students, so they quickly became the recipients of his energy and enthusiasm. First the younger crowds in Villa San Paolo and, later, in Villa La Fonte. In this special issue we have three contributions of his students and disciples at the EUI. In “During his exile in Florence, the jury of the King Jaime I Prize for Economics decided to award the 2015 Prize to Juanjo, for his contributions in two different areas of economics. First, for his work on the methodology of cointegration and other techniques in Time Series econometrics. Second, for his contribution to the study of the labor market, particularly its duality and its effects on the dynamics of unemployment. This special issue reflects his influence in both fields.Dynamic factor models: Does the specification matter?”, Esther Ruiz, Pilar Poncela and Karen Miranda empirically analyze the behavior of alternative estimators of dynamic factor models (DFM) under various sources of misspecification. In particular, they focus on factor estimation and in-sample and out-of sample forecasting. “Moment tests of independent components”, by Enrique Sentana, Dante Amengual and Gabriele Fiorentini, focuses on the identification of shocks in structural VAR models. More specifically, it proposes specification tests that check the normality as well as potential cross-sectional dependence of the shocks.One of the areas in which Juanjo has made outstanding contributions recently is in the study of factor models , his birth town (Zaragoza) and the city where he did his PhD studies (Oxford). They conclude that although the three cities are experiencing warming, the patterns are quite different. Unfortunately, they don’t reach definitive conclusions on the impact of warming patterns on Juanjo’s personality, which hopefully will be clarified in future research.Something that we hope is clear by now is Juanjo’s out of the ordinary, if not to say extraordinary, character. In their article ““Econometrica” (Chen et al., “Rocketman.”In January 2019, the belltower of Puerta del Sol welcomed both the new year and Juanjo’s return to Madrid and Carlos III. Everything had changed yet remained the same in Getafe. A simple walk with Juanjo from one building to another would still take you about 30 min, since Juanjo talks to the gardener, the porter, the bar tender and some students on the way. And at lunch you’d be hopeful that it’s time to eat, but would lose him yet again to another table and then another one, busier than a groom at his own wedding. But endless corridor talks aside, despite his incessant musings on the latest music and Netflix series, one day Juanjo will skip into your office, happy as a child, telling you that his old tradition has been upheld, yet again—the tradition of, shortly after arriving at UC3M, he will be publishing a paper in And to finish as we started, we will go back to the initial quote. Juanjo resembles an elephant from another perspective: he has a prodigious memory. Apart from papers and their exact methodology and number and name of co-authors and journals and issues they have published in, he can remember completely random stuff, like the name of the boyfriend of a PhD student he met in Florence seven years ago, the name of the wife and kids of any bar tenders he’s been served by, the year someone got tenured, got promoted or her thesis title. His memory is amazing! So, we hope he will forgive us for leaving something out from this extensive report on his academic and personal life. Usually, the introductory comments of a volume are just a few paragraphs long. We went over this limit, as it was really tough to fit a “pink elephant” into such a small space.Great thrills are in store for us all,while the world is on such a slant,though he's a bit funkythe students love his trunk!He's a hit, he is exuberant,but they want to retire our elephant.If you should meet him, please give us a call.We do not want him to retire at all!You're bound to see himat the classroom or a record shop.Even though some people can't.Get used to believing in elephantsDo not call the guardHe's playing another cardHe bungled this seminar for sureHe blew it in styleBut he's just a child!And given the unusualness of our introductory comments, we would also like to finish in keeping by paraphrasing “It’s an elephant world”, by Bruce Cockburn:We love you, Juanjo.Laura and Evi and co.