Household air pollution is a major cause of ill health, but few solutions have been effective to date. While many quantitative studies have been conducted, few have explored the lived experiences and perceptions of women who do the cooking, and as a result are those most exposed to household air pollution. In this study, we worked with groups of home cooks, and sought to use art as a means of engaging them in discussions of how household air pollution from cooking affects their lives. In the Terai district of southern Nepal, we held four focus groups that included 26 local women from urban and peri-urban areas, as well as six local artists. The women then met approximately weekly over four months, and produced images related to air pollution. Transcripts from the focus groups were reviewed independently by two authors, who initially categorised data deductively to pre-defined nodes, and subsequently inductively reviewed emergent themes. Women identified a number of health effects from air pollution. The main physical effects related to the eye and the respiratory system, and women and young children were seen as most vulnerable. The psychosocial effects of air pollution included reduced food intake by women and lethargy. Suggested solutions included modifications to the cooking process, changing the location of stoves, and increasing ventilation. The main barriers were financial. The lived experiences of women in southern Nepal around the problem of air pollution offers a more nuanced and context-specific understanding of the perceptions and challenges of addressing air pollution, which can be used to inform future interventions. Biomass fuels are renewable organic materials such as animal dung, charcoal, coal, crops, and wood . They arWe have previously shown evidence of high air pollution concentrations in southern Nepal and high levels of exposure amongst children , and othLocal women represent a source of experiential knowledge, and—as primary cooks—are one of the primary target audiences for interventions to mitigate household air pollution. Although little has been done to involve them in the research process, they may be a key resource in identifying why the problem persists, and what potential solutions might be. A recent systematic review of factors influencing the uptake of cleaner stoves highlights the need for better understandings of the needs of socio-economically disadvantaged groups in particular . HoweverOne approach to unravelling these complex issues is to use art as a means of generating discussion. Art has been used extensively as a tool in participatory global health research to engage communities and draw out implicit knowledge on health-related topics . DrawingIn our study in southern Nepal, we sought to discuss household air pollution with women who do the cooking, and are the primary people affected by it. Our aims were to explore their lived experiences and perceptions of the health effects of household air pollution through open-ended discussions. In order to draw out implicit understandings of how biomass fuels impact on health, we involved local artists in discussions to help illustrate the issues around household air pollution from cooking, and stimulate thinking about potential solutions.We conducted a qualitative study in Janakpur, Dhanusha district, Nepal. Nepal is one of the world’s poorest countries, and Janakpur is a small city with little mechanised traffic or heavy industry, close to the border with India in the flat Terai region. The urban population lives mainly in concrete or mud and brick housing. The Nepal Census showed that 86% of households in Dhanusha district use either wood or animal dung as their usual source of fuel . PreviouThe research was conducted within a larger study that investigated the effects of antenatal micronutrient supplementation and air pollution, with ethical approval granted by the Nepal Health Research Council (reference 51/2011) ,28.A purposive sample of women living in Janakpur who were currently using biomass fuel for cooking were recruited from participants in the larger antenatal micronutrient supplement and air pollution study. For the larger study, women had been recruited from the obstetric unit of the local government hospital, and had been allocated randomly to receive multiple micronutrients or iron and folic acid during pregnancy . Their cLocal artists were recruited from the Janakpur Women’s Development Centre (JWDC). The JWDC is a co-operative organisation that produces local Maithili art. The female artists are mostly widows who come from poor communities nearby. As well as helping preserve their artistic heritage, the centre also works as a business that helps empower women.All of the participants were from a similar background, and came from urban or peri-urban areas. They tended to be from middle socio-economic strata—not the poorest or the wealthiest—and all used biomass fuels. Fifty women were visited at home and invited to take part, of whom 26 attended the first focus ground discussions (FGDs), along with six artists. Each of the four groups had between five and eight people, as planned.Focus group discussions (FGDs) were designed to serve two purposes: to gain insight into participants’ perceptions of air pollution from cooking through the use of art, and to guide a public engagement project. We conducted FGDs to obtain in-depth and nuanced insights about commonly shared perceptions of the health impacts of cooking. We held four initial FGDs in March and April 2013, conducted by two trained female Nepalese researchers, according to a topic guide. The guides covered cooking fuels and the reasons for choosing them, the health effects of air pollution, and possible ways to mitigate them. The facilitator allowed participants to talk about their experiences and opinions, and gain insights from each other with little input other than prompts for further information and the posing of questions when a topic was fully exhausted. One researcher facilitated the discussions and the other took notes. The artists were invited to participate in these initial discussions, since they were also women from the community who experienced similar issues. The research facilitator had previously conducted focus groups and women’s groups in the region, but had not met the participants beforehand. FGDs were held in a participant’s home or nearby. Participants provided written informed consent, and discussions were conducted in Nepali or the local language, Maithili.After the first round of FGDs, the participants met with the JWDC artists in a series of workshops held approximately weekly over four months to illustrate their perceptions of the health effects of air pollution from cooking. The workshops were not formally recorded, but meeting notes were kept. Four different groups of women attempted to illustrate the problems they faced and possible solutions to them. All of the workshops were observed by one of the researchers, who took notes to guide the analysis. Prototype pictures related to how participants themselves saw the issues, and they themselves chose the final means of display. They decided to produce 11 large pictures with the intention of showing them around the city. A community meeting with local officials was held to identify locations to display the artworks, which were painted either directly on walls or on large billboards. They were placed in prominent locations around the city; for example, in the main public hospital, the railway station, and at a school.Focus groups were audio recorded and transcribed and translated into English by two members of the research team. Two authors independently reviewed and coded the transcripts. One of whom also conducted the groups, was fluent in the local languages, and had a deep understanding of the problems faced by the local women. In contrast, the other was from the United Kingdom, and was not involved in conducting the discussions, which provided an alternative perspective to the analysis of the data.A thematic analysis was used to analyze the data using both inductive and deductive approaches . InitialWe identified several common themes about the impacts of air pollution through our analysis of the FGDs on women’s lived experiences of cooking and health. These themes are presented below in order to describe how women interpreted and made sense of their experience of household air pollution, together with the illustrations produced by the artists during the workshops.General conceptualisation of air pollution: ‘bad smells’.In all four FGDs, air pollution was identified as an issue, and it was usually described as “bad smells”. Some felt that all ill health associated with household air pollution was related to the large amounts of dirt it created. Biomass cooking stoves were commonly mentioned as a source of household air pollution, although tobacco smoke was also mentioned. One participant explained the problem as “polluted air comes by cooking rice on mud stove that can affect … people living inside the house” (Focus Group 2 Participant 7 (FG2 P7). Smoke was thought to be a problem throughout the whole house, but particularly in the kitchen. Seasonal variation was important, with people feeling particularly “uneasy in hot seasons although they have to cook food” (FG2-P2). The problem of household air pollution in the hot season was felt to be exacerbated by having to use fans to keep cool.A diverse range of other causes was perceived to be important, both inside and outside the home. In the house, women were aware that toilets were often not cleaned with water, and that this was problematic. Where toilets were absent, children sometimes urinated directly on the floor. Outside the house, women reported other “bad smells”—for example, food , animal dung, and urine—as sources of pollution. They discussed several circumstances in which such pollution was intensified. For example, it was reported that “bad smells” were exacerbated by adverse weather conditions, particularly in households with inadequate windows or doors. Other present but less important sources of pollution included dust and dirt being blown into the home, as well as mud and dust from non-brick houses. Dirt and bad smelling air were central to how air pollution was perceived. One woman said, “From the drain, when we close our window, then bad smells do not come, but when we open our window, then bad smell comes inside the house and make it more dirty” (FG1 P1).All of the participants acknowledged negative health effects of air pollution, although they emphasised them with varying strengths. Rather than focusing on respiratory health, the most commonly mentioned body part was the eye, with participants saying things like “eyes get swollen” (FG1 P1), “it causes pain in our eyes” (FG1 P3), or “the eyes become red” (FG1 P6). Air pollution was thought to lead to consequences such as itchiness, nausea, swelling, pain, irritation, redness, dizziness, and, in more extreme cases, transient visual impairment. The other main symptoms mentioned were breathing problems, fever, cough, weakness, runny nose, feeling faint, and head, neck, and chest pain, many of which are also visually represented in More generally, smoke was associated with a feeling of unease and restlessness. Participants reported a number of illnesses that they felt were associated with air pollution, such as whooping cough, asthma, tuberculosis, pneumonia, chest infections, stomach ulcers, cancer, diarrhoea, kidney disease, and heart disease. Pollution was also thought to increase the presence of flies and mosquitoes, leading indirectly to an increase in malaria and kala azar .Women were seen as particularly vulnerable to health-related harms, because they took primary responsibility for cooking; men spent much less time in the home. Children were thought to be even more vulnerable, particularly younger children who spent most of their time with their mothers. The smallest children could not leave the kitchen because of their dependence. Some mothers reported holding their children while cooking, resulting in exposure to more concentrated smoke. One participant said, “We are all big and can bear anything … but the children cannot bear it. The small children, from the time they are born, cannot bear that. Therefore, the children get sick immediately” (FG1 P7). Another said, “we have to save our children from the smoke” (FG2 P5). While cooking, another explicitly told her older children, “go now, and come back here when the food is cooked” (FG1 P3) to protect them as much as possible. Mothers also reported that their children complained about the effects of smoke. As with their mothers, eye problems were a major concern. Children were reported to generally get sick—cough and coryza were specifically mentioned—and to suffer from allergies, whooping cough, and pneumonia, which were all related to the smoke: “The symptoms shown in children like pneumonia, cough and fever” (FG4 P4); “Children having allergy from the dirtiness” (FG2 P5); and “By the blowing of straw and sand children get affected by having whooping cough and coryza” (FG3 P2). Although most of the harms mentioned by participants were related to health, some additional negative consequences were noted. One woman said, “Polluted air inside the house can affect the children living inside it, and they aren’t able to perform at their best or pay attention to their education” (FG4 P1). It was felt that the associated sickness, particularly in children, prevented people from “eating the food nicely and … any kinds of work like in festivals such as Tihar … going to temple and doing worship or staying at home for watching TV” (FG1 P1).Smoke could sometimes be so unbearable that a woman had to put out the fire and start cooking again, or, in the most severe cases, would simply not cook, going without food and only drinking water. This sentiment was echoed by several women, who said things such as, “for two out of three days I drink water only due to the smoke” (FG1 P1), “When we become worried, we do not eat food and take tension” (FG1 P4), and “Women go … without eating the food” (FG1 P3). The nauseating effects of air pollution and the effects on both women and their children are illustrated in Using biomass fuels was felt to be time-consuming in relation to cooking, cleaning surfaces covered in dust, and managing illnesses. One participant said, “The house looks black and dirty by cooking food as a result of the smoke” (FG3 P2). Dealing with smoke-related illness and lost productivity from cleaning were felt to be a significant financial drain. One participant said that, on dealing with air pollution related problems “by not spending money, we can save it for our children’s future” (FG4 P6).Overall, there was acknowledgment that dealing with household air pollution had dramatic benefits and led to improvements in physical and mental health, productivity, and happiness.Participants said that food should ideally be cooked quickly and the fire put out rapidly with water on completion, but the inherent limitations of biomass cookers meant that it was always a slow process. Using firewood instead of dung-cakes to start the fire was reported to lead to less smoke, and kerosene was felt to worsen the smoke. Puffing on the fire with a pipe (instead of by mouth) was seen as minimising smoke exposure for the person starting the fire. With regard to stove design, two feasible options suggested to reduce smoke were channeling it out via holes in the house (increasing ventilation) or via a chimney pipe, as illustrated in One participant said that a doctor had recommended wearing spectacles to protect her eyes while cooking, and others mentioned wearing masks. In discussions about alternative stoves, heaters, coal stoves, and rice cookers were all mentioned. The most popular option was gas cookers, with many participants saying things like, “If cooking using gas, then there will be no smoke” (FG1 P1) or “we would like to cook the food using gas” (FG1 P3). However, there were concerns about accessing reliable gas, and about the cost of gas for poor communities, with one participant saying, “from where do poor people bring gas?” (FG1 P1).There was a preference to have a kitchen outdoors, or on the roof (of concrete buildings), except during adverse weather conditions: “Cooking food outside. If there is a roof, then in roof. Now this is the room to cook food” (FG1 P3). Smoke was felt to be less concentrated in big open spaces , and “If there is no place to cook outside the house, then they have to cook food inside the house” (FG4 P2). The effects of smoke were thought to be greater in smaller, lower spaces. Other, more pragmatic, solutions involved only cooking on one side of the room and eating in a different room (or outside), away from where the smoke was most concentrated. However, it was acknowledged that smoke diffused throughout the house, and the practical benefit of cooking and eating in separate locations was limited. Some mothers stopped others from entering the kitchen whilst they cooked, although this was impractical for those looking after small children. Opening windows or doors was felt to help disperse smoke, particularly if kitchen windows could be opened, but this had the potential to make things worse if it was windy or if there was significant outdoor air pollution. Another strategy was to use fans to disperse the smoke. One woman discussed how she had made a structural change to her house by knocking down a wall to allow the smoke to escape.There was a consensus amongst the participants in one focus group that household air pollution was a problem, but that little had been done about it. The main reasons for this were insufficient money, or sometimes not knowing how to deal with the problem. This was especially so in small houses in which families lived, worked, slept, and cooked in the same room.Feelings of helplessness were clear: “I am uneducated and I do not understand much. I just cook the food” (FG1 P2). Time to find a solution was an issue, particularly for mothers who had young children to look after. Many women commented on the need to prioritise other activities over those that would reduce air pollution. Comments were often fatalistic, such as saying that participants could not reduce the problem because “God has given us this air” (FG1 P5), and many said that they felt there was no effective solution. Certain challenges were thought to be very difficult to overcome; for example, ventilating the house, while knowing that opening windows lets in outdoor air pollution. The use of biomass stoves for heating during the winter may present a particular barrier to change. One participant said, “If we go near the fire in cold months … our house gets hot” (FG1 P1). However, this was only mentioned by one participant, with all of the other comments highlighting the negative aspects of this cooking method.The aim of our study was to gain a greater understanding of the meanings that women draw from their lived experience of air pollution associated with cooking in southern Nepal. The main strengths were the novel use of art combined with qualitative research techniques to understand participant perspectives. We think that this has enabled us to gain greater insight into the problems caused by air pollution and their potential solutions.Generally, participants’ understanding of the health effects of air pollution was similar to the health effects described in the literature. Women identified air pollution as an important cause of ill health, and many said that reductions would lead to benefits in their lives. However, while they were aware of and concerned about a range of illnesses associated with air pollution, they prioritised them in specific ways. For example, the main concern was eye problems, rather than respiratory disease. As it stands, promoting household air pollution mitigation to reduce long-term outcomes such as chronic obstructive pulmonary disease may not be as motivating as promoting it to prevent eye problems. Importantly, in some cases, air pollution also led to the cessation of cooking. We were not able to quantify the extent of this problem, but it has potential nutritional implications for the family. We are not aware of this side effect of air pollution being reported previously.Overall, participants saw biomass fuels as the main source of air pollution; however, contrary to our quantitative work, they perceived firewood as producing less smoke than dung, and that levels were higher in the summer, when combined with the hot weather and spread by fans. In this respect, they felt that heat exacerbated the air pollution, whereas our measurements showed much higher levels in the winter when heating was also prevalent . Such diIt was of interest that air pollution was conceptualised together with other “bad smells”. Opening windows would help reduce smoke, but it could also let in bad smells. Participants also felt that dirtiness and air pollution were synonymous, and that having a dirty house was also bad for health. This has implications for interventions that can tackle both. A combined approach that improves both hygiene and air quality could reduce multiple major infectious causes of child mortality such as pneumonia, diarrhoea, and vector-borne diseases.In general, similar types of qualitative studies have tended to focus on outdoor air pollution in high-income urban environments , where tA common intervention is improved stoves, but these may not be designed to meet local needs. They also may not yield sufficient financial or time savings, and there may be a mismatch between expectations and what is delivered . StanistTwo main ways to improve air quality would be to reduce the amount of smoke produced, with alternative fuels for cooking or improved stoves, or to reduce smoke exposure, ideally through chimneys or smoke hoods. Compared to the current scenario of cooking with biomass on open stoves, there was a clear preference for gas in all of the FGDs, and the main barrier to this appeared to be availability and cost. However, solutions to the household air pollution problem cannot be dissected from the context in which the problem occurs. This includes the need for heating and the broader concept of “bad smells”, which encompasses concerns about outdoor air pollution, as well as the general cleanliness of the home. These would need to be addressed, even if alternative cooking fuels could be provided. Any intervention is thus likely to be much more successful if it draws on a participatory approach or direct community involvement.Initially, we had hoped to involve men in the FGDs, in separate groups. This would have provided an important perspective, as men are often the head of the household, and the decision maker is often male in Southern Nepal. Unfortunately, it was not possible due to a lack of male volunteers. Future work addressing the understanding of men would be valuable. As we have highlighted, our study may have limited generalisability. While the problems faced in our population may be similar elsewhere, beliefs and barriers to change are likely to be context-specific. Similar qualitative work would be valuable to provide greater local understanding.A number of research projects and programmes have been conducted to reduce the levels of household air pollution that women and other family members are exposed to, but few have asked those directly affected what the problems and solutions might be. Using a novel approach that combined FGDs with artwork, our study has summarised how women in southern Nepal interpret problems related to air pollution based on their lived experience. The in-depth insights gained can be important in the first step in the future design of locally appropriate and effective solutions.


A day in the life of a cell,There are so many stories to tell.Ribosomes are cooking proteins,It smells delicious in cells kitchen;The beauty of the genetic code,Is inside the Nucleus laid hidden.Kinases are busy kissing proteins,They leave the lip mark of phosphate on them;Phosphatases are running here and there with jealousy,Removing phosphate is their game.Of all these stories inside a cell,Those are required to keep the cell neat;This is the story of autophagy,The process by which cells ‘self-eat’.When there is dark everywhere,And not enough food on the table;When cells feel unstable,And bacteria, viruses, and oncogenes prevail.A glimmer of hope emanates in the cytosol,Wearing the double membranous veil;‘So do not fear’ Autophagy roars,‘I declare war against adversities and will prevail’.Collecting intelligence cues from diverse signaling,Autophagy breaks shackles of mTOR;ULKs and Class III PI3K complex next join the war,The first battalion is formed at the phagophore.Mimicking the Ubiquitin system,ATG5-ATG12-ATG16 then join the noble cause;This war is about ‘to be or not to be’,There is no excuse for rest or a pause.Final reinforcement of LC3,Ultimately decorates the lipid bilayer;The membrane is going to form a circle,Engulfed materials will soon disappear.Nevertheless, like in any war,Autophagy complains-‘Rumors were spread against me’;‘Autophagy is brutal’-it was told,Engulfs and kills targets indiscriminately’.Alas, they did not know,Autophagy can be very selective;Autophagy receptors p62 or NBR1,Perform the selective autophagy trick.Mitophagy for mitochondria, lipophagy for lipids,And pexophagy for the peroxisomes;There are many secrets of autophagy hidden,Those are yet to be known.Autophagosome dumps the cargo on the lysosome,An organelle full of protease knife;All the contents are then chopped to be recycled,Executing the beautiful ‘art-of-life’.This is the story of Autophagy,Keeping the cell clean its ultimate motive;Autophagosome ends its life in the lysosome,But the cell continues to live.


Over the last 20 years, increasing attention has been given to associations between dispositional forgiveness and specific mental health problems. However, few studies have assessed whether forgiving real-life interpersonal hurts may be related to diverse psychological health outcomes. The present study addresses this gap by investigating, in depth, relationships between perceptions about state forgiveness and a variety of mental wellbeing outcomes as well as exploring perceptions about the factors that may modify such effects. Developing an understanding of a forgiveness wellbeing relationship is of relevance to healthcare workers, researchers and policy makers with an interest in improving public health. In-depth semi-structured interviews were conducted, and data were analysed using grounded theory methods. From England and Ireland, eleven adults who were affiliated with religious/spiritual and secular/atheist groups were recruited using purposive and convenience sampling methods. Key themes that appeared to be related to the effects of unforgiveness were: increases in negative affect; reduction in cognitive abilities and barriers to psychological and social growth. For the majority of participants, state forgiveness had strong ties to participants perceived sense of mental wellbeing, including reductions in negative affect, feeling positive emotions, positive relations with others, spiritual growth, a sense of meaning and purpose in life as well as a greater sense of empowerment. The data also revealed a number of factors that may positively or negatively influence a forgiveness–wellbeing link such as: viewing an offender as spiritually similar or different, responsibility/karma, blaming, wanting restitution/apology as well as practices such as meditation and prayer. The findings suggest that forgiving a range of real-life interpersonal offences may be an important determinant of psychological wellbeing, particularly among religious/spiritual populations. Further research is, however, needed. Interpersonal hurts are common, and they can occur due to experiences of physical or emotional abuse, or in other cases, due to conflicts relating to feeling unacknowledged or rejected  forms of forgiveness and subjective wellbeing. Some have found only a weak association between trait forgiveness and a single measure of life satisfaction  as well as improved relations with the wrongdoer as a result of practicing forgiveness  forgiveness on specific mental health problems, or in a few cases, connections with subjective levels of happiness. There is as such limited research exploring in more detail the perceptions of individuals who have practiced forgiveness (state) in response to a real-life interpersonal hurt in order to better understand whether forgiveness is linked to wider domains of functioning. At present, very little is also known about factors facilitating or obstructing forgiveness among secular and diverse religious samples. Thus, a further aim of this study is to examine whether specific religious or secular beliefs and practices are perceived to be associated with changes in forgiveness and general wellbeing, prior to the conduct of further research.The aims of this qualitative study were to: (1) explore the perceived effects of practicing state forgiveness on a variety of mental wellbeing outcomes and (2) to explore factors influencing a forgiveness–wellbeing relationship.N = 5), Muslim (N = 2), Buddhist (N = 1), Theosophist (N = 2) and secular/atheist (N = 1). Table Eleven English-speaking adults affiliated with New Religious, Buddhist, Muslim and Secular/Atheist groups were recruited using purposive and snowball sampling methods through a variety of means such as social media (Facebook groups), direct email and telephone. Participants that met the criteria of having practiced forgiveness in response to an interpersonal hurt were invited to take part in the study. The types of hurts experienced by participants related to parental love deprivation, hurt by romantic partners and feelings of neglect within the context of work relationships. Six respondents were recruited from England and three were recruited from Ireland. Most were male , ranging in age from 27 to 50 years. The average age of respondents was 36 years. Eight participants were white, two were Pakistani and one was black. Four participants had completed a higher degree, five had completed college-level qualifications and two had completed secondary education. The sample included participants affiliated with the following religious groups: A Course in Miracles, ACIM  were contacted via telephone, the Internet (Facebook) and directly via email. Group organisers were also asked to assist in recruiting affiliate members and subsequently emailed information about the study to their members. All participants were provided with detailed information sheets about the research before consenting to take part in the study. Where appropriate, participants were also sent a list of questions they would be asked during the interviews. Arrangements were then made for the respondents to be interviewed. All participants were made aware that they could withdraw from the study at any point, without giving a reason.N = 4) were based within the Midlands and surrounding areas, and so it was possible to travel to them. However, where distance and recruiting were an issue, interviews (N = 7) were carried out via video link (i.e. Skype). All participants were informed that interviews would take approximately 1–2 h; the majority of interviews lasted for approximately 80 min. A semi-structured interview schedule was used to elicit responses from participants regarding the process of forgiveness and its effects. All questions were open-ended, and, with permission, all interviews were audio-recorded and transcribed.In-depth semi-structured interviews were conducted. Some participants (Grounded theory (GT) methods were applied to analyse qualitative data. These procedures consisted of the following steps: (1) repeated reading of the transcript; (2) writing memos regarding what may be emerging from the data; (3) open coding involving the separation of data to define concepts such as thoughts, ideas and meanings contained within blocks of raw data; (4) constant comparison such as assessing similarities and differences in emerging concepts within each transcript and across participants; (5) classifications where similar and different concepts were grouped together; (6) categorisation where concepts were developed into categories which were further defined in relation to their properties and dimensions; and (7) axial or intermediate coding . This final stage of coding concerned relating concepts/categories to each other, such as assessing relationships between themes.This research was reviewed and given favourable opinion by the Biomedical and Scientific Research Ethics Committee at the University of Warwick.Analysis of participant’s accounts revealed three key themes that appeared to be related to the effects of unforgiveness. These were: negative effect on mental health such as how participants felt; negative effect on participant’s mental health such as participant’s cognitive abilities; and barriers to growth that were both psychological and social. There appeared to be no obvious distinctions in these themes on the basis of religious/spiritual affiliation.All of the participants spoke about the negative consequences that a lack of forgiveness had on their mental health and wellbeing. Fuming, you know when you’re in a state of bitterness, when you can’t really see or reflect properly but you’re just completely bitter and emotionally disturbed. Many said that they felt depressed , stressed and ‘no sense of peace’ . Some also described feeling fear , guilt  and a lack of confidence , whilst other examples included feeling a ‘lack of energy’ , ‘static’ and generally ‘less dynamic’ .All participants described a variety of affective states resulting from unforgiveness, which on the whole, appeared to prevent them from adequately functioning emotionally. One Theosophist participant illustrated this theme by stating the following:Stuart (ACIM) described how negative emotions of unforgiveness made him feel that he could not change his state, whilst Amira (Muslim) indicated that a lack of forgiveness resulted in a strong physiological response whereby she experienced feeling an intense negative reaction towards the offender. Another participant  said that he was unable to sleep, experienced intense anger as well as mood disorder, and Trisha (ACIM) indicated that holding on to grievances and not forgiving caused unhappiness and a lot of fear.In addition to highlighting how unforgiveness negatively affected the way that participants felt, they also indicated that it negatively affected aspects of their cognitive health such that their thought processes appeared to be overwhelmingly negative. For example, many appeared to experience an ‘inability to think clearly’ , whilst others indicated the presence of suicidal thoughts and of ‘harming others’ . On the whole, and linked to the previous theme, participants appear to have experienced a state whereby they were unable to feel or think constructively.It stops you from getting on with life, if you can’t forgive you’re stuck in that rut, stuck there in that place. I feel that. I felt I moved on so much with my sister in law (and husband) from where we were but I can’t move on from that particular person (brother in law). Others also commented on how it negatively affected wider dimensions of wellbeing such as general relationships because the anger and resentment they felt were preventing them from forming new relationships. This was illustrated in a statement made by the secular/atheist respondent:I do remember being quite bitter, which didn’t help with the ability to form relationships with anyone else. Overall, participant’s accounts suggested that unforgiveness did not just negatively effect how they felt; it also appeared to have a detrimental effect on their cognitive health and social wellbeing.A recurring theme among participants was that unforgiveness is a barrier to growth whereby many felt they were unable to develop or move forward psychologically or in terms of their social wellbeing. For instance, participants spoke of how a lack of forgiveness ‘freezes your mind’ making you ‘less dynamic’  as well as ‘emotionally and cognitively slow’ . One participant described how her vengeance and anger made her feel as though she could not move forward:For the majority of participants, state forgiveness had strong ties to their perceived sense of mental wellbeing, including reductions in negative affect, feeling positive emotions, positive relations with others, spiritual growth, having a sense of meaning and purpose in life as well as a greater sense of empowerment. Each of these categories is presented in Table I no longer have any animosity towards him (father). If he said something that would annoy me before or have feelings of animosity, without having to think about it, it just drops off me. I don’t have any negative mental reaction to him. I just have an accepting and compassionate view of him. I no longer say to myself, quietly in my mind, “I really hate you” Another Theosophist also indicated how feelings of unforgiveness were causing him to feel generally depressed. However, forgiveness enabled him to overcome his mood disorder and feelings of bitterness and instead ‘heal’ his mental health . Similarly, an ACIM participant indicated that although he was experiencing suicidal thoughts and a lot of ‘darkness’, forgiveness enabled him to let go of wanting to harm himself, change his depressive state and experience greater happiness   Table .Table 3Going through the last few months, although there was conflict, there was rage, there was everything, I’m just much happier, more peaceful within myself; I don’t take things as seriously as I used to. Another ACIM participant described how he experienced a reduction in negative affect followed by an increase in positive emotions as a result of forgiving:I ended up feeling like I was in a different state of mind that I usually am in, much more positive and loving. And there was also the negative in the sense of negating that feeling of being stuck in the anger. I didn’t feel stuck in the anger anymore. For all religious/spiritual participants, forgiveness appeared to be related to an improvement in general positive emotions and not just event-specific feelings such as love and compassion. Some examples of common descriptions by participants regarding how they felt after practicing forgiveness included (feeling) ‘content’, ‘joy’ , ‘calm’, ‘better’ , ‘happier , ‘uplifted’ , ‘stronger’ and ‘independent’ . Feelings of inner peace were also commonly described by Muslim and new religious participants. Reflecting the views of other ACIM and Muslim participants, one respondent who was able to overcome the depression he was feeling from unforgiveness stated the following regarding the outcomes of his forgiveness practice:It (forgiveness) has totally healed my relationship with my parents. We get along all the time now. There’s less in the way of getting on and they can see it in you that you look at them in a nicer, more loving way. One Muslim participant described how her relationship with her husband had improved. She stated that ‘we can talk to each other about anything and everything’, ‘we trust each other’ and that their improved relationship made it ‘healthier for the kids’, . The Buddhist participant, Jax, felt that his relationship with his father was more pleasant and that he had developed compassion and understanding towards him, whilst Alfred, the secular/atheist participant, was able to maintain a friendly relationship with his former partner who had rejected and offended him. One of the Theosophist participants also stated that he ‘gradually thought of (his father) in a less negative light’ and had developed ‘an accepting and compassionate view of him’ . Another Theosophist participant felt ‘compassion, kindness and peace’ towards an ex-partner who had severely deceived him and also found that his general relationships improved:You develop compassion, kindness and peace through forgiveness that leads you to healthier relationships with people. The majority of participants described experiencing improved relationships such as being able to work together constructively, experience intimacy with their partners, empathy, open-mindedness and acceptance as a result of their practice of forgiveness. For example, common themes reported by ACIM participants included: being able ‘to love (in an) environment that had been so hostile’, ‘willing(ness) to work together’ , ‘closer family relationships’, ‘understanding and love for each other’ , ‘more open’, ‘tolerant’  and people ‘more valuable, real, worth loving’ . ACIM participants reported that relationships were a significant component of their wellbeing; as one participant stated ‘there can be no wellbeing unless your relationships are healed’ , and forgiveness was a key strategy utilised for this purpose:Most participants spoke of experiencing spiritual development. For new religious participants in particular, this took the form of spiritual growth whereby they experienced a shift in understanding about their own self, which also appeared to give them a sense of meaning and purpose to life. For instance, one participant  spoke of how he ‘learned something’ about human nature and the importance of insight. He stated that through a lack of forgiveness he was identifying with a superficial self, which was selfish and lacked concern for others, and that unforgiveness resulted in a state that caused him to feel depressed and was a barrier to his spiritual and social wellbeing. In contrast, forgiveness enabled him to manifest beliefs about his ‘true self’, which he described as inherently selfless.I felt it was a real turning point for me (forgiving); it was really occasioned by a sense of tremendous leap forward in terms of my own spiritual journey. My goal is spiritual awakening and I think forgiveness is the key in that process. Participants felt that their understanding of life and of people expanded as they developed a new sense of  self, in which they placed more emphasis on concern for the welfare of others, as well as being compassionate towards themselves and others, which were key elements of their spiritual development:Forgiveness also appeared to give participants a sense of empowerment and control as they were able to overcome negative feelings associated with unforgiveness such as hatred and the desire for revenge, and change the state they were in for the better. For instance, common themes found among religious/spiritual participants were feeling ‘stronger’, ’independent’ , ‘confident’, ’hopeful’, ’calmer’  and ‘in control’, . Many ACIM participants stated that by ‘healing’ the mind (through forgiveness), they had improved their health and wellbeing . The Buddhist and new religious participants in particular believed that they could choose whether or not to prolong the initial suffering experienced. This may have been related to their beliefs about taking responsibility for how they reacted and what they focused upon. Brandon (ACIM) suggested that any feelings of resentment were caused as a result of his own thought processes, which he believed he could change at any point, and stated that accepting responsibility was ‘a lot more empowering’.If I focus on what the other person is doing then all the power is in their hands; they have complete control over me. Letting go is a way of taking back control. For these participants, the choice appeared to be between identification with ego  or with the ‘higher self’ (i.e. love/compassion) and by choosing to forgive they appeared to be able to reverse the effects of the harm through inner  change. Letting go, or forgiveness, as one Buddhist stated, was a means of taking control of his life:Participants also highlighted a number of factors that seemed to influence their forgiveness and wellbeing levels. For example, many stated that blaming, lack of acknowledgment, powerlessness, ruminating, revenge, ongoing transgressions and physical proximity obstructed their forgiveness process. Of the participants that described barriers to forgiveness, the same respondents also spoke about factors that promoted their forgiveness practice. Key themes assisting forgiveness among respondents were: a sense of connectedness with others, focusing on positive qualities, accepting responsibility, acceptance of karma, beliefs about being of benefit to others, meditation, self-observation, prayer, empathy, persistent effort (by the offender) to repair the situation as well as talking to and support from friends.For the majority of religious/spiritual participants , forgiveness appeared to have ties with wider dimensions of wellbeing. For instance, they described experiencing spiritual development, positive relationships, positive affect, and a sense of meaning and purpose. On the whole, however, it seems that participants, who largely applied inner transforming strategies, without necessarily expecting a change in external conditions, appeared to experience greater levels of forgiveness and mental wellbeing. Unforgiveness on the other hand, which appeared to be reinforced by factors such as blame, feeling powerless, ruminating and desires for revenge, had a variety of negative effects on participants mental, emotional and social wellbeing. Whilst the themes described here are tentative, there is indication that regular practice of a combination of inner transforming factors such as meditation, responsibility and helping others/connectedness may be effective in facilitating forgiveness of a specific transgression among certain religious/spiritual samples.The central purpose of this study was to explore connections between state forgiveness and a variety of psychological wellbeing outcomes and to investigate what factors may influence a forgiveness–wellbeing link. Analysis of the qualitative interviews revealed relationships between unforgiveness and depression . In the present study, most participants appeared to benefit from different processes of forgiveness, albeit to different degrees. However, prior research has indicated that conditional forgiveness is associated with greater psychological distress and reduced levels of psychological wellbeing among a sample of older Christian adults (Krause and Ellison This study has further contributed to knowledge by highlighting factors that may influence a forgiveness–wellbeing link. Most previous research has focused on the role of religious and secular factors in influencing dispositional forgiveness, and very little is known about novel mechanisms employed by religious and secular people that may assist or restrict forgiveness of real-life interpersonal offences. The present study extends on previous research by highlighting potential effect modifiers among under-studied samples. The findings suggest that specific beliefs and practices, including viewing an offender as spiritually similar or different, responsibility/karma, blaming, restitution/apology, as well as practices such as meditation and prayer, may help to facilitate or act as barriers to forgiveness. The study also highlighted that those who more strongly emphasised practicing unconditional forgiveness appeared to experience greater The present study indicates that beyond reducing depression and anxiety, state forgiveness may be a key facilitator of general cognitive, emotional and social wellbeing outcomes. Future studies should as such include a wider range of psychological health measures so that greater awareness can be raised regarding the costs and benefits of forgiving or unforgiveness. Also, consistent with prior research (Kidwell et al. Whilst the qualitative component of this study has provided an in-depth understanding of the experiences of forgiveness among diverse and under-studied groups, it has a number of limitations. For instance, the number of Buddhist, Secular/Atheist, Theosophist and Muslim participants who took part in this study was quite low, and therefore, the findings should not be generalised to others affiliated with these groups. Moreover, whilst the study recruited a demographically diverse group of participants, further studies that include more participants of different genders, ethnicities and socio-economic backgrounds as well as an assessment of their personality characteristics are needed to assess participant’s perceptions about the effects of these factors on their forgiveness process. Further research is also needed to examine the influence of factors that may modify the effect identified in the present study among diverse groups and to investigate whether forgiving real-life interpersonal offences is causally related to general wellbeing outcomes.


Self-rated health predicts health outcomes independently of levels of disability or mood. Little is known about what influences the subjective health experience of stroke survivors. Our aim was to investigate stroke survivors’ perceptions of self-rated health, with the intention of informing the design of interventions that may improve their subjective health experience.We conducted semi-structured interviews with a purposive sample of 28 stroke survivors recruited from a stroke unit and follow-up outpatient clinic, 4–6 months after stroke, to explore what factors are perceived to be part of self-rated health in the early stages of recovery. Qualitative data were analysed using a thematic analysis approach to identify underlying themes.Participants’ accounts show that stroke survivors’ perceptions of self-rated health are multifactorial, comprising physical, psychological and social components. Views on future recovery after stroke play a role in present health experience and are shaped by psychosocial resources that are influenced by past experiences of ill-health, dispositional outlook such as degree of optimism, a sense of control and views on ageing.Severity of physical limitations alone does not influence perceptions of self-rated health among stroke survivors. Self-rated health in stroke survivors is a multidimensional construct shaped by changes in health status occurring after the stroke, individual characteristics and social context. Understanding the factors stroke survivors themselves associate with better health will inform the development of effective approaches to improve rehabilitation and recovery after stroke. Patient-reported outcome measures such as self-rated health, are an important component in the assessment of health status , 2. SelfThe presence of a stroke is generally associated with a poorer SRH compared to that seen in other older people; and a reduction in SRH from pre-stroke status , 14. ForIn a previous cross-sectional quantitative study we conducted of over 700 stroke survivors from the Medical Research Council Cognitive Function and Ageing Study (MRC-CFAS), psychosocial factors including depression and not “getting out and about” were found to be important determinants of SRH in patients who have had a stroke . UnderstIn this study we use a qualitative approach to gain depth and insight into stroke survivors own perceptions and experiences of their health and investigate what modifiable and non-modifiable factors may influence the subjective health experience in the earlier stages of recovery following a stroke.Potential participants were identified from a rehabilitation stroke unit at Cambridge University NHS Foundation Trust Hospital and by a stroke consultant or a specialist stroke nurse at a follow-up outpatient clinic. We used a purposive sampling approach, and aimed to recruit participants from a range of ages and levels of disability. We included individuals with a first confirmed stroke, who had the ability to take part in an interview and provide their informed consent. We excluded stroke survivors with severe clinical aphasia and cognitive impairments  score of less than 20) , and thoAge, gender and postcode were obtained for all participants by the study team. The Index of Multiple Deprivation (IMD)  was deriEthical approval for the study was obtained from the National Health Service (NHS East of England) – Norfolk REC (ref 11/EE/0108). We obtained written informed consent from all participants prior to taking part in interviews. Semi-structured interviews were conducted with stroke survivors to investigate what factors they perceived contributed to their subjective health. LL, ES and NM interviewed participants over a 10-month period between September 2011 and June 2012. Interviews took place in their own homes, between 4 and 6 months following their stroke. Informal carers, often spouses, were present in one third of the interviews, based on participants’ preference. Interviews lasted between 45 and 80 min.The interview topic guide was developed based on review of existing qualitative studies exploring perceptions of wellbeing and quality of life among stroke survivors and analysis of two prior focus groups with stroke survivors from a local Stroke Association patient group (unpublished). During the interviews, stroke survivors were asked questions about their health, including their perceptions of recovery and health after stroke; the impact of the stroke on daily life and social relationships; the quality and nature of relationships with health care professionals; and their views about future health and recovery.All interviews were audio-recorded, transcribed verbatim and then stored, managed and coded in NVivo (Version 9.0) Computer Aided Qualitative Data Analysis Software. Transcripts were first read and re-read by NM and LL and coded for themes using a thematic analysis approach to identify similarities and differences in themes between participants . Coding Twenty-eight stroke survivors were interviewed (age range 47–86 years), comprising 19 men and 9 women. Participant characteristics including SRH responses, socio-demographic characteristics and number of co-morbidities are shown in Table Our analysis identified a number of themes describing stroke survivors’ perceptions of their own health following the stroke see fig. . These iFor participants with physical disabilities following their stroke, impairments such as limb paralysis and aphasia were key influences on reports of SRH. Such limitations impacted on the ability to carry out activities of daily living, work and leisure activities. The desire to return as much as possible to ‘normality’ i.e. pre-stroke functioning, and progress in rehabilitation, were key concerns for these stroke survivors. Among those with no or minimal physical disabilities, self-appraisals of current health status were often closely tied to their perceptions of having made good progress with their recovery. Participants with physical disability commonly identified practical solutions for minimising the impact of residual disabilities on their experiences of health. These included strategies such as performing daily tasks in different ways, for example moving regularly needed objects to lower shelves in the home among those with hemiplegia, or in those with swallowing problems taking smaller portions of food and drink. For instance, Mr A said:My brain rather is learning how to cope with these restrictions and finding a way round them. So doing the things that I want to do in a slightly different way if you like …… If I use a spoon normally with this hand and you go to put a spoonful of liquid in your mouth, I can’t do that because by the time I get the spoon up near my mouth half the liquid has run out because I can’t control it. If I start off with the spoon half full, yes I can do it. They’re the sort of things that you adapt to. Perceptions of self-rated health among stroke survivors were also negatively shaped by experiences of post-stroke pain in some participants, and in a greater number of participants by ongoing stroke-related fatigue. For example, Mrs B commented:I: When you said your health was average, what kind of things went through your mind?P: I get cross with myself because I think, oh why can’t I do that … but then I know that if I do too much then my knee will be so painful, I’ll be up all night, so I tend to sit…Well I’m not as able bodied as I was, I get tired quicker. Stroke survivors commonly reported co-morbidities, some of which had developed after their stroke, such as a fall-related fracture or frozen shoulder. Such disabilities had interrupted or significantly slowed down their rehabilitation and progress with recovery, and impacted on current perceptions of self-rated health. The need to take daily medication following a stroke, including medication to reduce blood pressure and cholesterol levels, and the need for multiple attendances at medical and other appointments also negatively affected perceived current health status. For example, Mr C said:I: When you think about your health do you think having had the stroke changes how you feel in yourself about your health?… P: It has to a bit because I find I’m getting endless hospital appointments. There’s the stroke and then I had some urology issues Other physical influences shaping current perceptions of SRH among stroke survivors included diet and level of exercise. A quarter of participants reported making changes to their diet and exercise following the stroke, and reducing alcohol and smoking, as strategies to feel healthier and minimise risk of stroke recurrence. A few also felt that they had an improved understanding of their physical health since their stroke, including a greater awareness of their body, being less willing to stress themselves physically, and to cherish their health. One man reported:I: Has the stroke made you think about your health in a different way?P: “I think so, yes, yes, ... I am much more free and easy with my health.” Mental health status, cognitive problems in relation to memory and concentration, and changes in mood and affect  all impacted negatively on SRH. Reporting of anxiety or depression was common in both those with minimal and significant physical disabilities and reported by at least one third of participants. For example, one middle-aged woman Mrs E, said:Well …it does affect your attitude and your moods .…Mentally, I have had some down times, it was a little shocking for me to have this, because I’ve always been a very confident person. Low mood was perceived to be mostly related to loss of independence, changes in occupational and social status, slow progress in rehabilitation and loss of confidence. For example, this included Mr C, who despite making a good physical recovery, lacked confidence in being able to carry out some of his usual activities, including taking part in sports and travelling on his own:I’m superficially in good health. Superficially. There's a few things underneath which are, you know, undermining my confidence. In contrast, approximately one third of participants reported psychological changes that positively impacted their feelings of wellbeing and subjective health, such as becoming more patient, content, tolerant, thoughtful, appreciative, and valuing the smaller things in life such as time spent with family, friends and neighbours. Such changes were mostly the result of a modification of psychological outlook in response to what was perceived as a serious threat to their health after experiencing a stroke.Almost all stroke survivors, in particular those with significant physical disabilities, described a range of psychological strategies to cope with the psychological impact of their physical limitations following the stroke, and positively appraise their own health. A commonly used strategy in over half of the participants, including those with significant disability, was making comparisons with others, both those perceived to be less fortunate, and those who had made a good recovery from the stroke, with the latter seen as a source of inspiration and motivation for their own recovery. Some participants also compared themselves with others of their own age, feeling themselves to be in relatively good health despite their stroke. Many reported being grateful for being alive, for their remaining physical abilities and progress in rehabilitation:I: So you said your health’s not bad?P: I don’t think so.I: What makes you say that?P: Well see I mean it depends what you add up. I mean if I sit there thinking of what I’ve had and what I’ve got, I go into decline, but I think well, you know, I don’t think it is bad, I think I’m given a lot of grace to pull myself together and do things, and as long as I can do that then my health’s alright. Other coping strategies used by stroke survivors to appraise their health in a positive light, included having life goals and motivations for their recovery and keeping busy with activities, such as returning to usual hobbies and activities. Determination, hard work and perseverance with goals, having a sense of control, taking personal responsibility, striving for independence and a lack of reliance on others were all psychological strategies adopted by these participants to appraise their health and perceptions of future progress with recovery and control over their health positively. For example, one man and one woman said:I: And what’s got you here to this point?P: Yeah. If at first you don’t succeed, yeah. Determination…Don’t let people mollycoddle you, just get up and go and do what you have to do. If you want a cup of tea, go and make a cup of tea, that sort of thing. For some stroke survivors with significant disabilities, psychological acceptance of current physical limitations following the stroke, but also other co-morbidities prior to the stroke and the ageing process, were important factors mediating perceptions of SRH. A couple of participants who positively coped with physical disabilities also spoke of having a strong faith in a God or a higher power to whom they entrusted their health and recovery. For example, Mr. F said:I think faith helps an enormous amount. Yeah… I do believe that we have a Father who looks after us… I don’t know how people can live without faith to be honest, so that is an enormous comfort to me. … I sort of think now give a little time and it will come back and he’ll make the hand work again so (laughter) … Yeah I don’t expect miracles but I do know I get miracles… The majority of stroke survivors interviewed reported a number of social influences shaping perceptions of SRH in both positive and negative ways. These included their immediate home environment, work, family, social circumstances and their ability to get out and about.I enjoy my music, I enjoy reading, of course I like being with my wife, I have my garden. What’s going on around my environment really keeps me healthy. For half of stroke survivors, changes in circumstances, such as being unable to work, the loss of roles inside and outside the home, and inability to carry out hobbies and leisure activities, impacted on reports of their overall health and particularly, mental health:It’s just getting used to not doing anything. You know, I’ve worked all my life and then suddenly you’re not doing anything, you sort of find… I had an allotment. I was going to carry on with that, but I found it’s too much to get down there and trying to do things, you know, and then you get tired quite quickly too, you know … It’s getting around and not having a car anymore, you know. I’ve got to go to town, I’ve got to walk there and [that] sort of thing. I had to go to the doctor the other day and I had to walk there and it rained, so I got soaking wet. You know, that sort of thing, but, ah, it’s part of life, you know, so it must carry on. The quality of social relationships was an important factor shaping perceptions of SRH among stroke survivors. The presence of a supportive spouse and family members were particularly important: having regular contact with family members, including children and grandchildren, was one of the most important sources of mental wellbeing and enhanced experiences of health identified by stroke survivors. Two participants reported positive changes in family relationships following the stroke, for example, with siblings or children becoming emotionally closer, while none reported a worsening of relationships. The majority of stroke survivors identified family members as key sources of social support and encouragement when undertaking activities of daily living, exercises as part of their ongoing rehabilitation, following advice with regards to making lifestyle changes, and getting ‘out and about’. For example, one man said:If you’ve got a good family they’re the best medicine in the world to make you sit up. I mean my wife or my son won’t let me mope. A minority of stroke survivors reported a lack of close family support after the stroke, which had a negative impact on their perceived mental health. Specifically, two women spoke about a lack of emotional and practical support from their spouse. A number of other stroke survivors also described family members as being over-protective and trying to limit them from carrying out daily tasks in case they got tired, which similarly had a negative impact on their current experiences of health.The majority of participants reported changes in the type and quality of their social relationships after stroke, which they spoke about in the context of their health. For some, friends and neighbours became more supportive and helpful, for example in terms of visiting more often and helping with tasks, although others reported friends and neighbours subsequently avoiding them. Those with minimal physical disability spoke of challenges with ‘invisible’ disabilities, such as being unable to concentrate and tiring easily in their interaction with others.Several stroke survivors attributed their good health to the quality of health care they had received, including timely interventions and positive interactions with healthcare professionals who were perceived to be caring and supportive. They often praised the good work of hospital and community staff, but felt that poor support given by primary care when discharged from hospital had had a negative impact on their health and recovery. Rehabilitation therapists had played a greater part in discussions about health among those with more significant disabilities. However, there was little difference reported in perceptions of satisfaction with health services among those with differing degrees of disability. One man, Mr H, with a significant disability after his stroke typically said:My health… in general... pretty good, well looked after, I put it down to that, and the attention that’s been given to me, principally by the hospital Participants’ accounts of their current SRH often included reference to their lives and previous health before the stroke, across the same physical, psychological, and social domains.The majority of stroke survivors, especially those of older age, reported living with long-term conditions prior to their stroke, in particular diabetes, hypertension, arthritis or cancer. Stroke onset was largely perceived as adding a further significant burden to their current health, both physically and emotionally. For example, one female participant, Mrs. E, said:Average [health], not fantastic ‘also’ because of the diabetes and since I’ve had cancer I haven’t had the stamina that I had before, so I would say it [current health] was just average really. Similarly, another woman commented:P: I have insulin-dependent diabetes, I have kidney disease, I have heart disease and now I’ve had a stroke, I’ve had retinopathy, so if we’re ticking off the boxes for complications from diabetes, I think I pretty much have them all (laughs). And so, even if I were in the most excellent of health with my diabetes, these other complications that I have would still put me only in mediocre health, I don’t think I’ll ever have excellent health again (laughs).I: Right and did the stroke change your perception of your overall health?P: Oh no, it just was one more box to tick off in the complications. Previous lifestyle habits were considered among a third of stroke survivors, including both men and women, as having an impact on perceptions of SRH, either by contributing to the development of stroke, or conversely, by positively impacting upon current health post-stroke. For example, one man said:I try and eat well and do plenty of exercise, yeah I think I’m as healthy as any, if not healthier than any late 50 year old to be honest, yeah, yeah … But yeah as the consultant said, he said because I was, I’m pretty fit that’s helped me over the stroke really, you know. Stroke survivors often identified aspects of their personality and life history (particularly difficulties in childhood) as influencing their current outlook, resilience and beliefs about their health and in their ability to overcome the challenges of rehabilitation. Two participants, one man and one a woman, felt that their experiences of having coped with prior illness or in looking after other family members or friends had shaped their ability to cope positively with the impact of their stroke currently:I really wasn’t too upset about it because I’d had such a bad time with my husband two years previously who had had a stroke. Several participants when describing their health also reported that that they were ‘upbeat’, naturally happy and content within themselves, and this positively shaped perceptions of their health following the stroke. For example, one man, Mr H, reported in the context of being happy with other aspects of his life including his wife’s support, and despite experiencing significant stroke-related disabilities and other comorbidities including cancer, that this did not get him down:Your health, you can forget it, you know, you can, and as I say, from the stroke and everything in general, I’m exceptionally happy. Almost all stroke survivors believed that a positive disposition and optimism were important to their health and recovery from the stroke. Other positive character dispositions including possessing a self-reliant and independent personality were reported by almost a third of participants, which shaped their ability to cope with their rehabilitation after the stroke. A number of these participants also spoke of having been resilient in the face of adversity throughout their lives. For example, one man and one woman considered that their resilient characters shaped their current positive outlook on their health following their stroke:My parents, particularly my mother, you know, you can either be defeated or you can get over this. She was never very sympathetic if anything went wrong that was minor, you know, “Get over it, you know, you’ve got to learn to handle it, it’s up to you, you can get wherever,” but she was always there as a tremendous support but I do think it was the way I was brought up. I: What do you think’s made you be a positive person?P: Because I had to fight for when I was a little’un, I think during the war I was a bit of a bugger, I, when the doodlebugs used to fall whenever they hit we used to run around and find what we could, you know, furniture, bits of shrapnel and then we were brought up in an orphanage, I had to be positive, you know. In contrast, two other participants, both of whom were men, reported that they had always had negative psychological traits such as being impatient, which they perceived made their rehabilitation and return to health after their stroke more challenging.Participants reported that a number of pre-existing social factors had positively impacted on their subjective health experiences and wellbeing following the stroke. These included prior financial stability, enjoying work, a positive home environment, supportive family and friends and the ability to continue with social activities and to travel, which were all sustained after the stroke. For example, one man said:I do a lot of walking. I go and visit different towns just to get out and do something really.......I went on holiday in February, I went to the Gambia for 12 days. I’m going off to Singapore and to Borneo in September for 17 days. .......Well, I don’t lack anything that I feel that I need. I’m not short of a few shillings, I have lots of people around me that are great friends, I have a good life, I can do whatever I want to do. I just feel so totally and utterly frustrated and I kept doing me own exercises ... but my policy is it’s happened, I’ve got to get on with life as best I can … You’ve got to have a positive outlook I think, that’s all I can say really, yeah. Participants looked to the future when reflecting on their current health status after the stroke. Expectations of recovery from stroke-related disabilities and perceived rate of progress of improvement in physical function were intimately connected with perceptions of mental health and wellbeing. A minority of stroke survivors, however, also feared the process of getting older, and worried that this would negatively impact on their ability to return to independent physical functioning. However, the majority of stroke survivors were willing to accept the impact of the ageing process on their health and preferred to take ‘life as it comes’. This included more than half of participants with significant disabilities, including those with significant hemiplegia who reported that being optimistic was central to their health and future recovery. Five participants, reflecting four men and one women, who did not feel that they were inherently optimistic, nevertheless tried to be positive and hopeful about their future recovery and improvements in health status. For example, one man, Mr N said:In contrast, nearly one third of participants described ongoing anxiety and concern about the possibilities of poor physical recovery and potential stroke recurrence, having a negative impact on their perceptions of SRH and wellbeing. For example, one woman Mrs B, commented:Well supposing I had another one [stroke], although they said it was very unlikely but supposing I had another one and I was on my own ... I’m aware if I don’t feel 100% that I think, oh dear, am I going to get another one … Many stroke survivors voiced that they may have been influenced in their views of their own health by family, friends and healthcare professionals’ projections regarding the potential for their future recovery. One man commented:When they watched me struggling to get on the bed, I suppose, ‘Ooh, you are doing well. Good. Jolly good. You’re coming along beautifully with your physio and everything. You’re making progress. You’re so positive and strong’ and really wonderful ... my friends tell me I’m an old bugger who’ll live forever.… A few stroke survivors also looked to the future with hope of improvements in their financial position and social participation with regards to returning to work, and other activities such as driving, hobbies and interests. Feeling healthier in the future was linked by some to a potential positive change in social circumstances.I: Is there anything that you think would make you feel healthier?P: Well, my car. (laughs) … P: Yeah, winning the lottery. (laughs) This is the first qualitative study to explore in-depth the self-rated health experiences of stroke survivors. We found perceptions of SRH among stroke survivors in our study to be multidimensional, and both positively and negatively shaped by physical , psychological , and social dimensions . Our findings, whilst seemingly less evident than among individuals with more stable and long-standing disabilities, such as in spinal cord injury , point tThere is significant overlap between our findings and the existing literature on self-rated health in the wider population. Indeed, physical functioning and social influences are known to modify subjective health perceptions in the general population and among those with long-term conditions , 29–40. Following a stroke, levels of physical impairment in the shorter term are subject to change, have an uncertain trajectory with varied individual responses to rehabilitation, with prediction of rate of recovery and outcome often difficult . The lacWhile the relationship between physical functioning, disability and self-perceptions of health among stroke survivors is complex and strongly mediated by context and individual factors , their iStroke survivors with severe stroke-related disabilities and poor SRH were less likely to agree to take part in an interview. Exclusion of people with significant aphasia and those with cognitive deficit (due to being unable to provide informed consent), means that our findings are therefore largely limited to those who have made better recoveries following the stroke. Further research investigating self-rated health perceptions among stroke survivors with severe aphasia and whether these are influenced by factors other than those identified in this study, would be important in informing post-stroke care of survivors with aphasia. Interviews in this study were also conducted only with individuals with a first diagnosed stroke, which may not always be applicable to those who have survived multiple strokes.We aimed to recruit and interview a purposive sample of stroke survivors with a range of socio-demographic characteristics. However due to the catchment area of the study, there was some homogeneity, for example, a higher number of older individuals of white ethnic backgrounds and higher social class took part. Whilst the views of carers who were present at the interview were not used as data in this analysis, carers’ presence may have influenced some participants’ willingness to express fully their views. On the other hand, many participants appeared more comfortable to speak to the interviewer in the presence of their carer. Our study also provides only cross sectional information based on individual interviews, so we were unable to assess how influences on SRH change over time. Furthermore, we carried out interviews with stroke survivors at between 4 to 6 months following their stroke to minimise variations in different stages of recovery between participants and to ensure early recovery had taken place by the time of interview. We acknowledge that there may have been subtle changes in self-rated health assessment during the period between SRH measurement and interview. It is also uncertain whether our observations focusing on subjective health perceptions in stroke survivors would remain true for participants in the longer-term.Patient-centred perceptions of SRH are important in predicting future health outcomes. Subjective appraisals of health after stroke are multidimensional reflecting a combination of physical, psychological and social influences, and past and future perceptions of health, rather than related only to current disability levels among stroke survivors. Such contextual factors may help to explain an apparent disability paradox in the accounts of stroke survivors’ perceptions of their own health. As well as focusing on physical functioning, attention to contextual factors influencing long-term adjustment including psychological outlook, sense of control and availability of social support are important to long-term recovery. We propose that targeted interventions to enhance subjective health after stroke, including optimising psychological resilience, coping and social support are integral components of effective programmes of post-stroke rehabilitation.


Bioethics and Biopolitics: Presents and Futures of Reproduction symposium draws together a series of articles that were each submitted independently by their authors to the JBI and which explore the biopower axis in the externalization of reproduction in four contexts: artificial gestation (ectogenesis), PGD for sex selection, women’s (reproductive) rights, and testicular cryopreservation (TCCP). While one contribution explores a “future” of reproduction, the other three explore a “present,” or better, explore different “presents.” What may counts as “present,” and what may count as “future,” has dramatically different connotations depending on the geographical declination of the tense.This  Human reproduction is increasingly being externalized. We have a number of technologies that make this possible: in vitro fertilization (IVF), preimplantation genetic diagnosis (PGD), gamete donation, surrogacy, and, more recently, mitochondrial transfer technologies and uterus transplant.This externalization goes hand in hand with an increasing commercialization of human reproduction which, in turn, goes hand in hand with an unprecedented responsibilization of reproduction whereby individuals become “managers” of their pregnancies. Nowadays, this is one of main axes of biopower and biopolitical management, where “individuals themselves are responsible for the enactment of biopolitics in reproduction” Mills , 112.Bioethics and Biopolitics: Presents and Futures of Reproduction symposium draws together a series of articles that were each submitted independently by their authors to the JBI and which explore the biopower axis in the externalization of reproduction in four contexts: artificial gestation (ectogenesis), PGD for sex selection, women’s (reproductive) rights, and testicular cryopreservation (TCCP). While one contribution explores a “future” of reproduction, the other three explore a “present,” or better, explore different “presents.” What may counts as “present,” and what may count as “future,” has dramatically different connotations depending on the geographical declination of the tense.This The paper “The Perfect Womb: Promoting Equality of  Opportunity” by Kendal  discusseAs a matter of fact, this is not research that is impossible to do (as studies in other species show), but it is simply research that is not done. Why is that the case? Although the paper by Kendal cannot explore this further, it seems to indicate that it might be a “taboo” subject in research, where there are so many other ethical “battles” to fight (think of embryo research or of the renewed conflict around women’s reproductive rights). Perhaps the battle to liberate women from their biology is not one that raises the appetite of many, including funders, in a system of scarce resources where there are more “pressing” issues to attend. The reading that ectogenesis could finally “empower” women with a final decoupling of reproduction from biology is also, one should note, a partial one. Another reading could be that ectogenesis could further “discipline women” along the lines of the ways in which IVF, oocyte preservation, and other technological means of delaying pregnancy without compromising the optimality of the process are now disciplining and “responsibilizing” women.The paper by Browne , “How SeKendall argues that we should move away from an understanding of autonomy in reproduction from an “option and decision heavy” model, towards an “ultimate goal heavy” understanding of autonomy. In Mills’ words , we shouThe paper by Princewill et al.  “AutonomHowever, one could not help but wonder what different analytical lenses applied to this case could reveal about the lived experiences of Ikwerre women. One example springs to mind—Miranda Fricker’s  concept Moving on, the paper by Petropanagos , “TesticInterestingly, Petropanagos notes that the range of limited ethical analysis of TCCP is the result of the emphasis on principlism as a framework for ethical analysis within the clinical setting. This approach lacks a discussion of the ethical considerations related to the social context and relationships between the four categories of individuals mentioned above and also lacks discussion of biopower as locus of control of the values shaping the development of medical technologies.Another interesting point raised by Petropanagos’ article is that TCCP could be used for other types of patients, and these other uses need to be included in the ethical discussion of TCCP. Indeed, paraphrasing historian of medicine Ilana Lowy , while tBioethics and Biopolitics: Presents and Futures of Reproduction symposium, taken together, articulate in different ways three points.The papers in the First, bioethics operates on two temporal dimensions: while the subject of speculative bioethics is the future, the actual point of influence is the present. It is in this sense that, as put by Schick , 225 “thA second point raised by the papers in this symposium is that an analysis of current practices can shed light on other practices. For example, we can note how the discussion of ectogenesis in the paper by Kendal  illuminaAlong similar veins, the discussion of sex selection though PGD in the paper by Browne  points tFinally, two articles in this symposium point to the importance of adopting different theoretical frameworks in bioethics. The article by Kendal  challengBioethics and Biopolitics: Presents and Futures of Reproduction symposium is a step in the right direction.As we know from Heisenberg’s uncertainty principle, observing a particle changes the position of the particle itself. The same, we could say, happens in bioethics, where an analysis of the futures of reproduction changes other, existing practices. Observing is intervening Hacking . That is


It enables to change dynamic parameters online and visualize the activation states of any component while the agent is receiving sensory inputs in real time. Using a simple example, we take the reader through the workflow of conceiving of DFT architectures, implementing them on embodied agents, tuning their parameters, and assessing performance while the system is coupled to real sensory inputs.Embodied artificial cognitive systems, such as autonomous robots or intelligent observers, connect cognitive processes to sensory and effector systems in real time. Prime candidates for such embodied intelligence are neurally inspired architectures. While components such as forward neural networks are well established, designing pervasively autonomous neural architectures remains a challenge. This includes the problem of tuning the parameters of such architectures so that they deliver specified functionality under variable environmental conditions and retain these functions as the architectures are expanded. The scaling and autonomy problems are solved, in part, by dynamic field theory (DFT), a theoretical framework for the neural grounding of sensorimotor and cognitive processes. In this paper, we address how to efficiently build DFT architectures that control embodied agents and how to tune their parameters so that the desired cognitive functions emerge while such agents are situated in real environments. In DFT architectures, dynamic neural fields or nodes are assigned dynamic regimes, that is, attractor states and their instabilities, from which cognitive function emerges. Tuning thus amounts to determining values of the dynamic parameters for which the components of a DFT architecture are in the specified dynamic regime under the appropriate environmental conditions. The process of tuning is facilitated by the software framework  This paper analyzes these problems and provides solutions, captured by a modeling workflow and the software framework 2In this section, we briefly review the core concepts of dynamic field theory. We first introduce dynamic neural fields and nodes. Next, we discuss how these can be coupled to form architectures. Finally, we discuss how they may be connected to sensors and motor systems typically found in robotic scenarios.2.1Dynamic neural fields are the core elements of DFT. A field consists of a distribution of activation, u, defined over one or more continuous metric feature dimensions x =  . On its own, the −u-term creates an attractor at u(x) = 0 and is thus ultimately responsible for creating the field’s stability properties. The negative constant, h < 0, is the resting level of the dynamics. It shifts the attractor, so that the activation relaxes to u(x) = h in the absence of any other inputs. Location-dependent input, s may shift this attractor upwards. At each field location, Gaussian white noise, ξ, adds random perturbations to the field, scaled with a noise strength, cnoise. Finally, the integral term describes neural interaction, which is positive for neighboring locations  and negative for all or distant locations , as characterized by the interaction kernel, k(Δx) ) ∈ . Different variants of the output functions may be used. In Amari  input value. In this case, a peak remains stable even when the inducing localized input has been removed. The peak location reflects past localized inputs, a model of working memory referred to as selection instability, in which a unique “winner” of the implied competition emerges.When interaction is mainly local, multiple peaks may be present at the same time. Global inhibition may lead to selection, in which a single peak suppresses all other localized inputs. Such a selection decision may be multi-stable, in the sense that any of the multiple peak locations may become realized depending on the history of activation and stimulation. When input strengths are sufficiently different at different field locations, this multi-stability may break down in the 2.2uuc > 0. Dynamic neural nodes may undergo detection and reverse detection instabilities and may also form working memory, that is, remain activated after s(t) has returned to zero. Selectivity is not meaningful for a single node. Multiple nodes may form competitive networks through mutual inhibitory coupling (see below). Such networks may perform selection and undergo a selection instability.Dynamic neural nodes (or nodes for short) are zero-dimensional neural fieldsbehavioral organization . It is always implied that the dimensions of the two fields are aligned with each other, so that the source field, Au, is defined over the same vector, x, as the target field, Bu. The software framework cedar ), is an additive contribution, B,As(x), to the external input, Bs, of the target field B. For one-to-one coupling,Coupling means that the output of the source field, B represents more metric dimensions than the source field A (b > a), the coupling is an expansion. This means that the vector, xB, which describes the dimensions of the target field contains all dimensions of the source field, xA, but has additional entries not contained in the source field. In expansion coupling,xB. Input is, therefore, constant along those additional dimensions  is a stf (u), and Gaussian white noise of unit variance, ξ(t), the stochastic Euler method isFor a stochastic differential equationit is a discrete sampling of time , which is approximately  equidistant, Δit = i − ti − t1, and ξi − 1 is the return of a Gaussian pseudo-random number generator. u(it) is then a discrete time approximation of u(t). Note how the stochastic term scales only with the square root of the time step, while the deterministic term is linear in the time step . DFT prcedar. MR implemented the architecture in the present paper and ran the experiments. All four authors contributed to the writing of the paper.OL, SZ, and MR developed The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer RL declared a past collaboration with the author GS to the handling Editor, who ensured that the process met the standards of a fair and objective review.