Unprecedented in scale, immense COVID-19 immunization programs have been rolled out globally. This article explores aspects of hypothetical vaccine acceptability in Soweto, South Africa, shortly before such vaccines became available. Whereas hypothetical acceptance was normative, this has not translated into uptake today, which remains concerningly low in South Africa, especially in Soweto. For that reason, we mobilize anthropological concepts to analyze acceptance, hesitancy, and denial to gauge public proclivity to inoculate. We found that COVID-19′s haphazard mediatization generated a ‘field of suspicion’ towards authorities and vaccination, which, amplified by dis- and misinformation, fostered othering, hesitancy, and denialism considerably. Further, we demonstrate that stated intent to immunize cannot be used to predict outcome. It remains paramount during vaccination rollouts to unveil and address aspects detrimental to vaccine confidence and selectivity, especially in lower-income groups for underlying context-specific cultural, spiritual, historical, and socioeconomic reasons. Appropriate mediazation alongside a debunking of counterfactual claims is crucial in driving forward immunization. Coronavirus Disease 2019 (COVID-19) is a Severe Acute Respiratory Syndrome (SARS), which has so far claimed more than six million lives worldwide (July 2022). Since its initial discovery in China in December 2019, it spread across the globe causing grinding lockdowns and economic disruption exacerbated by war in Europe and climate change  how conspiracy theories come into play” . In shorInitially, we should establish that deep inequalities in South African society offer differential access to communication technologies—smartphones, data affordability, et cetera—which may make vertical information dissemination particularly challenging in townships like Soweto. Briggs  posits tIt then becomes imperative to ask “how access to production and reception of authoritative knowledge about disease is distributed” . IdeallyThis morphed into an emergence of what Fairhead et al. called a ‘field of suspicion’ (or of ‘uncertainty’) . EssentiThe uncertainty regarding specific origins [of COVID-19], successful cures, prevention measures, and risk for transmission expressed within the scientific community is exacerbated in the public mind by conflicting messages from different health authorities. .In summary, the multidirectional mediatization of COVID-19 produced a field of suspicion in the community—as we learned from our interactions with Sowetans—in which almost half of our informants were swayed from acceptance into hesitancy or denialism.By now, we have a clearer picture of the main reasons for acceptance: safety and survival, the desire to return to ‘normal life’, and the notion of not having to wear a mask, which, at the time, was a novel nuisance. Finally, solidarity and the belief that a vaccine might aid other people is a contributing factor alongside hearing from confidants whose opinions are trusted—or who have lost a loved one to COVID-19.Vaccine hesitancy is the inability to decide whether to immunize. It is a wavering indecisiveness during which individuals attempt to make sense of conflicting arguments for and against in an ambit of incertitude and angst circulated by peers and through media channels and platforms. Hesitancy stems chiefly from conversations with friends, family members, colleagues, and inputs from COVID-19′s contradictory and haphazard mediatization despite the  availability of vaccination services. Furthermore, individuals may come to believe in counter factual claims or be (understandably) confounded by them. They may also simply lack knowledge about what vaccines are or how they work—causing this wavering within a now amplified field of suspicion .We found concerning levels of vaccine hesitancy (or indecisiveness) among low-income earners in Soweto. This hesitation was swayed by several intertwined, local factors ranging from doubt in vaccine efficacy to cultural and spiritual praxis. About one in every ten of our informants were hesitant, stating that more adequate information to validate the efficacy of the vaccine would increase their likelihood of accepting it. Others thought it prudent to wait and see what results it might produce in others and insisted on certain safety measures before agreeing to immunize.I can take it after some time when I have seen how it works. I won’t be part of the first people to get it.Likewise, in a study on acceptability and willingness to pay for hypothetical Ebola immunization in Nigeria, most of those hesitating affirmed that they would only accept a vaccine after observing its outcomes in others . MeanwhiThese things (vaccines) aren’t one hundred percent right. These people are playing with our lives, they should take a donkey or a cow and test it first.There are clear misunderstandings here and a lack of elementary comprehension of how clinical trials are orchestrated. Similarly, some participants laid out the conditions under which they would vaccinate against COVID-19 as “testing positive for it first” and so apparently did not grasp even the basics of immunization. Some stated that they would only “take the vaccine” were they to be encouraged to do so by a superior at work. One aging man believed that inoculation would be a “blood transfusion” and suggested diabolical influences:It also depends on how it’s done, because if it’s a blood transfusion, that’s bad. […] This thing is demonic [COVID-19].Vaccinologists have suggested that misinformation regarding vaccines, and poor knowledge of them, may induce anxiety and perceived (fields of) uncertainty, resulting in an overestimation of potential side effects . Again, sangomas  and have an arduous history of exclusion and marginalization brought down upon them by their own state?Qiao and colleagues proposed that to reduce concerns about the safety of COVID-19 vaccines, evidence-based health communication “should address misinformation about vaccines  and deliver vaccine knowledge using population-appropriate languages” . In SoweBack in 2020, a global survey of COVID-19 acceptability demonstrated that levels of vaccine hesitancy globally were high and probably rising . Today, According to Lazarus et al., the speed by which misinformation spreads through multiple channels has a detrimental effect on acceptancy worldwide. Several participants aired counterfactual claims and elaborated endlessly on  conspiracy theories to justify resistance towards immunization .They put laptop [chips] in the body.We will be getting shots and be controlled by 5G [5th generation mobile network].Social media informs decisions. Due to COVID-19′s mediatization, some Sowetans hesitated or denied inoculation, they said, because of unfounded and undocumented rumors that people who had volunteered for vaccine trails had subsequently passed away. On another occasion, a “doctor” was rumored to be offering money to subjects willing to “participate in tests”. These and similar accounts are indicative of an evolving perception of the virus and vaccination that reflects the deep unreliability of developing narratives and discourses across different media platforms.This is especially true of social media gossip and surely worsened by a paucity of critical thinking and conflicting messages from authorities, which brings on hesitation and creates doubt that was long ago “shown as a logical response to informational discrepancies […].” . Doubt, This ‘will to truth’ then seeks its ‘alternative knowledge’ and finds it in counterfactual claims and conspiracy theories, which have abounded throughout the pandemic and still do. Conspiracy theories have certain common denominators, namely that they always imply nefarious intent, that ‘something must be wrong’, and that nothing occurs by accident. Furthermore, they can be self-contradictory and entirely override suspicion in themselves in that they are immune to any form of evidence and inherently ‘self-sealing’. Meanwhile, conspiracy theorists perceive and present as victims of organized persecution, and, at the same time, “see themselves as brave antagonists taking on the villainous conspirators.” .COVID-19 ‘escaped’ from a Chinese laboratory, the 5G network is causing it, Bill Gates was scapegoated, it was created as a biological weapon, the US military deliberately imported it into China, and, somehow, genetically modified crops caused COVID-19, while the virus does not actually exist, and the pandemic is manipulated by a ‘deep state’, because COVID-19 is a plot brought on by ‘Big Pharma’, and its deaths rates are purposely inflated.In this light, it is perhaps not entirely incomprehensible that ordinary men and women might lose themselves in this maddening maze of disinformation and choose to defer their decision to immunize in an uncomfortable ambit of nagging doubt and incertitude.In a similar vein, a workman in dungarees related another incident in which individuals or institutions entrusted with the provision of face masks to protect the public had in fact infected these same masks with Coronavirus deliberately.They already gave us these masks that got us infected and now they want to finish us? No!Key here is the word ‘they’ (as opposed to an ‘us’), which is indicative of a social mechanism anthropologists have referred to as (transformative) ‘othering’ ,33. In pCould it be that perhaps it was biological nature? Perhaps, but communities, it seems, must have their culprits and scapegoats; never us, always them, the mekwerekwere, the foreigner, the other. According to Onoma, “the scapegoating of certain populations during disease outbreaks is very common [and] outbursts usually target noncitizens, foreigners, and those generally cast as ‘other’” . In shorWhile informants highlighted risks related to the uncertainty of novel vaccine trials, one grandmother pointed out that monetary compensation offered to clinical trial volunteers was not worth the risk. Another concurred.The testing is starting out [trials]. So, when they test you, what if you die? Our system can’t handle it [immunization]. It would’ve been better if we were used to it [vaccine trials], but now it will be difficult unless people get millions for it. We are scared of death.There are people now who have funding in Soweto to test vaccines and those vaccines are going to make people sick. How sure will we be that the vaccine is here and that it is the right one? If you’re not, then you have to withdraw from participating [in trials].Out in the vast, sprawling townships, people oftentimes questioned conditionalities of immunization and thus demonstrated hesitancy and perceived incertitude. A filling station attendant gave it some thought and then proposed that:I would be happy if a vaccine were available, but with what conditions will it come? Is it for free or do we have to pay for it? There’s no way they can say that it’s for free because there’re many of us, and if they say we must pay, how much will it be, and who can afford it, because obviously, if it’s pricy, then it’ll only be available for rich people.Questioning the integrity of the information that informants had so far received about inoculation, the intentions of stakeholders advocating vaccination came under suspicion. A car washer swiped her long, braided hair and asked:Why do they want to try the vaccine when people are recovering already?Another informant doubted the reliability of the vaccine seeing as how it was being sourced from foreign countries.Why should we believe a vaccine that’s mixed [manufactured] outside our country?Such statements illustrate profound suspicion of the trustworthiness of foreign institutions  as well as any local entities carrying out their interventions. Again, there is ‘othering’. Again, we see poor knowledge, mistrust, uncertainty, and doubt engendered by and further engendering misinformation, menacing rumors, and counterfactual claims in a downward spiraling self-perpetuating circle of half-truths and debilitating distortion.Vaccine hesitancy has been defined in public health literature as caused by a combination of beliefs, attitudes, and behaviors in laypeople in relation to immunization. The choice between vaccine acceptance and denialism is determined by individuals’ perceptions, preferences, and motivations as well as a polydemic’s prevalence in society.Vaccine hesitancy is an attribute ascribed to a large and heterogeneous category that regroups people who share varying degrees and motives of indecision and who hold an intermediate position along a continuum, ranging from full support for vaccination to strong opposition to any vaccine .In what constitutes the perceptual pluraversality of COVID-19, cultural backgrounds, beliefs, and attitudes do influence laypeople’s decision whether to ‘vax’ or not, and, in turn, “vaccine perceptions are shaped by complex socio-political and historical factors” . As suchIn Soweto and Thembelihle, it soon came clear that more adequate information is required to curb hesitancy and denial. This includes information about vaccine safety, effectiveness, and trial processes as well as appropriate language to communicate with specific groups, such as the elderly, parents, or youths. In summary, the following fueled hesitancy in particular: a low visibility of successful outcomes of inoculation, mistrust in the (ill) intentions of government authorities, suspicion of vaccines manufactured abroad (by ‘others’), doubt in safety measures and the trustworthiness of entities developing vaccines, a lack of transparency and adequate information, anxiety induced by (dis)information circulating in media, especially social media, and doubt in the actual severity of COVID-19 infection (or its origins for that matter): the polydemic’s perceptual pandemonium.Vaccine denialists, including COVID-19 conspiracy theorists—or in more militant jargon: ‘anti-vaxxers’—reject immunization even when available and despite its benefits clearly outweighing its miniscule risks . DenialiPeople from Braamfischer chased us out when we went there. They thought we were going to inject them with the vaccine until we explained to them what we’re about.One gentleman shared with us his lack of confidence in the vaccine, indicating a strong inclination towards alternative protective measures:No, I was not going to take it, as I did not even test for COVID-19, but I do take prevention methods all the time. I believe more in the African way of doing things.Phrases such as ‘the African way of doing things’, and many similar ones recorded in Soweto and Thembelihle, were oftentimes used interchangeably with notions of traditional medicine, usually in the form of herbs or ancestral worship. One elderly man bemoaned government’s disregard for non-conventional medicinal solutions while others denied inoculation unequivocally:Our government would rather have these vaccines tested on us rather than rely on our natural herbs, so you can see that our government is really turning its back on us.I would never take it!I would never [vaccinate]!That first statement brightly elucidates some of the cornerstones of denialism, namely, suspiciousness of government’s benign intentions, belief in traditional phytomedicines , and mistrust in authorities blended in with a foreboding sense of abandonment: “our government is really turning its back on us”. If one so feels and thinks, is it any wonder that one then vehemently shuns and denies immunization? In a study from Vietnam, reasons for vaccine denialism were reported as doubts and concerns about the efficacy and safety of the vaccine, rather than believing it to be unnecessary, or simply not having time to go for it . This waAlthough over 90 percent of the respondents stated that they would accept the COVID-19 vaccine when available, almost 50 percent of these people wanted to delay the vaccination until it was confirmed safe. People were unlikely to accept the COVID-19 vaccine [because of concerns over] risks, safety, and side effects of vaccination. One study reported that over 95 percent of the respondents had concerns about the efficacy, effectiveness, and safety of the COVID-19 vaccine .Many informants signaled that they were not willing to immunize, because the community did not believe that it would be beneficial. In addition, impoverished people are obviously less likely to inoculate if this implies financial expenditures—and it does because of transport costs and time spent away from income generating activities. Just as with hesitancy, vaccine denial is pluraversal and comprised of compounded factors. Based on the statements presented above, it comes to light that multiple approaches are required to address multiple aspects of acceptability. Vaccine denialists (and hesitators) also seemed concerned about the negative impact immunization might have on human bodies in terms of side effects and suspected, but undocumented long-term consequences: “you can turn into a monkey”, said one girl. Such sentiments are clearly detrimental to vaccine acceptability and these concerns may become particularly salient when a vaccine is new and rapidly developed ,39.In summary, vaccine denialism is fostered most prominently by financial costs, uneven access, lack of confidence in successful outcomes, faith in traditional phytomedicine, lack of reassuring information, vaccine-skepticism stemming from trusted companions and confounding mediatization, alongside whispers of counterfactual claims and conspiratorial schemes.Despite relatively high hypothetical vaccination acceptance in the communities, uptake can be much improved—although intent may be present, more often than not, it does not translate into action. In other words, stated intention to immunize does not predict outcome. We saw 55 percent of our informants  accept inoculation putatively, whereas in Soweto today, only around 20 percent have finished their immunization, suggesting that little less than two thirds of those who said they would immunize did not. Initially, information about how vaccines were developed and tested, including their safety and efficacy, could have been communicated in a sounder fashion. Instead, contradictory messages and counterfactual claims abounded in COVID-19′s mediatization. This, in tandem with widespread absence of even basic notions, comprehension, and knowledge about how vaccine trials and inoculation function, further amplified a field of suspicion towards the virus, immunization, and health authorities. Add to this the (much abbreviated) list of COVID-19 conspiracy theories presented in the above, and the uncomfortable doubt and increasing uncertainty become more understandable. Added to this confusion is an inherent human fear of death in a population that oftentimes prefers traditional African remedies over modern biomedicine. Throw into this blend an under-capacitated government marred by corruption, which has given its people little reason to trust it, while on the contrary, historically, it has given them plenty of reason not to. Lastly, an ensuing scapegoating and othering fueled anxiety and created false binaries, in which, at times, only the ‘others’ were vulnerable to the virus, not ‘us’. Though perhaps inadvertently, ultimately, the compounded effects of the above can be seen almost as promotors of hesitancy and denialism. The field of suspicion in Soweto and Thembelihle was repeatedly amplified to the extent that it eventually swayed the vast majority away from acceptance and into denial. Mistrust in government’s authority and healthcare institutions—alongside the influence of ‘anti-vax’ movements and conspiracy theories propagated on social media—can transform cautious wavering into resolute denial. This then further compromises government’s ability to impart knowledge, build trust, and implement policy. Attention must be given to these phenomena to inform future vaccination programs. Media platforms could be utilized in this process by addressing public concern in a constructive and culturally appropriate manner, particularly in areas where misinformation is rampant. More social behavioral research should be undertaken in different population groups to understand culture-specific issues essential to boosting acceptancy. It is paramount for uptake to comprehend and mitigate social and behavioral circumstances that may impact detrimentally on aspects of acceptability.


Recognized as complex and relational, researchers endorse a systems/social-ecological framework in examining bullying and cyberbullying. According to this framework, bullying and cyberbullying are examined across the nested social contexts in which youth live—encompassing individual features; relationships including family, peers, and educators; and ecological conditions such as digital technology. Qualitative inquiry of bullying and cyberbullying provides a research methodology capable of bringing to the fore salient discourses such as dominant social norms and otherwise invisible nuances such as motivations and dilemmas, which might not be accessed through quantitative studies. Through use of a longitudinal and multi-perspective mixed methods study, the purpose of the current paper is to demonstrate the ways qualitative interviews contextualize quantitative findings and to present novel discussion of how qualitative interviews explain and enrich the quantitative findings. The following thematic areas emerged and are discussed: augmenting quantitative findings through qualitative interviews, contextualizing new or rapidly evolving areas of research, capturing nuances and complexity of perspectives, and providing moments for self-reflection and opportunities for learning. Bullying and cyberbullying are increasingly recognized as complex phenomena that are considered relationship problems  explore youth experiences and perspectives and their parents’ and teachers’ conceptions of cyberbullying; (2) explore how youth and adults view the underlying motivations for cyberbullying; (3) document the prevalence rates of cyberbullying victimization, witnessing, and perpetration; (4) identify risk and protective factors for cyberbullying involvement; and (5) explore social, mental health, and health consequences of cyberbullying among children and youth aged 9 to 18  over 3 years.In addressing the objectives, we use an explanatory sequential mixed methods design , 7th (n = 243), and 10th (n = 267) grades; (2) their teachers (n = 103); and (3) their parents (n = 246). A stratified random sampling strategy was utilized to select participants. First, a random sample of 19 schools was drawn from one of the largest school boards in North America. Schools were stratified into three categories of need  based on an index developed by the school board that ranked schools on external challenges to student achievement  students in 4th . All three participant groups completed quantitative questionnaire packages, and a sub-sample of each group participated in individual interviews. Quantitative data were collected from students and parents in each year of the study, while qualitative data were collected during years 1 and 3, to allow for enough time to elapse for changes in perceptions of cyberbullying to emerge.In year 1, students completed a 45–60-min quantitative questionnaire package in the school setting, while parents completed a questionnaire package by mail. Questionnaires for teachers, which took approximately 45–60 min to complete, were administered in the participating schools. This study utilized several quantitative measures, including standardized measures and measures developed specifically for the study. Student, parent, and teacher surveys obtained information related to experiences with bullying/cyberbullying . Items for each outcome scale  were summed to calculate total or subscale scores for each measure.The quantitative findings in the larger study , 7th grade (n = 21), and 10th grade (n = 16) in the qualitative sub-sample were purposively selected for interviews from the larger quantitative sample, based on gender, grade, school need level, and whether they reported bullying/cyberbullying victimization, perpetration, or witnessing. After selecting student participants, their teachers (n = 30) and parents (n = 50) were invited to participate in interviews. Interviews lasted approximately 1 h, ranging in length from 30 to 90 min. All year 1 interviews  took place in the school setting and utilized a semi-structured interview guide. Following preliminary analysis, this interview guide was refined for use in the year 3 follow-up phone interviews with the students and parents. Areas explored with students comprised understanding of cyberbullying and how it compares with traditional bullying, experiences of online aggression, and others’ attitudes and responses. Questions were informed by existing literature and the research team’s considerable experience. Parent and teacher interviews included questions on their awareness and understanding of cyberbullying, their child or student’s involvement in cyberbullying, links between cyber and traditional bullying, support, and their responses to cyberbullying.Student participants in 4th grade  that makes visible the connections across ecological systems levels.In discussing how qualitative research contributes to understanding bullying and cyberbullying and complements quantitative findings, the following new thematic areas are discussed: augmenting quantitative findings through qualitative interviews, contextualizing new or rapidly evolving areas of research, capturing nuances and complexity of perspectives, and providing moments for self-reflection and opportunities for learning.By examining process, context, and meaning for participants, qualitative methodology can augment quantitative findings. Quantitative methodology establishes outcomes and causal relationships and puts forth generalization and predictions Yilmaz, . Our bacIn our paper, “Benchmarks and bellwethers in cyberbullying: The relational process of telling”While cyberbullying is no longer considered a new phenomenon, the rapid development of technology is continually altering the cyber landscape, creating a need for perpetual knowledge generation . In the quantitative questionnaires, we included one question related to sexting for students in grades 7 and 10 and their parents and teachers. Our quantitative survey found that 15.6% of students in grades 7 and 10 had seen nude or sexual photos of friends, family, boyfriend, girlfriend, or other romantic partner online or over a cell phone. Furthermore, 27.8% of teachers had witnessed or were aware of their students viewing sexually explicit images, video, or text on cell phones at school. The data indicated that digital sending and receiving of sexually explicit images, video, or text was a new phenomenon among youth participants in grades 7 and 10 in a rapidly changing digital environment.We did not explicitly inquire about sexting in the interviews with students, parents, and teachers. Rather, we asked participants about the students’ negative experiences with cyber technology. During analysis of the interview data, however, sexting emerged as a new and pertinent phenomenon among youth, which generated knowledge about rapidly evolving cyber dynamics that warranted further attention and inspired a paper entitled, “Gendered and sexualized bullying and cyberbullying: Spotlighting girls and making boys invisible” (Mishna et al., Bullying and cyberbullying are exceedingly complex and must be studied within the contexts of the involved youth as well as within the larger social context of youth (Cross et al., Qualitative interview data allow for an interpretive approach that draws upon patterns of understanding, similarity, and contradiction, thereby teasing out underlying assumptions that shape how people define and assess experiences and phenomena such as bullying and cyberbullying (Mishna et al., Qualitative interviewing provides an opportunity for participants to express their views and ideas when discussing the topic of interest which can elicit novel conclusions and nuances. As an example, at times, youth who claimed not to have involvement with cyberbullying may go on to describe situations that actually seemed to fit the definition of cyberbullying. In our Spotlighting Girls paper, many participant reports aligned with stereotypes regarding differences in how boys and girls bully others. These stereotypes were shared, however, even when they contradicted participants’ own experiences. For instance, similar to other research findings (Eriksen & Lyng, The critical role of witnessing in bullying and cyberbullying is well documented (Salmivalli, Qualitative methodologies are recognized as providing participants opportunities to self-reflect in the context of being listened to empathically (Birch & Miller, Recognizing the potential risks in research with children and youth (Mishna et al., Corresponding with previous research, the reflexivity of sharing their narratives and views seemed to contribute to some participants coming to a different understanding of their experiences. Such reflection was evident in our interviews with students and their parents and teachers. When asked whether he had witnessed cyberbullying, for example, a boy reflected that only in being asked about cyberbullying in the interview did he recognize the behavior as cyberbullying: “When I think about it now, I actually did a few times. I didn’t feel that it’s cyber bullying, I wasn’t thinking that it’s a huge deal. It’s basically a few arguments between people on Facebook, like writing things about each other in public, not in private, chats.”In another example, a parent reconsidered her views during the interview. This parent first commented that girls and women are “more vindictive” than boys and men, who, she explained, have “your spat, you get over it, and you move on.” After reflecting on her assumptions, she wondered how much of this widely held view of the behavior “is just media driven because I guess the victims that we see on the news, at least in Canada, have been girls, right?… but that doesn’t say that boys aren’t also being bullied.” Similarly, a girl contemplated her assumptions after first casting boys in a favorable light in contrast to girls. In commenting that girls bully each other because of appearance, she praised boys, “because usually they don’t tend to worry about those things...They’re proud of themselves, and they don’t pick on other people. They’re good with what they have.” After pondering these stated differences between boys and girls, this girl surmised, “I think it’s from when we were little because those Barbie dolls are super skinny. We wanted to have blonde hair, blue eyes, and be like Barbie. I think it’s just how maybe we were raised.” Another girl, who asserted that while cyberbullying occurred with equal frequency among boys and girls, added that it was not “a big thing” for boys, in contrast to girls who, “would show it off more, be like oh yah, blah, blah, blah.” Rather than concluding that this difference indicated that cyberbullying was not a big deal for boys, however, this girl attributed the difference between boys and girls to dominant masculinity norms. She asserted that “guys kind of hide it in more” and explained that “they don’t want to show that they’re weak because guys tend to be, they think that they’re very strong, kind of thing.” The evolving perspectives throughout this and the previous exchanges demonstrate the process of deepened understanding that can occur because of qualitative interviewing.think of different ways that I could help someone else if I see it happening… Just talking about it makes you think about what could cause it, what could make someone bully someone else. It makes you realize how it could make someone feel. Also, talking about how there isn’t really a support system at school. It makes me want to go and talk to someone to organize it, because it does happen a lot and I know it affects a lot of peopleSuch new understanding can inspire a desire to act and make change through community engagement. A girl explained that the research was the first time she had spoken with anyone about cyberbullying. This girl’s appraisal of her participation is consistent with findings in which participants may be motivated to take part in research for the opportunity to effect and advocate for change and help others (Cutcliffe & Ramcharan, The inclusion of qualitative interviews in mixed methods research brings forth new information about content, process, and meaning that is otherwise not visible. By engaging youth voices as well as adult perspectives through both quantitative measures and qualitative interviews in the mixed methods study discussed in this manuscript, entitled Motivations for Cyberbullying, understanding of bullying and cyberbullying was advanced, thus enriching the quantitative methodology. The findings of the interviews extended knowledge related to bullying and cyberbullying in the following ways, which can inform “bottom-up research and intervention efforts” (Dennehy et al., Qualitative research constitutes a significant venue through which to amplify the voices of children and youth (Dennehy et al., According to the United Nations Convention on the Rights of the Child (Assembly UG,


The analogy of the leaky pipeline has been used to describe STEM education, with lower student diversity from compulsory to post-compulsory education and beyond. Although extensive research has explored the views and experiences of school-aged children about STEM, fewer studies have examined the career intentions of STEM students at university, especially those from under-represented backgrounds . This paper draws on a large qualitative study that interviewed 110 under-represented STEM undergraduates in the UK. We focus on students’ STEM career intentions and the likely directions of their post-degree trajectories, drawing on the lenses of science identity and Social Cognitive Career Theory.drive into an STEM future. The second group stated intentions for non-STEM-related careers, leaving the STEM pipeline. The reasons students gave for their imminent departure from STEM are the better financial reward on offer in some non-STEM sectors, especially in finance and business, as well as wider social inequalities and stereotypes. The third group was undecided, those who are uncertain or unclear about their futures. Students described a general lack of direction or clear career pathway, from a complete lack of career ideas to an overload of options.Three pathways were identified. The first group plans to pursue a career in or from STEM. While social inequalities may persist, the potential impact of these challenges may be neutralised by the personal drive and passion of STEM career-oriented students, who seem committed to forced off the road by social inequalities and exclusions.We conclude with a reminder that the STEM pipeline is far from secured or equitable, despite apparent progress in participation and representation. We reiterate the importance of fostering a diverse, inclusive and supportive learning environment that maximises the participation, strengths and potential of all students, especially those from under-represented backgrounds. While it is not uncommon for STEM students to pursue careers outside of STEM, we need to be wary that those who exit the STEM pipeline are not The online version contains supplementary material available at 10.1186/s40594-022-00366-8. In many countries around the world, there is growing recognition that the participation and attainment of students in Science, Technology, Engineering and Mathematics (STEM) is unequal, including in higher education  . To begin, we sought permission from selected staff who teach undergraduate STEM modules to relay our recruitment message to their students. Interested students then signed up through a short survey, where students submitted their contact and background information, including details of their under-representation in STEM. Students were then contacted to book an online interview.Data collection was conducted between summer and autumn of 2020 and involved semi-structured interviews with 110 STEM undergraduate students. Due to the coronavirus pandemic social distancing restrictions, all interviews were carried out online. Each interview began with a video introduction from the researchers to provide an overview of the project and the interview process. For better quality, all cameras were switched off during the recorded phase of the main interview. After the recording, the researchers restarted the video to formally conclude the interview and thank the participants for their involvement. The average time for each interview was 50 min. All interviews were audio recorded, transcribed verbatim and data anonymised for publication.Students were asked to discuss their views and experiences of their STEM education, including their choice of study, sense of belonging and identity at university, perceptions of the typical student in their discipline, post-degree plans, as well as how being an under-represented STEM student may have shaped their experiences .Each interview transcript was analysed in drive into an STEM future to those who believe they have reached the end of the STEM road, as well as those who are at a crossroads in STEM. We include the raw student numbers and their percentages for contextual purpose, but our focus is on the qualitative data. A range of demographic backgrounds are represented in each pathway .Below, we discuss the career intentions of our under-represented STEM students in three pathways, from those who expect to Around two-fifths  of students in our study had clear intentions to continue with STEM careers. They studied a range of STEM degrees, including the applied sciences (9/12), the biological sciences (18/37), engineering (1/16), mathematics (2/10), medicine (8/9) and the physical sciences (7/26).n = 1), the biological sciences (n = 8) and the physical sciences (n = 3). These students said they had already thought about doctoral research as part of their plans to continue with a postgraduate degree. While half of them (6/12) also mentioned an alternative career plan, such as in commercial research and development, the other half were convinced that their future was in STEM academia. For instance, Odessa (White British middle class woman), a biology student, said:I really want to become an academic researcher. Working in someone’s lab and then potentially, hopefully, one day, running my own lab. That’s my goal… I want to be a scientist. Even when I was quite young, that was what I wanted to do. Doing my course has made me realise that.Just over a quarter (12/45) of students with an STEM career intention plan to work in academia, while the rest (33/45) indicated that their primary aspiration is to enter the STEM workforce in the discipline of their study. The 12 aspiring future academics study the applied sciences  spoke of their lifetime passion in nature and the environment:Perhaps a surprise, only one of our engineering students, Deku , stated a career intention to work in engineering, but even he expressed uncertainty about this pathway, because ‘a lot of my friends and a lot of my seniors… tend to associate [engineering]… with things like consultancy or finance [careers]’. This apparent deviation is revisited in the discussion. Similarly, only a few mathematics and physical sciences students wanted to work in STEM, with careers in data science or analysis the popular choices.I think the issue of race, whether it’s consciously or subconsciously, I think there will always be barriers there. But I don’t let those define me, in the sense that I think I know how to navigate those things. Maybe, I think there will be barriers there and I will encounter them as I come across, but I just try not to let them hinder my choices.For STEM-career-oriented students, their intentions to pursue a career in STEM were rarely in question because of their interest in the discipline and commitment to achieve their dreams. Their science identities appear strong, even though for some this also required a level of resilience and self-confidence to counter negative remarks by others, particularly related to their under-represented identities  appears already prepared that her background may put her at a disadvantage in her aspirations to be an academic. Yet, she was adamant that ‘it will completely not stop me from getting where I need to be… [even if it] might take me longer’. As Lakshani explains, ‘I’ve always associated research with biology. That was kind of the first thing that came into my mind before I even did the degree’. While social inequalities persist and were highlighted by some STEM-career-oriented students, this does not seem to drive them off the road. As Lent et al.  argue inAlmost one in four  students in our study stated no aspirations to pursue a career in or from STEM, thus exiting the STEM pipeline. These students study mathematics (6/10), engineering (6/16), the biological sciences (8/37) and the physical sciences (7/26). No students from medicine or the applied sciences stated their intentions to leave STEM. The most popular intended career pathway, mentioned by half of the students who planned to leave STEM , was to work in finance, while the others expressed interest in consultancy work, the creative industries, the education sector, general office work, and entrepreneurship.I have been considering finance because… [these] are big money careers… I’m trying to get a summer internship for next year in finance… I don’t really know much about the nature of the profession… it was mainly to do with the fact that it’s a good-paying job… it might as well be what’s most beneficial to me.The main reason students gave for their imminent departure from STEM was the better financial reward that is on offer in some non-STEM sectors, especially in finance and business  explained that a high-paying job will enable her to be financially independent, ‘essentially, right now my goal is to be independent. And so, I need to earn enough money to be able to detach from my family and be able to provide for myself’. Elif explained that while she is still passionate about STEM, she must be realistic and pragmatic about her future, especially with regards to financial security, which appears easier to achieve in the world of finance when compared to the field of STEM. If the STEM pipeline is to be secured for all students, regardless of class and personal/family finances, clearer pathways are needed into secure well-paid employment, for example, through paid internship opportunities and graduate schemes, as is prevalent in finance and business. Such schemes help to manage students’ outcome expectations of different pathways, a key feature of SCCT approaches to analysing STEM career decisions. Perhaps such schemes could be considered in more STEM professions, whether facilitated by universities, government or STEM employers themselves to help provide clearer pathways to secure, well-paid employment in STEM.Aside from higher economic returns, the conclusion of the STEM pathway also reflects a saturation or re-evaluation of their earlier interest. It is not unusual for career aspirations to evolve over time, even during undergraduate study, as students develop and enrich their experiences. Some students said they were inspired and intrigued by their work experiences outside of STEM, which prompted a gradual shift in interest about their future. A handful of students confessed their loss of love and passion in their STEM degree, but felt it was too late to change or disengage from their current study. Beatrice (Black British woman), for example, admitted her struggle to maintain motivation in her study of biology, because she realised her interest is now in psychology. She plans to undertake a psychology-related Masters, but this required, ‘getting through the [undergraduate] degree and then not looking back’. While students generally agreed that their departments are supportive of careers in academia, with lab experience and internships on offer, there were fewer opportunities and support from staff related to career opportunities outside of their discipline, especially those unrelated to STEM. Physics student Greg (White British working class man) said that the opportunities provided by his department were narrow, often focused on becoming a physicist. Greg’s career aspirations were broad, currently in the business sector, perhaps as an entrepreneur. He felt there was a lack of career advice for people like him, because tutors were more invested and adept in supporting aspiring academics. As such, Greg felt departmental support for students with non-physics-related career intentions was limited, a view which we revisit in the discussion.I had friends but I was alone… I spent a lot of lunch times sitting by myself … A lot of people found friends quickly, and I didn’t know why I didn’t find friends that quickly … maybe it was the added pressure of being the only black girl ... I felt like people didn’t know how to approach me.As mentioned earlier and in existing literature  of our STEM undergraduates were unsure about their future pathways. Many are still exploring or have multiple ideas about their future, including careers in, from, and outside of STEM. Students from all disciplines are represented, including engineering (9/16), physical sciences (12/26), the biological sciences (11/37), mathematics (3/10), the applied sciences (3/12) and medicine (1/9). It is not unusual for students to enrol in higher education with limited ideas about their future. Undergraduate study often provides students with the time to experience and develop their interests. However, students who expressed career uncertainties existed across all undergraduate levels, from first to final year.Students who are at an STEM career crossroads described a general lack of direction or clear career pathway, from a complete lack of career ideas to an overload of options. For instance, biology student Heather (British East Asian working class woman) said she has ‘looked at a couple of career options… [but] not sure what exactly I want to get into’. She explored ‘going into sort of technology and that industry in terms of software engineering’, but also ‘professional finance sector… like auditing, insurance and things like that’. She was also keen on ‘different areas of consulting’, as well as ‘NHS [National Health Service] scientist training programme’ and ‘being a patent attorney’. In short, she and others like her have interest in a wide range of careers but are undecided about any particular pathway.Coming from the background I come from, I’ve not really been exposed to a lot of people who work in degree environments… but I don’t really know what people with degrees do all the time.On the other end of the spectrum, John (White British working class man) said his reason for studying mathematics was purely ‘out of interest’, despite his lack of awareness about ‘where that leads as a career’. He recognised that:John’s educational pathway in mathematics was interest-driven and supported by his family and school, who seem to adhere to the discourse of mathematics as a ‘good’ study option, even though John himself remains uncertain about his career pathway. At the time of the interview he had just been accepted onto a Masters in statistics, ‘with a view to hopefully being inspired towards a specific career’. He hoped ‘the extra year at university’ would allow him to ‘ask all the questions that I want to ask, to find out what I could do beyond sort of general careers skills, sort of now take an opportunity to speak to people’. For working class students, such as John, their engagement with STEM, including plans for postgraduate study, may be borne out of uncertainty and a lack of understanding about their future options. For John, further study means he can buy time and institutional support to build and strengthen his knowledge about possible career pathways.I just hear so many stories about how difficult it is to get jobs in research now. I’m going to do a Masters somewhere else and specialise in something else that’s a lot more applied… that’s a lot more specific to getting a job, basically. And then go from there.Even amongst students with greater clarity about their career intentions, especially in STEM, we found expressions of uncertainties relating to self-identity. For example, physics student Diana (White British working class woman) aspired to continue doing STEM research but was stifled by her lack of self-confidence. She said, ‘I’m not especially talented… the theoretical side of physics is not really my skillset’, even though she recognised her own disciplinary competence. However, the idea of a research career seemed less attractive when she considered the limited opportunities in research:Similarly, biology student Katherine (British mixed heritage middle class woman) thought about an academic career in STEM but remained unconvinced as to whether it was the pathway for her. She shared her concerns that academics seem ‘very intense… they don’t really have a work life balance from what I can see’, citing an example of seeing her lecturer ‘leaving his lab at like 7 pm on a Sunday’. She saw academics as ‘people who are willing to devote a lot of time and effort and energy into their research… devote your life to it and work really long, hard hours’, a pathway which Katherine admits is becoming less attractive. Here, students may feel conflicted between their personal interest in STEM, especially in an academic career, and the reality and nature of the profession, which are less appealing in terms of work-life balance and financial remuneration, when compared to some non-STEM careers.I didn’t have the best experiences with doctors, and they all happened to be male… I feel like the way they speak to me might be more of the like, speaking down to someone rather than speaking to someone… I felt quite bullied in that sense [and] it’s clouding my judgement [about] the whole medical profession.As the only medical student who expressed uncertainty about her future, Hafsa (British South Asian middle class woman) was initially hopeful and optimistic about being a doctor and ‘saving lives’. However, she was hesitant about a future in the medical field due to her negative experiences with some doctors. As Hafsa reflected:Hafsa’s experiences of gender inequality challenged her sense of identity and belonging in medicine. In particular, her experiences on work placements, which are central in medical training, raised doubts about her future as a doctor: ‘I was really struggling to see if I would fit in there if I would enjoy my time there’. As Hafsa has already completed 5 years of her medical degree, she decided to ‘give myself a couple of years in the NHS before I rule it out’, highlighting her uncertain future in STEM due to experiences of discrimination, despite her passion and interest in healthcare.As can be seen, a degree in STEM, even medicine, does not guarantee a career in the discipline, even if students are interested and skilled. As science identity theory highlights, the importance of external factors, especially negative experiences and structural inequalities, can act as barriers to sufficient recognition by others. Such experiences can also damage their outcome expectations, a crucial part of future career planning as discussed in SCCT, which can challenge their career intentions in the short or medium-term.This paper investigated the career intentions of under-represented students in STEM higher education. We identified three pathways, namely, driving into an STEM future, the end of the STEM road and a crossroads in STEM, to highlight the fragility of the STEM pipeline during the transition from undergraduate study to further study or work. In this section, we discuss the implications of our findings, revisiting the lenses of science identity and Social Cognitive Career Theory (SCCT).For students who are committed to continuing their journey in STEM beyond undergraduate study, their aspirations are fuelled by interest in the discipline alongside a high degree of self-efficacy and relatively positive future outcome expectations  or less rewarding economically . STEM careers in academia or research are perceived as less desirable because of their apparent heavy workload, limited career opportunities, and lack of work–life balance, especially in the initial phase.SCCT suggests that appetite for STEM jobs is low, because the STEM field is seen as excessively competitive, with limited opportunities and economic rewards, weakening students’ outcome expectations and interest. For these undergraduates, STEM careers are ‘not for me’ and their identity in STEM would appear more pragmatic and extrinsic Wong, . Their eFrom a policy perspective, the enrolment of under-represented students in STEM degrees is a success, but their career intentions away from STEM merit further attention. On the one hand, the exchange value of STEM degrees is being realised, which would strengthen the discourse around STEM qualification as highly valuable in a wide range of careers. On the other hand, the departure of STEM graduates from STEM jobs, when governments and industries have concerns about shortage in STEM-skilled professionals EMSI, , might aThe third pathway we identified was the undecided, or those who were at a crossroads in their STEM future. Over one in three STEM undergraduates in our study were uncertain about their careers and these students included different disciplines and levels of study. Again, it is common for students to be open and flexible about their future, as higher education allows students time to develop their career intentions. However, if we wish to support students’ post-degree pathways, we need to facilitate and support their decision-making process. Given the rising importance of ‘graduate outcomes’—a metric that rates UK universities by undergraduate employability 18 months after degree completion—there is a growing emphasis on universities expanding the career support for their students Hewitt, . Yet, ouFrom a strategic perspective, our undecided students would constitute a ready-made pool of potential STEM professionals who are trained with valuable STEM knowledge and skills. Their undecidedness can also be seen as an opportunity for different stakeholders in STEM to respond with targeted efforts and diverse opportunities for STEM undergraduates to reinvigorate their career aspirations in or from STEM. Much like the breadth of initiatives that aim to promote STEM as a viable study option beyond compulsory education (especially for under-represented students, such as girls, see Prieto-Rodriguez et al., We are reminded that the STEM pipeline is far from secured or equitable. We conclude by reiterating the importance of fostering a diverse, inclusive and supportive learning environment that maximises the participation, strengths and potential of all students, especially those from under-represented backgrounds. Our data and the broader literature highlight that intersecting inequalities in STEM and society more generally can have a significant impact on students’ science identities and decisions around future career pathways. However, intersecting inequalities and under-representation are not deterministic; some students manage to persist down the STEM road and we can learn from the factors which facilitate their journeys. General efforts to address inequalities in STEM and society can disrupt barriers to STEM entry and ongoing participation. However, more tailored careers support and STEM identity development are also important, particularly external recognition of students’ STEM identities from academic staff, peers and potential STEM employers. The fostering of strong science identity throughout students’ STEM journeys can help to ensure robust disciplinary identities to withstand different barriers and setbacks.forced off the road by social inequalities and exclusions or unsupportive transition from graduation to graduate employment.Finally, the enthusiasm for non-STEM graduate schemes and other secure, well-paid graduate jobs should act as an encouragement for STEM employers to provide more supported routes into STEM employment, and for universities to provide clearer advice on how to navigate more complex and non-linear STEM career pathways to help manage students’ outcome expectations when unsure STEM futures discourage otherwise qualified and passionate STEM graduates. While we acknowledge that it is common for STEM students to pursue careers outside of STEM, and this is the right decision for some students, we must be wary that those who exit the STEM pipeline are not Additional file 1. Interview Questions.


Conceptual Metaphor has been a prevalent theme in the linguistic field for the recent twenty years. Numerous scholars worldwide have shown interest in it and published many academic papers from various stances on this topic. However, so far, there have been few rigorous scientific mapping investigations. With the help of bibliometric analysis tool, we selected 1,257 articles on Conceptual Metaphors published from 2002 to 2022, as collected in the Web of Sciences Core Collection database, from unique cognitive perspectives. The global annual scientific output of Conceptual Metaphor, including the cited articles, sources, keywords, and research trends, will be examined in this study. The most notable findings of this study are the following. First, there has been an upward trend in Conceptual Metaphor research over the last two decades. Second, the five most prominent research groups on Conceptual Metaphors are in Spain, the United States of America, China, Great Britain, and Russia. Third, future research on Conceptual Metaphors may focus on corpus linguistics, neurolinguistics, psychology, and critical discourse analysis. The interdisciplinary study may enhance the growth of Conceptual Metaphors. There is an enormous amount of literature in numerous research areas in the times of big data e.g., . Much reThis study is a valuable resource for academics and researchers working in the CM field. Beginners interested in CM can be offered the information required to start their research. Experienced CM researchers can familiarize themselves with the advances in the field and promote collaboration and networking between institutions and authors.1. It is a unique tool using the R programming language for statistical computation and graphics following a logical bibliometric process. The bibliometric tool is controlled by Bibliometrix and its web-based graphical interface based on Web of Science (WoS), Scopus, and Dimensions data  refers to comprehending one thought or abstract concept in terms of another. Since 1980, theoretical clarification of CM has been the topic of extensive studies and lengthy introductions by many researchers e.g., . They sh JOURNEY , p. 45, Undeniably, the growth of academic papers on CM has contributed to the advancement of CM research. Numerous scholars have conducted a significant amount of research into CM from various perspectives, such as psycholinguistic metaphor research ; deliberHowever, researchers need help to pinpoint the research status and anticipate research trends rapidly and correctly. Keeping up with articles published instantly also becomes increasingly challenging. By using a bibliometric analysis, this knowledge map will be an invaluable resource for beginning researchers to learn more about information and study results to start their investigation as soon as possible. Additionally, this study will identify future research gaps and find potential cooperators for seasoned scholars. In addition, this study will provide some rating agencies with a trustworthy benchmark to assess the effectiveness of authors, institutions’ sources, and nations in CM research. Nevertheless, there has not been a thorough visual of CM studies so far. The bibliometric analysis of Bib text provides extra data statistics, including author, affiliation, and keyword . TherefoWith the bibliometric tool, this study aims to provide an overall picture of CM research over the recent two decades and address the following three questions:(1)What was the basic information about the development of international CM research in the past two decades?(2)What is the present situation, including yearly scientific advancements, subject orientations, most renowned authors, and the most pressing issues in CM research?(3)What predictions may be made regarding its future development based on a bibliometric study?2.All the data in this study were obtained from WoS Core Collection. It is the platform’s flagship resource, covering over 21,000 peer-reviewed, high-grade scientific articles , more than 205,000 conference proceedings, and more than 104,000 editorially selected bookIt offers more reliable journal coverage of scholarly published articles  than anyThis study discerningly chose the WoS that confined the data from 2002 to 2022. The literature data gained comprised the whole archives, such as the author’s name, source year, abstract, keywords, citation frequency, DOI number, and references in the article. Data collection consisted of three stages. The first was data reclamation. We prudently chose the papers and early access collected in the arts and humanities citation index (AHCI) and the SSCI to evaluate research questioning. We scrutinized the principal articles consistent with the research topic. The second step was data scrubbing. We sifted papers discreetly to avert data duplication. In the third step, documents were downloaded and compacted. We downloaded 1,000 files the first time and 257 the second time. Subsequently, the two files were compacted using bibliometric instruments. Currently, diverse instruments are accessible to present visual studies, such as CitNetExplorer, CiteSpace, and VOSviewer. This study selected a Biblioshiny program to obtain an overall visual picture of CM study in the past two decades because it has unique features. The set menu in Biblioshiny presents analysis from source, author, and document dimensions. Additionally, this menu offers conceptual, intellectual, and social knowledge structures. Maps can be exported to HTML or Pajek, tables can be copied to the clipboard or saved as Excel or PDF files, and maps can be printed. We analyzed the data using the Rstudio software and the bibliometric R-package version 4.2.0. The bibliometric analysis was first enabled in the R environment using the following command code:install. Packages library (bibliometrix)biblioshinyThe Biblioshiny web interface was presented once the Google Chrome browser started with the above code. Raw WoS data were imported and analyzed using the Biblioshiny. We then went on to describe and evaluate the critical results of the study, which were shown with the statistics and pictures. This study employed pertinent authors, institutions, countries, articles, top highly cited publications, keyword co-occurrence, word clouds, thematic maps, trend topics, and conceptual framework to answer the above three research questions of the study.Gender, Ideology, and Conceptual Metaphors: Women and the Source Domain of the Hunt   . NotablyMetaphor Interpretation as Embodied Simulation , which aids in sketching a conceptual structure of the area and locating groupings of texts that express similar concepts. Using MCA, one may do a mathematical and graphical analysis of seemingly multivariate data . Figure Co-occurrence network development relies heavily on correlation inference. The co-occurrence network has several study and application disciplines, and each color refers to a field. Language is a cognitive tool and a product of human intellect. With the rise of multidisciplinary study, cognitive explanations for grammar creation, semantics, discourse, and metaphor have become widespread, founded on empiricism and cognitive science research. It attempts to explain that language phenomena conform to the human understanding of the brain and thinking, i.e., human language is the product of the human brain, and its construction principle is identical to that of other cognitive domains. Therefore, The co-occurrence of keywords analysis is a valuable method for constructing a comprehensive framework for comprehending the significant areas of CM study during the past two decades. In the same way, In conclusion, several terms were used in the investigation of CM. The terms “metaphor,” “language,” “comprehension,” and “English” featured prominently and were among the most often co-occurring in the text. This demonstrated that these issues were central to the CM study. Words like “brain,” “discourse,” and “deficits” also occurred together at the network’s edges, which demonstrated that a wider variety of issues were investigated in CM studies. Despite these variations, it is safe to say that “metaphor,” “language,” and “comprehension” were essential and fundamental study issues, while “knowledge,” “mind,” and “discourse” had an impact on the development of CM and were also widely studied.The bibliometric tool of Thematic Evolution and Thematic Trends is employed to predict the directions of potential future CM studies.Examining Thematic Evolution and Trend Topics may reveal interesting research subjects and possible future orientations. However, throughout 2017–2022, “language” became the primary area of research interest, shifting attention away from “context” and other growing topics like “mind,” “comprehension,” “metaphor,” “discourse,” and “corpus” of CM. Some scholars conducted research into combining critical discourse analysis with self-constructed corpora of diverse genres to determine the underlying ideology metaphor . Some acDragon Seed and pointed out CMT and CBT were concerned with interpreting higher-order concepts such as meaning, language, sign, and representation and their interrelations. They complemented each other and contributed to discourse analysis. CM in literary works might be related to the writer’s cognitive and social contexts. Pearl Buck’s metaphorical thinking was closely related to her experiences in China. It may be extrapolated that these themes have a significant potential for CM research to continue to flourish.Regarding discourse analysis, several efforts emphasized CM used in literary discourse . Using tThis study employed a bibliometric technique to investigate 1,257 papers on CM research over the past two decades. The following are significant findings with productivity, content, and citation analysis. First, CM is a cognitive concept and has a widespread academic interest. “Metaphors,” “place,” “discourse,” and “corpus” were the central issues among the various study subjects. “Conceptual integration,” “comprehension,” “language,” and “mind” are also active and popular study topics in CM research. Second, in the past two decades, CM has been a research focus that has included many aspects, including authors, institutions, countries, and sources. Most of the cooperation survey was done with writers and institutions from many nations. The top five countries are Spain, the United States of America, China, Great Britain, and Russia. A rise in the number of academics studying CM suggests that CM research in cognitive linguistics applies to several facets of human cognition. Great Britain and China contributed the most to the growth of CM research, and substantial cooperation and networks were developed among them. These components of CM research are intertwined since the most cited individual contributes to establishing nations, institutions, and papers that significantly impact CM research.Third, based on an examination of the Thematic Evolution and Trend Topic, we can infer the essential themes in CM research, such as “metaphors,” “discourse,” “space,” and “corpus,” may get greater attention in the future, which aligns with the Thematic Evolution between 2017 and 2022. In addition, “simile,” “adults,” “cancer,” “metaphors,” “words,” “brain,” “corpus,” “perception,” “conceptual integration,” “mind,” and “comprehension” will remain popular themes. The “interdisciplinarity” of CM demonstrates the effect of cognitive context, social context, and other cultural aspects on the framework of CM. The growing number of papers using bibliometric analysis across all disciplines suggests that it meets the desire of researchers who want proper research based on a wealth of literature.This study will be helpful for beginners in the CM field, allowing them to classify information and find research results of CM quickly so that they may start their research projects. In addition, it may serve as a reference for seasoned researchers to comprehend the progress of CM research over the last two decades, find a suitable collaborator for their present research, and identify research gaps that they may block up in the future.This study emphasizes the presentation of images and statistics because it is a quantitative study using a bibliometric tool based on data gathered from a database. However, it needs to go more in-depth to complete an evaluation of any specific theme of CM. We urge future research to broaden the study to use a range of more data gathering to examine concerns in CM to create a more thorough comprehension of CM.The original contributions presented in this study are included in this article/supplementary material, further inquiries can be directed to the corresponding author.XZ initiated the research idea, instructed YZ to analyze the data using bibliometric software, and co-wrote the article. Under the direction of XZ, YZ gathered and extracted the data and co-wrote the article’s analysis. XCZ contributed to the manuscript’s design, drafting the first part, introduction. All authors participated in revising and approving the version that was submitted.


However, in practice they may give rise to significant moral problems for health professionals, patients and next of kin. Here, patient values must be considered. It is relevant to study the moral views and intuitions of the general population on NTDs and special areas of contention such as the role of next of kin in decision-making.Decisions about appropriate treatment at the end of life are common in modern healthcare. Non-treatment decisions (NTDs), comprising both Electronic survey to members of a nationally representative panel of Norwegian adults. Respondents were presented with vignettes describing patients with disorders of consciousness, dementia, and cancer where patient preferences varied. Respondents answered ten questions about the acceptability of non-treatment decision making and the role of next of kin.We received 1035 complete responses (response rate 40.7%). A large majority, 88%, supported the right of competent patients to refuse treatment in general. When an NTD was in line with the patient’s previously expressed preferences, more respondents tended to find NTDs acceptable. More respondents would accept NTDs for themselves than for the vignette patients. In a scenario with an incompetent patient, clear majorities wanted the views of next of kin to be given some but not decisive weight, and more weight if concordant with the patient’s wishes. There were, however, large variations in the respondents’ views.This survey of a representative sample of the Norwegian adult population indicates that attitudes to NTDs are often in line with national laws and guidelines. However, the high variance among the respondents and relatively large weight given to next of kin’s views, indicate a need for appropriate dialogue among all stakeholders to prevent conflicts and extra burdens. Furthermore, the emphasis given to previously expressed opinions indicates that advance care planning may increase the legitimacy of NTDs and prevent challenging decision-making processes.The online version contains supplementary material available at 10.1186/s12910-023-00900-5. Three questions concerned the moral acceptability of NTDs, and the final question concerned the moral significance of the costs of care. Respondents were asked to state whether they agreed or disagreed with the following propositions: Q1. “It is here acceptable to stop the provision of fluids and nutrition. The patient will then die”; Q2. “If I was in a situation like this patient myself, I would have wanted the provision of fluid and nutrition to stop, so that I would die”; Q3. “If the patient develops pneumonia or any other serious infection, it is acceptable to refrain from treating the infection. The patient may then die”. Thus, while Q1-3 all referred to non-treatment decisions, Q1-2 concerned Vignette 2 then described a patient with serious dementia, reduced function and apparent suffering. The vignette read, “Patient N. is an 80-year-old man with dementia (Alzheimer’s disease). He is now bedridden much of the day but can walk with support. He lives in a nursing home. The disease has reduced his ability to think and speak, and staff now believe that he is no longer able to make his own decisions. He often groans and seems sad. In the last month, the patient has rejected all attempts at feeding. After this, he has received fluid and nutrition through a feeding tube connected directly to the stomach. The doctor and nurses are now considering whether this treatment should be continued.”In the same way as for the preceding vignettes, respondents were randomized to receive additional information concerning the patient’s earlier expressed preferences. Respondents were asked the same three initial questions about the morality of NTDs as in the preceding vignettes. Thus, questions Q5-7 correspond to questions Q1-3. They were then presented with the following (Q8): “Imagine that the doctor and nurses think that treatment ought to be stopped. They discuss this with the patient’s closest next of kin. The next of kin wants the treatment to continue, so that the patient will live on.” They were then asked to answer the following question: “How much weight should the next of kin’s own view be accorded here?”Finally, vignette 3 described a patient with terminal cancer who preferred not to undergo a further round of chemotherapy. The two subsequent questions concerned the right to refuse treatment. The vignette read, “Patient L. is a 70-year-old woman with incurable cancer. She has been through two series of chemotherapy to slow the progression of disease and attenuate symptoms. A third type of chemotherapy is now an option. The patient does not want this, because she had bothersome side effects of the previous drugs. However, the doctor and relatives think it is right to give it a try.” Respondents were then asked to take a stand on two questions. Q9 read, “The patient’s “no” to chemotherapy ought to be respected”. Q10 read, “In general, patients who are able to make their own choices should have the right to say “no” to all medical treatment”.To all questions posed as propositions except Q8, the alternatives were “fully disagree”, “somewhat disagree”, “neither agree nor disagree”, “somewhat agree”, “fully agree” and “do not wish to state”.Religiosity was determined by the answer to the question, “Which of the alternatives below best describes your worldview?”  is higher than withdrawal of treatment (Q1&5) when patient preferences are either unknown or are in favour of treatment.Respondents are slightly more accepting of NTDs for themselves than for the patients described in the vignettes , more respondents disagreed than agreed. Thus, H5 was disconfirmed.In general, respondents who stated a religious affiliation were less likely to accept non-treatment decisions. The effect was moderate. For instance, on Q1 , among religious respondents 43% supported treatment withdrawal whereas 37% did not; the corresponding numbers among non-religious respondents were 51% and 32% (p = 0.012). On Q6, which asks what respondents would have wanted for themselves in a situation like the dementia case, fewer religious than non-religious respondents would want treatment withdrawal . Thus, H6 was confirmed.In the cancer scenario, large majorities agreed fully or somewhat that the patient’s refusal of chemotherapy ought to be respected and that competent patients’ refusals of treatment ought to be respected in general  wanted next of kin’s preference to receive decisive weight, but a majority did not, thus confirming H8  This is a well-known phenomenon; even though withholding and withdrawing treatment are usually seen as ethically equivalent, they may be emotionally different . The propatient’s prior expressed preferences) to be given some weight in decision-making, even when the next of kin’s preferences run contrary to the patient’s previously expressed preferences. This would go against present health law but might be more in line with actual practice [As discussed above, Norwegian health law gives next of kin a limited and clearly demarcated responsibility when the patient lacks competence to consent. The majority of our respondents do not challenge the physician’s decision-making authority. However, many appear to want next of kin’s own preferences (as distinguished from next of kin’s report of the practice . More reThe findings might carry consequences for how physicians interact with next of kin of patients lacking decisional capacity for whom NTDs are considered. The large variations in the responses indicate a strong need for careful dialogue with patients and next of kin about this kind of questions. To be able to clarify and adapt to individual preferences, but also to clarify and comply with the rules, and possibly sometimes to make informed and well-justified exceptions, is important. Furthermore, the emphasis given to previously expressed wishes and next of kin’s views points to the need for appropriate advance care planning.Furthermore, what might at first glance appear as a conflict of opinion—the physician wants to stop treatment, the relative wants it to continue—might actually mean that the relative is naturally cautious about being the one to agree with and support the physician in the decision to let a loved one die. This is probably more so if previous dialogue and advance care planning has been sparse or non-existent. Both in advance care planning and shared decision making “here and now”, information about the legal roles and rights should be given. In Norway, the physicians are the ones responsible for making the decisions. Thus, the relatives may “lower their shoulders” and be more forthright with their true feelings about the matter, and also give more information about their knowledge about what the patient would have wanted.Another application of these results could be the active use of advance care planning to avoid overtreatment . Given tdo want to be kept alive, despite being in a state of UWS, MCS or dementia. Obviously, health care professionals need to be aware that this subgroup exists. One cannot automatically assume that “no patient would want this life”. Physicians therefore need to engage with patients and next of kin with an open mind, treading carefully, while trying to elucidate the attitudes of the patient or family in question.A particular point of interest is the rather sizeable minority that Still, according to conventional medical practice and ethics in Norway, keeping alive patients in an UWS or even MCS with little hope of improvement is challenging as well . WhetherThe study indicates that although a minority view, some patients and next of kin will find non-treatment decisions ethically problematic. This is in line with findings from other European studies , 12. OurAccording to the belief-sampling model of survey response, the attitudes tested by such surveys are seen as “a kind of memory structure that contains existing evaluations, vague impressions, general values, and relevant feelings and beliefs” . Thus, aAlthough a non-response bias cannot be ruled out, the moderately high response rate of 40.7% lends some support to the validity of the findings. In the invitation to participate in the survey, panel members were told the survey would assess “attitudes towards ethical issues in healthcare”. Conceivably, respondents with an above average interest in the topic could have been more likely to respond.A limitation in surveys asking respondents to take stands on “paper cases” is that certain simplifications must necessarily be made. The phrasing of the information and questions involves a risk of these being interpreted differently, or of outright misunderstandings. Respondents are expected to take a stand based on very little information and without the opportunity for follow-up questions or dialogue with experts. This marks an important contrast with real-life decision making.This survey of a representative sample of the Norwegian adult population indicates that attitudes to NTDs are often in line with national laws and guidelines. Many respondents accept NTDs, also in the context of disorders of consciousness or dementia. However, there are large variations in the responses. A majority want next of kin’s own views to be accorded some weight. These responses are sometimes in friction with Norwegian health laws, something which indicates that careful dialogue, shared decision making, and advance care planning should be given high priority. This may prevent conflicts, unnecessary burdens, and overtreatment.Additional file 1. Appendix 1: Questionnaire translated from the original Norwegian into English.