N = 40, who tried three similar systems including Visit & Climb). Offline tests showed that the proposed system suggests crags to climbers accurately as the other classical models for top-N recommendations. Meanwhile, online tests indicated that the system provides a significantly higher level of information sufficiency than other systems in this domain. The overall results demonstrated that the developed system provides recommendations according to the users' requirements, and incorporating contextual information and crag characteristics into the climbing recommender system leads to increased information sufficiency caused by transparency, which improves satisfaction and use intention.Outdoor sport climbing is popular in Northern Italy due to its vast amount of rock climbing places (such as crags). New climbing crags appear yearly, creating an information overload problem for tourists who plan their sport climbing vacation. Recommender systems partly addressed this issue by suggesting climbing crags according to the most visited places or the number of suitable climbing routes. Unfortunately, these methods do not consider contextual information. However, in sport climbing, as in other outdoor activities, the possibility of visiting certain places depends on several contextual factors, for instance, a suitable season (winter/summer), parking space availability if traveling with a car, or the possibility of climbing with children if traveling with children. To address this limitation, we collected and analyzed the crag visits in Arco  from an online guidebook. We found that climbing contextual information, similar to users' content preferences, can be modeled by a correlation between recorded visits and crags features. Based on that, we developed and evaluated a novel context-aware climbing crags recommender system Visit & Climb, which consists of three stages as follows: (1) contextual information and content tastes are learned automatically from the users' logs by computing correlation between users' visits and crags' features; (2) those learned tastes are further made adjustable in a preference elicitation web interface; (3) the user receives recommendations on the map according to the number of visits made by a climber with similar learned tastes. To measure the quality of this system, we performed an offline evaluation , a formative study, and an online evaluation (in a within-subject design with experienced outdoor climbers  Outdoor sport climbing (OSC) is a popular recreational activity in Northern Italy due to its vast amount of rock climbing places .via a PE visualization panel with sliders. The formative study includes three strategies of how outdoor sportspeople of different levels use web searches to find the potentially interesting crag for their trip. Moreover, the online user study is, then, performed in a within-subject design: 40 outdoor sport climbers were asked to find climbing crags for their hypothetically planned climbing trip in Arco. We gave participants three existing websites in this domain: 27crags.com, a content-based climbing RS  as follows:RQ1: How to model climbers' preferences, including their contextual information, in the outdoor climbing crags recommender system?RQ2: How to develop the preference elicitation interface for the crags recommender system so that users can express their contextual information and crags content choice?The climbing recommender system is already a well-established domain: for instance, Wilkes and Janowicz  developeIn other similar outdoor-related sports, e.g., hiking or running, RSs have already addressed contextual information. For instance, Knoch et al.  develope27crags.com) offers users to choose their context with the PE interface. However, their contextual preference adjustments are somewhat limited by several factors, such as the distance between the items and weather conditions. In fact, several user studies were performed with outdoor climbers about their perceived views toward the interface of e-guidebooks: Lean  install bolts so that every ascending sportsperson can place their equipment  for their safety. Moreover, rock lines equipped with those bolts form climbing routes. Typically, those routes are not higher than 50m, and a safety chain is installed at the end of the way to help climbers abseil down. The e-guidebook usually shows sport climbing crags as points on a map or items in a table view. The schema of a map with several crags from Arco  is shown in Usually, in a climbing e-guidebook, crags' information consists of their characteristics (features) defined by the route setters or people who commented on guidebooks online. In this study, we provide 33 crags' attributes and their descriptions from the electronic guide “Vertical-Life.” Those features form climbing contextual factors and climbing crag content-related information; some are binary variables , while others are categorical . We also use icons to visualize crag-related information in the system accordingly , and the second, third, and fourth columns show correlations for three existing climbers from the database, namely, User 1”“, User 2”“, and User 3”“, accordingly. The blue color illustrates a positive correlation, and the white-yellow color is negative. We can observe from the first column that the feature of “Routes amount” is positively correlated (0.66) with the number of visits for All users.”“Moreover, the more amount of “7a”, “7b”, and “>8c” grades related to the increased amount of all climbers' visits . Furthermore, one can conclude from the second column of the figure that User 1”“is more interested in visiting crags with a larger value of “7c” grades (his visits' correlation with this feature is 0.53). In contrast, User 2”“(column three) has the highest correlation (0.24) with the “Family-friendly” feature . Finally, User 3”“(fourth column) is more interested in climbing “>8c” grade routes (correlation with this feature is 0.48). We can conclude that there is a clear correlation between certain crag features and the number of user visits; thus, we propose to model the subjective preferences based on this conclusion. To do so, we employed the Pearson correlation for users' profiles. We used the following equation to model the tastes of a user u for each feature f :To answer RQ1, we analyzed whether there is a correlation between certain features and amount of visits. For example, we plot a heat map showing this correlation for several interesting cases from the data in fc is a specified feature of a crag c, N is the overall amount of crags, fc among all crags, vutc is the number of visits made by the user ut to crag c, ut to all crags; and tu is vector representation of preferences of a target user. In this formula, the correlation produces the relevant score toward the importance even for binary features, as it normalizes their values with a summation.where For computing similarities, we used another Formula 2: it shows the most similar user from all climbers .k is the most similar user id, ku indicates preferences vector of user k, U presents set of all users; dist computes distance between two users.where To answer the research questions posed in this study, we conducted three studies: the first one was the offline evaluation of several recommender models for ranking prediction; the second one was a formative study where we interviewed climbers about their view on climbing crag RS; and the last one was an evaluation of the developed system V&C. Based on the findings from those studies, we defined several goals to overcome the limitation of current systems, providing climbing crag search and recommendations.We employed two formulas given above for user taste modeling and developed novel CARS for crags called Visit & Climb. It consists of three steps as follows: (1) contextual information and content tastes are learned automatically from the users' logs by computing the correlation between users' visits and crags' features (Formula 1); (2) PE interface described in Section 4 provides weights for interactive slider tool adjustments, the user adjusts his tastes; (3) recommendations are forecasted as the previous visits made by the most similar user (vector of preferences weights for existing users is computed from their logs based on Formula 2). The third step follows the collaborative filtering approach and assumes that similar climbers would visit similar crags. For the purpose of similarity computation, we compared several metrics and chose the best-performing one based on its accurate suggestions .For the offline evaluation scenario, we selected 106 users who visited at least 20 unique locations, and 99 items reported being visited by at least 3 climbers. Then, we created a user-item interaction matrix for each user, where each cell represents the number of visits a particular climber made to a specific crag. If the user recorded several routes within the same place for a particular day, we consider this one visit; thus, we assume only unique crags' visits per day. To avoid possible bias connected with the fact that many climbers visit the same place many times because of their living location (it might be that they live very close to this place), we made unique crag visits limited to three amounts . This idea comes from the fact that climbers typically use recommendations while they travel to a new destination. Since traveling time is limited, they only visit the same place for up to 3 unique days. Furthermore, crags' ratings are measured as average ratings given by the other users for climbing routes within this crag (as provided in the e-guidebook).We split the data by time: for each user, we split the data in a ratio of 80 and 20% . As a baseline model for evaluation, we assumed predicted values in the testing set to be the same as in the training set. To further evaluate and compare the V&C performance, we considered the evaluation of other top-N recommender models: several regression-based models for ranking forecasts, such as RandomForest,t-test). We assume that more users in the comparison dataset can solve this issue since there are now only 654 users. Thus, we conclude that V&C performs comparatively accurately than the other recommender systems.Furthermore, for each of the systems above, we performed cross-validation on a train data set (number of folds = 3), to find the best parameters of the models (hyperparameters tuning). Thus, in the resulting table, we report evaluating the parameters found during this process. For the evaluation of models, we measured the commonly reported metrics to the ranking assessment, such as Mean Average Precision (MAP@k), Recall , and Normalized Discounted Cumulative Gain (NDCG@k) at top-k . The values of the metrics vary from 0 to 1, with the worst ranking quality equal to 0, while the best ranking will be 1. The results of the models' pre-training are presented in We argue that the advantage of V&C is that it employs the learned tastes' weights in the interactive interface and overcomes the cold-start problem. One can oppose that they can similarly utilize the linear regression weights for the preference panel. However, in this case, the coefficients can not be normalized with Pearson correlation coefficients, which have minimum and maximum values of –1 and 1. Thus, presenting linear regression weights to the climber in a preference elicitation tool is tricky.27crags.com) and, in addition, 48 climbers regarding the existing content-based climbing RS  professional climber is as follows:Addthe access, the sun exposition, the morphological traits of climbing, the history of an ascent).”“approach time” and “sun exposure” features are essential for the crags' choice.He suggested that “Another climber gives a valuable comment as follows:I would like amore concise list of recommendations. Also, would be nice to have information onthe best season/time of the dayfor the recommended crags.”“sun exposure” and “suitable month for climbing” in We can observe that he was optimistic about the RS and pointed toward the quality of the list of recommended crags and the best season/time  - apositive wall, vertical, oroverhanging. I did not immediately find this information on my smartphone, and it would be convenient to have it on each route.”“sun exposure” and “wall steepness” in From this comment, we can conclude that the climbing travelers consider the aspects of shadow in the sector and angle inclination  and immediately select categories in the range from and before.”“During this experiment, we video-recorded how three experienced outdoor climbers searched for the crags for their planned trip to Arco. This study aimed to understand how people search for crags with web tools. Hence, we selected participants familiar with web e-guidebooks, had at least 1 year of outdoor climbing experience, and had traveled before practicing outdoor climbing for their vacations. We also wanted to analyze the search strategy for several different groups of climbers based on their level. Therefore, following the unified approach of climbers classification . You have several days of climbing and would like to find interesting climbing crags for this trip. You can plan this trip with your girlfriend/boyfriend, wife/husband, kids, etc. Perform your normal search procedure to find what you would potentially look for while trying to find a suitable climbing place to visit (30 min).” Each session lasted for 40 min: the first 30 min allowed participants to explore any web search tool they preferred, then the last 10 min were used for asking several questions regarding the Visit & Climb system interface. During the user exploration step, participants showed their standard efforts when searching interesting crags, and their activities showed what is more important for each person. During this session, we asked several questions: (1) What tools do you usually use to find climbing crags with the web tool? (2) What type of information source (other than web tools) will you also look into? (3) Which features of climbing crags are the most crucial for your decision?https://27crags.com for this purpose. He pointed out that the grades are the most important aspects for him, as he would not visit a crag with higher levels than he can climb (feature “The number of climbing routes for fourteen grades/difficulty levels”). Moreover, he explained that “Approach time” and “Sun exposure” are additional crucial parameters that would lead him to choose the place. The second person (advanced level) was from the UK: he used the British electronic guidebook (ukclimbing.com): interestingly, while searching for the crags, he was looking for the comments of the other visitors rather than the search via interface and PE panel; therefore, he wanted to find good reviews for the place visited by the others. Plus, he was interested in high crags' ratings; he assumed that the place which is not popular might also not be well maintained by the route setters and, thus, not pleasant to climb, that is related to the “Rating” feature from Among the participants, the first person (intermediate level) was based in Russia: he searched through google,We can conclude that different climbers' levels can be why they use different information to decide where to go; hence, one should consider different strategies for the climbers based on their preferred methods. The system V&C is developed to target the intermediate level's strategy and addresses their desired parameters to adjust. Plus, it provides ratings of crags, following the advanced level. As we can observe, it is not tailored to elite climbers.As a result of this performed formative study, we outlined the design goals positioned for the design of a new RS of Visit & Climb as follows: (1) to develop a better tool for expressing climbers' preferences with sliders; (2) to provide a list of recommended crags based on the visits of the most similar climber; and (3) to further evaluate proposed system design and functionalities.To address the design goals identified by the expert interviewers, we created an interactive climbing RS with a slider-based PE panel (the website is published onlineUser with similar correlation features (similarity is 68.0%) was predicted to visit the crags shown on the map (the bigger symbol indicates more visits).N = 40). We asked them to find several crags for their planned climbing vacation to Arco, utilizing three existing systems. 27crags.com, which was selected as one of the most frequently used by the other climbers for crag search: its interface supports users inserting certain constraints for crag features  clirags.com , and theParticipants were given the same assignments for each of the systems (in random order). The exact task was: “Consider a scenario when you (a climber) are planning to come to Italy (Arco) for a climbing vacation for 7–10 days . Your task is to find 2–3 climbing crags to visit during this vacation using the system.” While the participants interacted with the systems, we recorded their screens and video-tracked their activities on the website (mouse interaction). After the users tried out the websites, they were asked to answer the questionnaire, which measures the system's quality and recommended items and demographic questions. We adopted the user-centric evaluation framework by Pu et al.  for RS ewww.27crags.com), and we wanted to understand in which aspects it would be perceived better than the content-based RS. Each question response was scaled between 1 and 5, where 1 presents completely disagree and 5 presents absolutely agree. The session lasted for at least 15 min of interaction with the system and 10 min of answering questions.We recruited participants through social networks and from the local climbing gym  PE visualization panel; (2) recommendation algorithm; (3) explanation sentence; and (4) crags' information. The second and fourth items answer RQ1, and the other address RQ2. We identified limitations through personal conversations with the participants which were audio-recorded; therefore, we summarize the crucial issues pointed by the participants .PE visualization panel: Many climbers pointed out that adjusting too many sliders takes a lot of time; thus, one should develop fewer tools in PE. Thirty-three sliders are provided in the system now, which take much effort to adjust; hence, the new version with a few most important elements should be developed. For instance, one person suggested using “tags,” which would allow climbers to choose which features they prefer first to adjust. Moreover, people perceived sliders as a good visualization for grades , but for other features, it would be better to use buttons/switch tools instead of sliders, since it is a more convenient way to express preferences for those. This suggestion is because climbing grade distribution is important for choosing crags. At the same time, such values as “North” and “Rain safe” are binary variables, which can be expressed differently, e.g., climbers either choose “North” when summer or not. Unfortunately, approximately 40% of the climbers we interviewed did not like the PE panel interface with the sliders; even though they liked the recommended items, they did not want to spend their time understanding the meaning of each slider.Recommendation algorithm: Interestingly, many climbers found that the recommendations that have been provided by the Visit & Climb system satisfy them more than the recommendations given by 27crags.com and Content-Based RS. The system worked very well for lower grades [climbers whose redpoint level is less than 6a according to Draper et al.  should be provided.Explanation sentence: The explanation sentence was perceived as understandable by the climbers. Some users liked the fact that in the recommended crags, there have been several climbers already; thus, they better trusted this system. At the same time, some users found the explanation sentence to be too complex . Moreover, not every climber can observe the location of the box in the interface with the explanation sentence, so a clearer way to show the explanation should be developed. For instance, it was recommended to use a pop-up window with the sentence.Crags' information: In the system V&C, first, crags are shown in the interface of a map, and second, when climbers choose a certain crag, they can observe additional information about the crag with icons and explanations. Several important aspects have been suggested to be included: distance of the climbing routes in meters because sportspeople need to know the length of the climbing rope they should bring with them; the number of quickdraws in each route within the crag because athletes need to know the number of quickdraws they should bring to be able to climb a certain route; information about the type of stations on the top to understand how they should abseil; parking spot location to know where to park. Participants also suggested recommending crags based on several categories: beautiful views, crags located near the lake, and cultural places such as museums that could be visited nearby. Moreover, one should incorporate the reviews of other climbers who visited the crags and climbed the target routes into a climbing RS to improve confidence and trust.via metrics MAP, Recall, and NDCG at top-k levels (k = 1 and 3). The results showed that the V&C provides better recommendations than the baseline model (where the baseline considers past visits by the user as his/her future ones) and as accurate suggestions as the other systems.In this study, we hypothesized that climbers' previous visits would benefit recommender systems, suggesting outdoor climbing crags: they can be used to model a person's preferences for crags' features and their context. The motivation behind this hypothesis is based on the fact that climbers' visits correlate with crags' features and that users' preferences can be learned from their visits accordingly. Then, we assumed that users with similar tastes would visit similar places, and following this assumption developed a model Visit & Climb to predict the potential climbers' visits to crags. In an offline evaluation scenario, we compared V&C with other RS models  To further test the hypothesis, we performed a formative study with 73 climbers, asking them to comment on other existing e-guidebooks and recommender systems for climbing crags. Moreover, we recorded three sessions on how experienced outdoor climbers familiar with web guide tool search for the crags on the web if they plan a climbing vacation. Based on this study, we developed a web interface for Visit & Climb system to facilitate climbers in choosing the suitable climbing rocks in Arco, where the preferences are learned from the users' past visits and can be further adjusted by them with the slider-based preferences elicitation panel. We tested RS with a user-centric evaluation framework in a within-subjects study design: we asked 40 experienced outdoor climbers to try three systems (including V&C) for a hypothetical scenario of their planned climbing trip in Arco. The results of this study showed that the system of Visit & Climb achieves higher metrics for several aspects of recommendations than the other similar systems in this domain.Sun exposure,” “Suitable months to climb,” “Parking,” “Wall steepness,” “Type of rock,” “Safety,” “Rain safe,” “Rating,” and “Family-friendly”), and sliders or switchers for some other features .Overall, recommender systems for outdoor climbing is still a novel area by developing the V&C system; we also wanted to understand whether the users might perceive the slider-based PE panel as a good tool for climbing crag search. The results showed that the slider-based interface provides a high level of information sufficiency caused by transparency. At the same time, for particular crags' features, it is better to adopt a button-based PE and pre-filtering techniques for contextual factor adjustment (some users have found adjusting 33 components exhausting). Some items' characteristics are crucial for choosing crags (tourists traveling with children can only climb in a place suitable for children), while others are unimportant and could be removed. The best approach would be to combine some aspects of Content-Based RS and Visit&Climb RS in the PE interface: buttons for certain crucial features (“N = 40). Second, other exciting web sources could be considered as an alternative to RS V&C, for instance, ukclimbing.com.There are certain limitations of the system. First, online evaluation is performed with a small-scale user study . We assume that the essential improvement can be made by applying contextual pre-filtering. Moreover, incorporating the recent comments from other people who already visited places should be used to better filter crags based on a particular category, e.g., beautiful view, lake location nearby, and problems with equipment within the area.All those issues are good points to be tackled by researchers who designed a climbing recommender system for the outdoor climbing scenario. We hope this will lead to a more user-friendly interface for sport climbing e-guidebooks and provide more helpful information about rock climbing places, motivating climbers to climb.https://drive.google.com/drive/folders/1kNXs-vjygKJyYhMdZT-V5Dfhi2jv7LRZ?usp=share_link.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: The studies involving humans were approved by the Ethics Committee of Free University of Bolzano. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.II made substantial contributions to conceptualization, investigation, methodology, and analysis and interpretation of data. MW helped in the revision and gave final approval of the version to be published. All authors contributed to the article and approved the submitted version.


Carl Schmitt has been an inspiration to theorists and ideologues both on the right and on the left. On the left, for instance, Chantal Mouffe  has beenSchmittian inspirations come mainly in two forms. Some political actors might have never heard of Schmitt, let alone read his texts. They may still act in Schmittian ways, as they pursue the same way of thinking about the nature of politics and frame their own authoritarian drive perversely as the core of democracy. Therefore, Schmitt’s political theory can serve as a useful framework of analysis to better understand the political processes and political decisions in question. Other inspirations are more straightforward, as some political actors directly draw on Schmitt’s writings in their political and ideological claims and aspirations. They are expressed by scholars, propagandists, spin-doctors, and political influencers. Here, Schmitt serves as a direct source of political ideas and claims to legitimacy with regard to specific political actors and regimes.Leitmotif of his political thinking . Ehrlich coined the phrase ‘the center of political disposition’ to describe the locus of real power that operates from behind the façade of a separation of powers and democratic procedures. Hence, it is often argued that Kaczyński has embraced Ehrlich’s idea as a Conversations in the Safety of Silence. Carl Schmitt in the Intellectual History of the Early Federal Republic, Schmitt’s intellectual impact on the young Federal Republic was complex and certainly not marginal, despite his absence from academic institutions. He exerted much more influence on  democrats than other authoritarian thinkers like Julius Evola, even though Schmitt’s ideas were equally anti-pluralist, anti-liberal, and ultimately also anti-democratic. In recent years, the intellectual reception of Schmitt’s thought seems to have become increasingly apologetic. As Hasso Hofmann .Schmitt diagnoses situations when the parliament is incapable of decision-making in the name of the people with a phantom of ‘parliamentary tyranny.’ Since the parliamentary majority controls the process of law-making, it has the power to legislate anything, including solutions that are opposed to the will of the people , the New Left , and liberals. While China Path uses Schmitt’s concept of the sovereign to justify the unquestioned rule of the Chinese Communist Party, New Left wants to return to the Mao era of romanticized radical equality. The Schmittian state of exception here serves to justify a new wave of authoritarianism, which, in Schmittian fashion, is said to represent a better version of democracy. Libin and Patapan argue, however, that there are limitations to the application of Schmitt’s ideas in China. In particular, Schmitt’s concept of homogeneity implies an ethnonationalist understanding of the people, which poses a challenge to the current formal institutional set-up in China, based as it is on ethnic diversity. At the same time, the Schmittian notion of acclamation as an instrument of general will might be difficult to justify, unless there is a return to a Maoist cult of personality and a weakening of the Communist Party as the key political institution.Gábor Halmai uses Schmitt’s account to trace Hungary’s road from liberalism to autocracy after FIDESZ’s electoral victory in 2010. Halmai shows how FIDESZ has carried out systematic violations of democratic standards, initiated the introduction of extraordinary powers, and played a cat-and-mouse game with the European Union regarding standards for the rule of law. Schmitt’s disdain for liberal institutions of checks and balances and judicial review found support among leading figures of FIDESZ, including the co-founder of the party László Kövér. Such disdain is also exhibited by Orbán, who has been consistent in his violation of liberal institutions, including those created after FIDESZ electoral win in 2010. For instance, Orbán violated FIDESZ’s illiberal Fundamental Law when he introduced unlimited emergency powers during the Covid-19 pandemic. Halmai also examines the ideological interplay between some current Schmittian thinkers and political developments in Hungary, as the country has become the primary European playground for democratic backsliding.Acar Kutay explores Turkey as a case of Schmitt’s populist authoritarianism. Erdoğan appears as a Schmittian leader without direct reference to Schmitt’ writings but very much in tune with Schmitt’s understanding of politics. Kutay argues that Schmitt’s peculiar understanding of democracy can be used as a framework for analysis explaining the emergence of a populist authoritarian regime during the Justice and Development Party period and the charismatic leadership of Erdoğan. In tune with Schmitt’s ideas, Erdoğan introduced a friend–enemy distinction and identified with the masses against an allegedly corrupt and oppressive westernized elite. Moreover, he bypassed constitutional boundaries on several occasions, justifying these violations with reference to the legitimacy granted to him directly by the will of the people to rejuvenate the Turkish state. Erdoğan was also in tune with Schmittian logic as he relied on an image of a pure and homogenous people to exclude the opposition. By relying on his charismatic leadership, Erdoğan intended to establish a direct connection with the people without being restricted by core institutions of liberal democracy, such as parliament and political parties. Similar to other Schmittian autocrats, Erdoğan claimed to have established a true democracy. Kutay demonstrates how Erdoğan used the notion of a state of exception on numerous occasions to justify and consolidate his power.Petra Guasti discusses links of contemporary populism with Schmitt’s repertoire of ideas in the Visegrád Four (V4): the Czech Republic, Hungary, Poland, and Slovakia. She focuses on the figure of the sovereign dictator and his position outside of the constitutional order, on the one hand, and on the friend–enemy distinction, on the other. In particular, Guasti shows that during the Covid-19 pandemic, sovereign dictatorship and the friend–enemy distinction were at play in all V4 countries, where populists with authoritarian leanings formed governments. Nevertheless, Guasti argues that only Hungary’s Orbán came close to embodying the Schmittian figure of sovereign dictator due to his power of decree. According to Guasti, V4 populism is fused with plebiscitarianism, in which citizens play the limited role of spectators. The region also succumbed to nativist frames of the people, portraying migrants and local ‘others’ as enemies of a homogenous people. The intensity of nativism varies across the V4, with Hungary and Slovakia constituting the pioneers of nativist tendencies. In addition, claims of misrepresentation are common in the region, reflecting Schmitt’s image of parliaments as places where various groups can take over the political institutions and sever them from the true will of the people. Guasti argues that authoritarian populism in the V4 follows Schmitt’s notion of politics based on a deeply flawed myth of the unity of a homogeneous people, which violates the very basis of liberal democracy.In his analysis of Schmitt’s inspirations in the United States, William E. Scheuerman explores Trump as a ‘Schmittian backslider.’ Scheuerman begins by considering an internal tension with regard to Trump’s Schmittianism. On the one hand, Trump attacked independent institutions, showed disdain for democratic procedures, and used the resources of a powerful president claiming to represent the will of the nation. All this fits very well with Schmitt’s picture of a powerful leader. On the other hand, there is Trump’s administrative incompetence, his failure to grasp political complexities, and his pathological narcissism, which stand in the way of his full embrace of Schmittianism. Still, key elements of Schmitt’s thought, such as the idea of a homogeneous people or an understanding of the president as a quasi-monarch characterized Trump’s presidency. Trump treated his own activities and those of his cronies as above the law, enacted discretionary emergency powers when politically convenient, and used law against his opponents and ostensibly ‘hostile others,’ such as migrants or liberal elites. This strongly reflects the core of Schmitt’s political theory, which reframes pseudo-democratic authoritarianism as true democracy. The authoritarian tendencies of Schmitt’s thought notwithstanding, Schmitt arguably also captured a range of liberalism’s pathological political and legal tendencies that stem from contemporary capitalism. Scheuerman proposes to supplement the limited focus on Schmittian personalities with a consideration of these structural factors to fully understand the democratic backsliding.This Critical Exchange suggests that Schmittian inspirations abound in countries that experience democratic backsliding. Sometimes, Schmitt’s ideas are used explicitly, but more often they are implicit in the actions of political elites. Schmitt’s concepts belong to the repertoire of authoritarian actors who aim to demolish, delegitimize, and ridicule liberal democracy. This suggests the need for a more critical reading of Schmitt as an ideologue of authoritarianism rather than a concerned critic of liberal democracy.Ireneusz Paweł KarolewskiCarl Schmitt admired Mao Zedong and was intrigued with China. He would therefore be pleased that China is experiencing a case of ‘Schmitt fever’ . The China Path refers to institutional arrangements deemed fit for China, with the ruling status of the Chinese Communist Party (CCP) as its defining characteristic. China Path scholars use, inter alia, the Schmittian concept of an absolute constitution to justify the leadership of the CCP. Thus Chen (juedui) can also mean something beyond any doubt. Consequently, by resorting to the concept of an absolute constitution, and calling the leadership of the CCP the first fundamental law of the Chinese Constitution, Chen holds that the ruling position of the CCP cannot be questioned, negating any normative examination of its position of leadership.Schmitt’s thought has been especially influential for a group of scholars known as the ‘China Path’  – that is, political struggles between different ideological factions within the CCP. Finally, New Leftists criticize individual rights and liberalism as serving the interests of elites and call for greater democracy by relying on Schmitt’s repudiation of liberalism and his reconciliation of dictatorship and democracy  reiterates Schmitt’s thesis that the sovereign may, and sometimes even must, make decisions outside the legal framework, ranging from political and economic reform to the 1989 Tiananmen incident, in order to safeguard the existence of the state. Due to the decline of the analytical purchase of the concept of class, the New Leftists turn to Schmitt’s concept of friends and enemies to account for political conflict. For example, philosopher Wang Hui  resorts to Schmitt’s diagnosis of the age of neutralizations and depoliticizations in order to revisit the concept of ‘struggle between two ways’ ), call for the development of ethnic administrative areas  and representation of ethnic minorities in the NPC (Art 59), appoint an Ethnic Affairs Committee (Art 70), and grant the right to use ethnic languages (Art 139). Therefore, both in terms of class and ethnicity, contemporary Chinese politics makes Schmitt’s idea of a homogenous people inapplicable.Schmitt’s defense of democracy as rule of the people raises a further question, namely how the will of the people is to be ascertained and exercised. Rejecting parliamentary or representative democracy, Schmitt’s answer is a sovereign dictatorship, where a dictator will decide on the exception in the name of the people . The dictator discerns the will of the people through acclamation Schmitt, . When MaSchmitt’s theory has been widely received in China. And indeed, his democratic theory is useful for understanding Chinese political practice in the Mao era. Yet important elements of Schmittian thought, such as his notion of the people and its will, are at odds with post-Mao era Chinese political theory and practice. Even though Schmitt will most certainly continue to be relevant in China, essential aspects of his democratic theory will limit the attempts to deploy his thought to understand and shape Chinese politics.Xie Libin and Haig PatapanHungary was one of the first and most successful cases of political transition after the fall of the ‘Eastern Block’ in 1989. This transition produced all necessary institutional elements of a liberal constitutional democracy, including checks and balances, guaranteed fundamental rights, and the rule of law. At the same time, Hungary is also the first and paradigmatic case of constitutional backsliding from a fully fledged liberal democratic system to, first, an illiberal and, second, autocratic regime. This contribution describes these transformations from a Schmittian perspective.Hungary shared with other transitioning countries the need to establish an independent nation-state, a civil society, a private economy, and a democratic structure, all at the same time. The system of government introduced by the comprehensive amendment of the communist constitution assumed the presence of more than two parties in parliament and coalition-governance. At the same time, the ruling parties rejected semi- or fully presidential regimes that were implemented in many post-communist countries. They also rejected a Westminster-style two-party parliamentarism modeled on the United Kingdom. Combined with a strong judicial review process, Hungary’s new constitutional system seemed to work for more than twenty years, until FIDESZ’s overwhelming electoral victory in 2010, even though Hungary lacked a liberal democratic constitution.After 2010, Hungary became what Prime Minister Viktor Orbán called, borrowing from Fareed Zakaria , an ’illThis was the political context in which Hungary was hit by the Covid-19 pandemic. After the very first confirmed cases, the government used the pandemic as a pretext to claim unlimited emergency powers. But the legal presumption on which the initial emergency decree 40/2020, and the subsequent emergency statute (the Enabling Act), rest, violates Fidesz’ own illiberal constitution, the Fundamental Law of 2011, which does not provide constitutional authorization either for the decree or for the Enabling Act. .Führerdemokratie) are very similar to the idea of ’illiberalism’ à la Orbán.Even before the pandemic, with FIDESZ ascent to power in 2010, the authoritarian Hungarian constitutional system could be understood by drawing on Schmitt’s critique of liberal constitutionalism and its conception of the rule of law. As Heiner Bielefeld  demonstrThe Schmittian refusal of liberal democracy is mirrored in the rejection of any form of separation of powers in the current Hungarian constitutional system. As László Kövér , co-founThe question is whether Schmitt’s distinction between the legally bound ‘commissarial’ and legally unbound ’sovereign dictatorship’ represents a change in Schmitt’s thought, or whether it is an ad hoc response to Germany’s constitutional development from the Weimar era to Hitler’s Nazism. For Dyzenhaus , p. 39, It is no surprise that Schmitt’s ideas about the executive branch, as the proper locus of sovereignty, appear relevant in our own emergency situation and are used to legitimize authoritarian uses of the pandemic as a pretext for an expansion of power. For example, in an article published the day after the Hungarian Parliament’s enactment of the Enabling Act, Adrian Vermeule  proposedAs Dyzenhaus , 2020b rErmächtigungsgesetz – is justified in ways that echo the Schmittian defense of Hitler’s emergency measures: it is the Führer who protects the law. And just like during the Weimar Constitution, which was not formally abolished during the Nazi era, Orbán’s Enabling Act does not create complete lawlessness, as the constitution and laws are still in force. Nevertheless, the Nazi regime changed from an illiberal democracy into an autocracy. It remains to be seen if Hungary will follow in its footsteps.To sum up, the pandemic provided a pretext for Orbán’s claims that a sovereign dictatorial power should not be controlled, even by the Parliament. For this reason, the Enabling Act – a sort of Hungarian Gábor HalmaiCarl Schmitt is a controversial author: he was the crown jurist of the Nazi regime in Germany and an antisemite. Nevertheless, it is worth engaging with Schmitt to analyze contemporary populist authoritarianism. As Lars Vinx  argues, Of particular relevance is Schmitt’s distinction between friend and enemy, which helps us understand Erdoğan’s identification with the masses against an allegedly corrupt and oppressive elite. Also relevant is Schmitt’s account of the role of the president, which resonates with Erdoğan’s bypassing of constitutional boundaries on several occasions Gözler, . Like ScFirst, for Schmitt . He argued that the rulers of the new regime intended to construct an ethnically homogenous society, as evidenced by a population exchange between Greeks in Turkey and Turks in Greece. His ideas can also help us make sense of the current regime’s quest for unbridled presidential rule.Erdoğan and his political movement challenged and eradicated the secular and modernist establishment, which they claimed was preventing the expression of the nation’s will. However, the elimination of the establishment did not clear the path for liberal democracy. Even though Erdoğan and his party established civilian control over state institutions, like the judiciary, the military, and the bureaucracy, the regime also removed checks and balances, hollowed out the rule of law, and limited basic civil rights, such as freedom of speech and assembly. Echoing Schmitt’s conception of political compromise and parliamentary deliberation as obstacles to democracy, Erdoğan’s regime intended to remove all forms of political mediation between the people and the leadership. We can see this in a change of the constitution in 2017, which established a presidential system and accorded the president extraordinary powers to suspend, bend, or break positive law.The charismatic leadership of the president is key to understanding the Schmittian logic that informs contemporary populist authoritarianism in Turkey. Schmitt insisted that the identification of ruler and ruled could only be achieved by the president. Schmitt also suggests that the president decides in and on the state of exception. This involves presidential legal authority to suspend the law. Schmitt associates such power with the commissarial dictatorship in Roman law . Just as Roman commissarial dictators returned to the constitution after restoring law, Schmitt’s president must guard the constitution when acting as a commissarial dictator. Because the actions of the president are unchecked by positive law during a state of exception, there is a risk that exceptional measures might violate human rights. For Schmitt, such violations might be necessary to restore order, even as he rejected the notion of human rights as a cosmopolitan, liberal idea. Thus, the commissarial dictator restores the constitution in the particular sense in which Schmitt understands it.Schmitt’s account of the constitution turns on the distinction between an absolute constitution of the state and a relative constitution  constitution be created through a political decision and legitimated by a new ideology or myth. On the other hand, the sovereign dictator, representing the will of the people, must identify with the political decision to legitimate the foundation of the state.. In Turkey, these decisions were manifest as follows:Nizam- ı Alem) and was committed to the world domination of Islam (i'lay-ı kelimetullah) , Schmitt introduced two important concepts that resonate in the contemporary era of populism in the Visegrád Four (V4): the Czech Republic, Hungary, Poland, and Slovakia. These concepts are the friend–enemy distinction and the sovereign dictator. Schmitt reduces the political to the binary friend–enemy distinction along identarian axes. In Schmitt's definition, the sovereign dictator is outside of the constitutional order and formal authorization mechanisms , legitimizing his rule by claiming to exercise the constituent power of the people. Schmitt's sovereign dictator is in a liminal space between an old order that has been dismantled and a new order he must constitute.In This concept of sovereign dictatorship helps us to understand the V4, where populists were in power during the pandemic: Andrej Babiš in the Czech Republic (voted out of office in October 2022), Viktor Orbán in Hungary (re-elected for the fourth consecutive term in April 2022), Jarosław Kaczyński in Poland (as leader of the Law and Justice party since 2003 and Deputy Prime Minister between October 2020 and June 2022), and Igor Matovič in Slovakia . With varying intensity and degrees of success, each of the V4 populist leaders sought to avoid accountability and to accumulate power. However, only Orbán came close to the figure of a sovereign dictator by introducing rule by decree in the early stages of the pandemic  sovereignty has been a salient issue since the fall of the Iron Curtain, fuelling the rise of populism in the last decade , the populist party founded by Babiš, 'lured away voters from Social Democrats and Communists, neither of whom crossed the parliamentary threshold in the 2021 parliamentary elections. Babiš attracted those voters through excessive welfare spending, including an increase in the minimum wage, a significant increase in pensions, and free public transport. This came at a cost: during the first three years of the Covid-19 pandemic, the Babiš government implemented the highest increase in public debt among EU member states. Similarly, the Law and Justice party (PiS) in Poland attracted voters by introducing welfare measures such as child benefits. In Slovakia, Matovič is seeking to maintain crumbling support for his party through generous welfare spending beyond the country’s means – a program that is being slowed down by his coalition partners. Orbán, the leader least prone to big welfare spending, also introduced measures such as state-guaranteed loans to young families.The frame of the The ordinary people frame is most present in the Czech Republic and Slovakia. Both Matovič and Babiš use this frame to transcend the boundaries of the left and the right in order to attract voters from both sides of the political spectrum, with Matovič even calling his party the Ordinary People party. This is an effective electoral strategy, as populist voters tend to be less interested in coherent policy or fiscal responsibility than in direct transfers. Nevertheless, it complicates governance, as evidenced by Matovič and Babiš seeking to maintain popular support once in power – an effort that resulted in erratic and irresponsible policy. For example, Matovič imported the Russian Covid-19 vaccine Sputnik V without the consent of his coalition partners. When the Slovak health agency refused to approve the vaccine, Matovič relied on Hungary to provide approval. As a result, only five thousand Slovaks were administered Sputnik V, and the rest of the vaccines were sold back to Russia. Matovič was forced to resign as Prime Minister, but he remains in full control as the party leader and became Minister of Finance .Populism in power erodes accountability  and internal enemies  . Controversies about the 9/11 terrorist attacks had already made Schmitt a household name among U.S. jurists and political theorists. Trump’s ascent took things to a new level by transforming Schmitt into a reference-point for many journalists and political writers.It only took a few weeks following Trump’s surprising 2016 electoral victory for political commentators to unleash a cottage industry devoted to Schmitt and democratic backsliding. Schmitt’s name not only quickly appeared alongside Trump’s in the usual academic journals and edited volumes, but also in the pages of National Review’s claim that Trump’s personal foibles – in particular, his obvious narcissism – luckily obstructed his full-on embrace of Schmitt , viewed as partaking in a deeply shared identity and waging existential battle against internal and external ‘foes’ . Democracy, in short, became authoritarian right-wing identity politics predicated on preserving, whenever possible, equality understood as the body politics’ substantial ‘sameness,’ usually interpreted in ethnic and racial terms. Not surprisingly, core elements of Schmitt’s autocratic hyper-presidentialism simultaneously reappeared. In the Trumpist imaginary, the single person of the quasi-monarchical president possesses a mystical link to ‘real’ (read: white) Americans, the proper sovereign body, in a fashion akin to Schmitt’s imagined ties between the popular constitution-making (or constituent) power and the Weimar President . As the constituent power’s most direct institutional expression, the charismatic executive necessarily possesses vast and potentially unchecked powers.Predictably, while in office Trump treated his own activities – and those of his allies and cronies – as above or beyond the law. Flagrant corruption and conflicts of interest within his administration were pushed aside. When politically convenient – for example, in battles with Congress over immigration and the so-called ‘border emergency’ – his discretionary emergency authority was declared to be effectively unlimited. Even when Trump’s Attorney General, William Barr, paid lip service to the ‘rule of law,’ it usually meant deploying law as a political weapon against hostile ‘others’ . Barr’s authoritarian and extreme right-wing Catholic views about law, at any rate, include some eerily Schmittian traits Shaw, .As Lars Vinx has insightfully pointed out, Schmitt’s political theory offers a disturbingly ‘sophisticated re-description of the democratic ideal that puts that ideal into the service of’ pseudo-democratic authoritarianism Vinx, , p. 176.Vinx’s remarks provide a useful basis for making sense of the failed 6 January insurrection and, more generally, the Trumpists’ astonishing disdain for ordinary electoral mechanisms. Two years after the insurrection, self-described ‘America First’ political activists, who still deny the 2020 election results and tout wacko conspiracy theories, continue to gain ground in the Republican Party Berzon, . Many ofHere I instead want to focus on an issue that tends to get neglected in the debate. Both those who view Trump as a Schmittian political personality, and those for whom Trumpism as a movement and mode of governance exhibit Schmittian traits, say little about the sources of Schmitt’s apparent prescience, in part because the evidence for any direct or even indirect Schmittian intellectual ‘influence’ is sparse. So how then can we explain that a controversial twentieth-century authoritarian German thinker helps decipher disturbing features of contemporary democratic backsliding? One answer has already been anticipated by Vinx: as a devotee of right-wing, mass-based authoritarianism, Schmitt grasped its key components; unsurprisingly, much of what he had to say seems pertinent to contemporary authoritarian populism. But can we say more? By posing this question, I do not intend to celebrate Schmitt’s alleged brilliance, or endorse his claim to ‘classical’ status alongside Hobbes, Weber and so on. Rather, I simply note that Schmitt’s theory captures core features of democratic backsliding; this fact requires explanation.Situations-Jurisprudenz – that is, his embrace of exceptional or situational top-down executive rule – was best interpreted as the ‘legal theory and legal practice of bourgeois society’ as it transitioned from classical or competitive to a more organized, monopolistic phase . The latter phase, Neumann tirelessly documented, increasingly relied on non-general, non-traditional forms of law incongruent with the liberal rule of law, as conventionally interpreted. Core economic shifts, in conjunction with closely related political-institutional and legal developments, tended to corroborate precisely that authoritarian Situations-Jurisprudenz which Schmitt’s theory celebrated. The ‘crisis of parliamentarism’ which Schmitt diagnosed (1985 [1926]), alongside the authoritarian presidentialism he favored, meshed disturbingly well with real-life empirical trends whose roots ultimately lay in monopoly capitalism and its dependence on individual measures and executive decrees.Similar questions were faced and answered, with mixed results, by one of Schmitt’s most astute leftist contemporaries and critics, the Frankfurt School political and legal theorist Franz L. Neumann, another mid-century figure who has occasionally re-emerged in debates about Trump and authoritarian populism  as analytic ‘dead ends’ Müller, , p. 10. Of course, we will need a serious debate about how best to consider material versus other more strictly political factors. Absent that conversation, any theory of democratic backsliding will potentially prove incomplete and even one-sided. Writers then risk reproducing Schmitt’s analytic blind spots and silences in a way that will likely distort their analyses. They no longer would have the necessary critical distance from Schmitt but instead might inadvertently integrate some of his theory’s many flaws.William E. Scheuerman


Self-administered tests, self-injection of injectable contraception, or self-removal of intrauterine devices (IUDs) can increase people’s access to and autonomy over their own SRH. Objectives of this study were to assess women’s current interest in and use of SRH self-care and explore key informants’ (KI) opinions of self-care, especially during the COVID-19 pandemic.Data for this study came from female participants in the longitudinal Contraceptive Use Beyond ECHO (CUBE) study, and KIs, including healthcare providers, in South Africa and Zambia between September 2020 and June 2021. For this analysis, we used data from a participant phone survey (n = 537), and from in-depth interviews (IDIs) completed with a sub-sample of women (n = 39) and KIs (n = 36). Survey data were analyzed with descriptive statistics, and IDI data were analyzed using applied thematic analysis.Female survey participants in South Africa were more interested in learning about emergency contraceptive pills, subcutaneous injectable contraception, and CycleBeads, while Zambian participants wanted more information and access to condoms. However, in IDIs in both countries, women described minimal experience with self-care beyond condom use. In the Zambian KI IDIs, COVID-19 led to increased self-care counseling on subcutaneous injectable contraception and HIV self-testing. KIs who do not counsel on self-care were concerned that women may harm themselves or blame the provider for difficulties. Two KIs thought that women could possibly self-remove IUDs, but most expressed concerns. Reported barriers to self-care included COVID movement restrictions, transport costs, lack of accessible pharmacies, women’s low awareness, and possible stigma.Women surveyed reported interest in learning more about SRH self-care methods and resources, but in IDIs did not report extensive previous use besides condoms. KIs described some concerns about women’s ability to use self-care methods. Counseling on and provision of self-care methods and supplies may have increased during the COVID-19 pandemic, but ensuring that self-care is more than just a temporary measure in health systems has the potential to increase access to SRH care and support women’s autonomy and healthcare needs.The online version contains supplementary material available at 10.1186/s12978-023-01596-x. “Self-care” refers to healthcare that does not have to be given by a provider, but that people can use themselves. In sexual and reproductive health (SRH), this includes medicines or supplies like pills and injections that people can use to prevent or test for pregnancy or sexually transmitted infections. This study wanted to better understand women’s interest in and use of SRH self-care and explore key informants’ opinions of self-care, especially during the COVID-19 pandemic.We surveyed 537 women in KwaZulu-Natal province, South Africa and Lusaka, Zambia in 2020–2021. We also conducted interviews with 39 women and 36 key informants, including healthcare providers, government officials, and community advocates.Women surveyed in South Africa were more interested than those in Zambia in learning more about self-care contraception, especially daily pills, emergency pills, and injections they could give themselves. In interviews, some key informants said that they do not tell women about self-care because they worried that women could hurt themselves or blame the provider if they experienced problems. COVID movement restrictions, transport costs, and inaccessible pharmacies were all barriers that key informants mentioned to accessing tests, tools, or contraceptive methods that women could give or use themselves.Women surveyed were interested in learning more about self-care and those interviewed reported minimal previous use of self-care methods besides condoms. Providers also have some concerns about women’s ability to use self-care methods. Counseling on and providing self-care methods and supplies may have increased during COVID-19, but increasing access to self-care could help more women take care of their own sexual and reproductive healthcare.The online version contains supplementary material available at 10.1186/s12978-023-01596-x. In guidelines released in 2019, the World Health Organization (WHO) defined self-care as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a healthcare provider”  pregnancy test is negative, then it’s all well because you’ve already been injected and you are safe. But if it’s positive, “do you want to keep the pregnancy or don’t you want to keep the pregnancy.” If you do, then you wait and you go to antenatal clinic and register at 6 weeks and then you carry on the pregnancy. If you don’t want to keep the pregnancy, as soon as you do a pregnancy test, it’s positive, come back, [we’ll] give you a letter for the termination of the pregnancy… [Professional Nurse in SouthAfrica]If a client came in…late for a re-injection…usually you give the Depo and counsel the patient that, you know, “you need to do a pregnancy test in a month's time” ... And if Some people really used…the self-test kits. But for some of them, they care nothing. Why? Because they sometimes could get the kit, but don’t bring their results back. Meaning that they got the test and just dumped them. , which we can give to the women to be injecting to themselves at their homes, we never had during that period [the COVID-19 pandemic]. But the counseling was being done to them in case we have them so that they know how to inject themselves at home. [Midwife in Zambia]During the COVID-19 pandemic, we didn’t have methods...like the Sayana Press  from the pharmacies. [Registered nurse in Zambia]Self-care for some mothers that surely do not want to come to the facility, they come to seek guidance from us…We’ve advised a lot on the use of condoms for those that don’t want to come to the facility. They are afraid, they even say to us “we are afraid to come, we thinking maybe we can have this corona”. So we’ve advised them to use condoms if they are able to… or rather maybe, they can just purchase this Microgynon, Microlut, Usually we don’t advise any clients to go for self-care. We always tell them either to come here or go to the nearest facility around them instead of going for the over-the- counter self-care, because they might end up doing the wrong thing, which at the end of it all, it will fall back on us. We have not educated them on self-removal of IUDs, but I have an opinion to say if they can be educated, maybe do the demonstration…They can do it for themselves...If they are empowered, yes. They can do it…. That would give her a chance to say, “Okay, they have inserted it, but when I want to remove it, I will be able to remove it”. For one, I think it’s a good opportunity to look at the cervix at that time and also the number of reasons why she’s removing it, if she’s removing it because she wants another pregnancy…I mean if she’s due for a Pap smear that’ll be an opportune moment to actually do a Pap smear for her, you could treat an STI if she had one…I think it’s not safe.... because with us, at the facility, you are able to examine the woman, and see if it is infected. So if they do it at home, they won’t even be able to see that there’s an infection or something. So maybe they can just even pull it out. Ya, which is not safe, and they may injure themselves and may traumatize themselves. And then here we use sterile equipment...when removing that. So I don’t think it’s a good idea, but, in times of a pandemic, which, you know, doesn’t happen every day… if the women is able to contact you telephonically… and discuss with you… it is an option, but I don’t think it should be routinely provided.  lockdown [levelOB/GYN in South Africa]Emergency contraceptives under Okay, you’ve mentioned a lot of things that fall under self-care. So looking at the community that we are catering for...it’s not a very, for lack of a better term, “learned community,” so we really don’t advise for them to start doing self-care because they might do it the very wrong way, and then they’ll come and blame us. The best strength that you can actually teach them is when you…gather in one place and then you speak to them, and then you send the information. That’s sometimes more effective than we’ve seen because when we give even digital stuff without actually having a physical interaction with them, they don’t actually learn that way. But they learn more effectively when you see them, and they get to see the methods. So... when you speak about any...contraception they see them, they touch them, then they understand, “oh, that’s what it is”.  materials that could be used should be something that is simple to understand with the community because, if we put into technical language, not everyone knows how to read...It can be not only a cartoon, but in a way of messaging or breaking down into a cartoon or into different languages that they could read and relate. [Community Advocate in Zambia]The kind of IEC  in the bathrooms or in health facilities, but all the other ones that you’ve mentioned, the calendars check, the pregnancy test, those things are not available. I don’t even know, even as you’re talking to me now, I’m wondering…where are those packs available? [Community Advocate in South Africa]Okay, in order for there be a change or increase or anything like that…the youth has to be first aware that there are self-care services or management that are available out there…Like, the condoms, the only thing that they know about is where they can get [Finally, KIs shared their recommendations for making self-care methods more widely available. Suggestions included making all contraceptive methods more available on an outpatient basis and making people aware that self-care options are available and where they are available.In this study we found that few women in South Africa and Zambia have used SRH methods or services defined as “self-care” by WHO (apart from condoms), even in the context of the COVID-19 pandemic. However, South African respondents were interested in learning more, especially about ECPs, subcutaneous injectables, and CycleBeads, while Zambian respondents wanted more information and access to condoms. Key informants, including healthcare providers, generally endorsed benefits of SRH self-care, but some, especially in Zambia, had reservations about women’s ability to utilize these methods and services. Our findings highlight that even though women are interested in self-care methods, mixed views of providers and other KIs could prevent wider dissemination of self-care options.While survey respondents expressed interest in SRH self-care, most IDI respondents in this study had little direct experience with it. In addition, the COVID-19 pandemic exacerbated lack of access to self-care options such HIV and pregnancy testing because of movement restrictions  and incrOne way to potentially improve access to SRH self-care methods and services that female respondents expressed higher interest in, such as ECPs, condoms, and pregnancy tests, would be to make them available through the private sector. However, the costs of contraceptive methods and other SRH self-testing supplies, as well as physical accessibility of pharmacies and drug shops may still limit access to only those with resources. For example, as noted by key stakeholders in South Africa, costs are higher in the private sector, fewer pharmacies exist in rural or under-resourced areas (like townships), and, during the COVID-19 pandemic, extended periods of restriction on movement limited access outside immediate areas of residence. Therefore, introduction of self-care methods, such as over-the-counter OCs, into pharmacies, without considering other policy changes or innovations to service delivery will likely not be sufficient. Examples of policy changes from other settings that might increase access include advance provision of ECPs or pregnancy tests at health facilities and providing multiple months of OCs and doses of self-administered injectables during a single clinic visit. While this study did not ask respondents about their preferred source of self-care methods, it is an important topic for future inquiry to ensure access to these methods and supplies in convenient and discreet locations, whether that is the public or private sector or both.While expanding access to SRH self-care is crucial, it is important to underscore that not all people want to use SRH methods and tests themselves and some prefer to have some level of interaction with a healthcare provider. For example, people who desire covert contraceptive use, possibly due to partner opposition or fears of gender-based violence, may want to obtain their method at a facility . Also, aAs mentioned above, providers and key stakeholders had mixed opinions about the role of SRH self-care. More providers in South Africa reported seeing the benefits of educating women on these options and making them more available throughout the health system, while more Zambian providers were worried about women’s education levels and their ability to use the methods “correctly” and not “misuse” them, a concern found in prior research of providers’ perspectives on SRH self-care , 20. SimMost KIs interviewed were not supportive of the idea of IUD self-removal, though a small number mentioned that they think that women can be educated on how to do it and some acknowledged that it might be an option during emergencies like COVID-19. In both countries, IUD use is very low (< 2% of contraceptive users) , 4 and tThis study had limitations. Most importantly, this study was conducted from August 2020 to June 2021, when the COVID-19 pandemic was an ongoing worldwide public health emergency. Therefore, it is possible that female respondents and KIs expressed more interest or support for self-care than they would have in standard health care conditions. However, as we documented in the results of the COVID-19 survey, most respondents did not report difficulty accessing their preferred contraceptive method at the time . This prThis study found that few women in South Africa and Zambia have used self-care methods for SRH, but are interested in learning more about them. KIs, including health care providers, reported more mixed opinions, though they reported more frequently discussing self-care during the COVID-19 pandemic. Future research should confirm women’s desire for access to specific self-care methods as part of standard services outside of the unique conditions of COVID-19, as well as identifying populations that have particularly high demand. Healthcare provider perspectives are also essential, since without their acceptance and participation, access to self-care methods will remain stunted regardless of demand from users. Ensuring that access to self-care information, methods, and services is more than just a temporary measure deployed by health systems has the potential to increase access to SRH care and support women’s autonomy and healthcare needs.Additional file 1. Self-care questions asked in surveyAdditional file 2. Self-care prompts used during IDIs


Healthcare students are a population more at risk for mental health issues, especially anxiety, depression, and suicidal thoughts. The health faculty of Université Paris Cité in France, Paris has implemented a Mental Health First Aid (MHFA) course aiming to improve students’ mental health literacy, self-care and peer-support and to decrease stigma about mental illness. We conducted a qualitative study exploring the lived experience of this MHFA training course among healthcare students so to better assess its implementation within this specific context and population.This qualitative study used the five-stage inductive process to analyze the structure of lived experience (IPSE) approach. All the healthcare students that had completed the 2-day MHFA training were approached to participate. Data was collected through individual semi-structured interviews and inclusion continued until data saturation was reached. Data analysis was based on an inductive, descriptive, and structuring procedure to determine the structure of lived experience characterized by the central axes of experience.Twenty students were included. Data analysis produced a common structure of lived experience based on three central axes of experience, (1) a personal experience, (2) a student experience and (3) a professional experience. The participants all experienced this course intertwined within these 3 axes. Their motivation to take the course was personal -being of feeling concerned by the topic-, was study-oriented – to learn and revise psychiatry- and was professional – so to develop both practical and soft skills. In their personal experience, participants reported a transformative experience and some interventions with friends and family, while both in their student and professional experience, they felt frustrated with both the content and the form of the course.The results reported similar outcomes reported in the literature about skills, knowledge, and awareness; but mostly produce original avenues about how to better adapt such course to this specific population so to better address students’ expectations and mental health issues. This MHFA course -with an adapted content addressing eating disorders, self-mutilations and sexual and gender-based violence – could be part of the early curriculum of healthcare students. The latter could then benefit from a level 2/advanced MHFA course years later specifically tailored for healthcare professionals. N = 1925), with similar prevalence of anxiety symptoms (55%), 7-day depressive symptoms (23%), 12-month prevalence of MDE (26%) and 12-month prevalence suicidal thoughts (19%)-  training to medical and healthcare students since April 2022. The French MHFA training program is an adaptation of the original Australian program -translated and tailored to fit with French culture and health system  – based To our knowledge, the only qualitative study focusing on healthcare students was conducted in Hong Kong among 25 nursing students, exploring their views about the MHFA training . These sQualitative research is a relevant approach in implementation research to explore an intervention – or here a training course- focusing on the process and effectiveness but also on the context in which and the environment where it occurs . This quThis exploratory qualitative study used the Inductive Process to analyze the Structure of lived Experience (IPSE) approach . IPSE isThe MHFA course has four pedagogical objectives: to acquire basic knowledge of the most common mental health disorders ; to gain a better understanding of the different types of mental health crises; to develop interpersonal skills; and to better cope with aggressive behavior. It lasts 2 days, with 16 participants divided over the 2 days into groups of four, to encourage discussion. The course content is detailed in The health faculty advertised about this training opportunity- optional and free of charge- in a monthly newsletter distributed to all the students through e-mails. Interested students then registered for the different sessions through the year. At the time when the study recruitment took place, 153 students volunteered and undertook the 2-day training course.Our research group included three psychiatrists and two medical students, all instructors in MHFA training. The train-the-trainer course takes 5 days, and participants are required to have completed the Mental Health First Aid course, as well as having theoretical, practical and/or experiential knowledge of mental disorders, such as being a mental health professional or expert patient. The course is based on theoretical presentations and practical exercises, enabling participants to “experience MHFAA training as an informed participant,” “explore the tools and practices available for conducting training” and “practice conducting Standard Mental Health First Aid training” .For heuristic purposes—that is, to enable to discover new unknown elements and to produce original findings—the group’s members were highly diverse, especially in their knowledge, age, gender, and backgrounds. The group worked continuously on reflexivity during open discussions among themselves.Two members of the group reviewed the qualitative and quantitative literature systematically, to confirm the study’s relevance and originality. They verified that no qualitative study of this specific topic had been conducted within a similar context. To ensure that the other group members could remain inductive and open to novelty, they had access to this review only after they had completed the data analysis.the quality of dialog during the interview, the aim of the study and the sample specificity. Inclusion of new participants continued until the analysis of new material no longer yielded new findings; that is, data collection and analysis were complete when the research group considered that the axes of experience obtained provided a sufficient explanatory framework for the data collected . No students that agreed initially to participate to the study dropped out. Data analysis produced a common structure of lived experience based on three central axes of experience: (1) a personal experience; (2) a student experience; and (3) a professional experience . TranscrN = 3), or through a family member (N = 3), or both (N = 5). Through this training, they were seeking to take better care of themselves and their loved ones.All participants said they were already aware of mental health related issues. Choosing to take this training course was directly linked to a personal involvement and motivation. More than half of the participants were directly concerned, either personally  just by the title, I knew I was going to like it, I wanted to know more."Finally, others saw it as part of their civic responsibility, a moral duty.P12 “It’s a feeling of duty done, I mean as a citizen, I’m doing my duty.”The importance of this personal motivation was so preponderant that one participant wondered about the course impact without such motivation.P15 "People who don't volunteer to take part, they won't be receptive, I don't know what they'd retain, I guess, it would still be better than nothing."Most participants considered this two-day training course to be a meaningful experience that left lasting impact on them and their views on mental health in general, and on psychotic disorders and suicidal crises in particular. Participants described a “deconstruction” (P1) of preconceived misconceptions, specifically on these two topics.P3 “The way I’ve seen it before, psychiatry is for the crazy people, both the real ones and the fake ones, the one that need to invent problems for themselves.”P5 “I think I had some prejudices that I wasn’t aware of.”Some participants recounted how MHFA training had helped them correct stigmatizing ideas they had about psychotic disorders, the disorders most misunderstood by students.P19 "I didn't know anything about psychotic disorders, I mean, I knew what everyone thinks they know about schizophrenia, which is bullshit! Well, now I know it's all bullshit, the stories about the dangerous, violent madman and all that."For some, however, this remained a boundary they could not cross.P9 "I don't feel too ready to intervene as a first aider… a psychotic crisis I don't feel at all ready to deal with, depression yes, anxiety attacks it’s fine too."Similarly, some participants reported the prejudices and stigmatizing ideas of other students about schizophrenia during the course.P1 "I was quite surprised to see that many had deep-rooted prejudices, all these false beliefs about schizophrenia.”P7 There's one thing that struck me, there was this student who said " yes but schizophrenia is another level” and I said to myself it's an absolute failure of this training, schizophrenia It's the most stigmatized disorder, he's there so he feels concerned, but only for depression, anxiety, but when it comes to schizophrenia, that's when things get stuck.”They considered the suicidal crisis as the paradigmatic application of the MHFA, and described a shift in their attitude, several explaining “dare to ask the question now” , or “ask again if there are suicidal ideas”(P8)-.P20 “when I learnt that you had to ask directly the question about suicidal thoughts, I wasn’t expecting it at all, I thought it was exactly the other way around, that you were supposed to turn around without saying it, my preconceived idea was completely shattered.”In general, many felts more empowered to act, and spoke about an increased capacity and willingness to engage with people with potential mental health issues.P4 "I don't know if I'm ready to be a mental health first aider, but I'd take the step of reaching out more easily."P6 "I've understood that listening means keeping quiet, leaving moments for the other person to really talk and tell me things."P20 the question “how are you”, I ask differently now, I really mean what I ask, I say “how are you feeling lately”. And I ask it even to myself.»Many participants did not have the opportunity to put their Mental Health First Aider status into practice. Yet, they were already “advocates”, correcting their loved ones when they made stigmatizing and discriminatory remarks.P2 "I told my uncle that it had nothing to do with laziness, that it was a symptom of his depression."Others had already intervened with a friend or family member with a chronic disorder, with the aim of encouraging them to seek help from professionals.P20 "My friend thanked me, saying that without me he wouldn't have gone to see a shrink, that's a personal satisfaction!"If this objective was not achieved, they noted a change in their interactions with this relative.P1 "I tried it with my sister, it wasn't too conclusive, but still by listening to her and comforting her, her attitude changed, it worked better."Finally, one participant recounted assisting a friend in suicidal crisis at a party, experiencing the practical value of what she had learned in the training.P11 "If I hadn't done the training, I wouldn't have succeeded, but there I was the only one who really went all the way and asked the questions about suicide! And having talked about it with friends, they said to me 'but I don't know how you managed to ask the right questions (…) from the moment I said it, it switched…; it broke a taboo and he really talked."Many of the participants, particularly the medical students, decided to take this course to learn – for younger students – or revise – for more advanced students – psychiatry, that is the academic course in their curriculum.P16 "I'm in my third year, we only had a few neuropsychiatry classes last year, but I'd revised more the neurology part, which was more difficult, so I really didn't know much, and here in two days, I got ahead of the program."P12 “It's for the general population, so I knew it wouldn't be detailed, it wasn't a psychiatric training course, but it's always good to have a reminder.”Taking this MHFA training course was motivated by a lack of courses on mental health and psychiatry in their academic curriculum.P5 "Honestly, we hardly have any courses on mental health or psychiatry in the first three years, so as soon as I see an option or training on the subject, I go for it."Students then expressed frustration with the theoretical content of the MHFA course; they would have liked to know more, to have gone into greater depth on aspects not covered by the training.P8 "I was expecting something more medical, a bit more medical gestures, a bit more explanations, more in-depth explanations of mental disorders."P13 “It was good for a first approach, but I would have liked to have seen a little more, a little more in-depth (…)to know more about the underlying mechanisms of the disorders.”Similarly, they would have liked a pedagogical summary or an exam to assess their knowledge.P17 "I would have liked it if, at the end, we could have gone over the key points together, the essential notions, that would have helped me integrate them."P19 "I was expecting a quiz or an exam, something to confirm or validate what we'd learned."Students emphasized both their ability and habit to learn and assimilate content quickly, hence a certain frustration not to have learned more.P8 “In medicine, we are used to learning fast, learning well and learning a lot.”P10 “We medical students are used to a higher flow rate, so there was a certain frustration not being able to go further.”Repetition of the same messages and memorization exercises, particularly the acronym listing the steps and actions in the MHFA plan, were seen as useless and a waste of time, even infantilizing for a few, undermining the pedagogical power of the course.P18 "We had to repeat, mime and draw “AERER”(the French acronym of the MHFA plan)… even though we had all understood it straight away… and then we didn't have time to answer more specific questions."Most students valued the course’s active and interactive pedagogy.P20 “It wasn't a top-down course, you had to stand up and move a lot, exchanged ideas, took part, got involved; that was so stimulating (…)”Very few students spontaneously addressed the issue of students’ mental health. When the interviewer did, many said that the course content was not sufficiently adapted to the specific suffering of students. Even if anxiety, depression, and suicide were well addressed and seen as the main issues they had observed in the student environment, others of equal importance to them were missing, namely eating disorders, self-mutilation and sexual and gender-based violence.P1 "I would have liked to see a focus on eating disorders, as they are very common among students.”Although the issue of sexual and gender-based violence was beyond the scope of this training course, several students felt it was essential to address this issue within the two day-course anyway.P10 "The only issue not tackled is sexual and gender-based violence, but it's not completely in the scope (…) the section on aggression focuses on physical aggression, whereas students experience more moral or sexual aggression… Being a woman and talking to my female student friends, I can tell you this issue is essential and should be in the course."Finally, participants raised the question of the student group that had formed over the 2 days, with a wide range of experiences, from a lack of ties and interactions to a strong sense of belonging and the prospect of mutual aid within the group.P5 "We weren't much of a group. At lunchtime, people scattered, people didn't eat together, at times when there was no training, we were free electrons."P10 "We were very interactive, we were a group, and we were able to really talk; in fact, we've kept in touch and we've already said we could help each other if needed."In addition to the personal and student motivations already mentioned, several participants reported a significant event during their internships at the hospital that led to their decision to take this training course. For one, it was an unsettling encounter with a patient with psychiatric disorders with difficult interactions both with the patient and the medical staff. For others it was a supervising health professional who recommended the training.P11 "During my nursing internship in orthopedic surgery, I went to talk to a patient who had psychiatric issues, but I hadn't been told. He started reacting strangely, and I was taken by surprise, so I left the room and cried because I didn't know what to do (…) "plus the doctors blamed me a bit, saying, your studies are going to be tough, so why are you crying?P10 "During my internship, a patient killed himself and the doctor told me it might be interesting to do this training."Most of the participants aimed, through this course, to be able to interact better with their patients, as part of their internship or in their future professional practice.P2 “If I was faced with a patient in crisis, I felt I did not have the tools.”Once again, this professional motivation was accompanied by frustration, as the training was not tailored for healthcare professionals. As future healthcare professionals, the students found it absurd that they were taught how to “encourage appropriate professional help,” but not what professionals do after.P3 "It's biased because I'm a medical student, so I admit I was a little frustrated, I was left wanting more… We're told how to direct them towards professionals, yes, but the professionals are us, well tomorrow, but I did understand that it was for any audience, so that's normal."P6 "We were learning to be first-aiders and not doctors, but it was often frustrating."The fear of doing things badly or not knowing how to do things was a recurring theme.P5 "I was a bit afraid, afraid of making mistakes and triggering reactions… and afraid of not being able to help, of not having the tools (…) either to do and do badly, or not to do, which is no better."All the participants then emphasized the practical, concrete knowledge they had acquired over the two-days course, and the know-how they had acquired. They specifically mentioned “communication tools,” “relational techniques,” and “phrases to say and those not to say.”P10 "learning concrete things is essential for our future work, words not to say, words or questions not to avoid… that's really what I was looking for in this training."P3 "This training showed me 'how to do it'… how to approach these people…"At the end of the training, many felt ready to apply this know-how in internships with patients more than in their everyday lives.P10 "In the street, not so much, but in my internships at the hospital, I feel ready, I feel ready to talk to a patient about these subjects."Similarly, they valued the concrete, “real-life situation” aspect of their training, which compensated for a gap in their academic teaching, making a distinction between learning about the disease as a theoretical object but not about person that is sick.P5 "We have psychiatry courses, and it's good to have all the theory, but we don't have an illness in front of us, we have a patient, a human being."Several participants also recognized that this concrete interactional know-how was more difficult to transmit and teach than the theoretical courses to which they were more accustomed to.P9 "practice is more complicated, it's more difficult than acquiring theoretical knowledge, plus we are so used to retaining theoretical knowledge in our courses."P4 "in the end, this course is mainly designed to teach us communication and listening skills, so it's harder to pass on and put into practice."For some students, the transmission of this know-how would have required more practical training, for example by doing more role-playing so that everyone could experience during the course what it is to act as a mental health first-aider. But others felt that the training was balanced in its theory/practice ratio, and that adding more practice would be at the expense of the reflection and theoretical knowledge needed by the mental health first aider.P10 "One role-play per person so that everyone has experienced it, for me that would be the basis."P11 "It's not as practical as I'd imagined, but on reflection, it couldn't be much more practical."In fact, this was the major difference raised by participants between somatic first aid and MHFA, which for them required more thought.P20 “(Somatic) First aid is about reflex, cardiac arrest equals massage, you don't ask yourself questions, MHFA isn't about reflex, it's about reflection,…the plan, the acronym you can't apply it stupidly, you have to think, and for that you need to know enough about mental disorders.”Many students felt that this training had also had an impact on their interpersonal and soft skills. First and foremost, it was a question of ethical posture in the relationship with the people they would be helping. They emphasized notions such as availability and respect for others.P3 “Being available, saying ‘I’m here’, that’s what I learned from this training.”Participants who were already in contact with patients talked about how they had integrated this “savoir-être” (know-how-to-be) with their patients.P1 "I feel more at ease addressing these issues, and I do so with my patients (…) I've understood that listening means keeping quiet, leaving moments for the other person to really talk and tell me things."The others projected that these soft skills would shape their future professional identity.P10 "I think it's important for future healthcare professionals to have already integrated a posture, a way of acting and interacting with patients, a way of doing things."Some findings of this study are in line with some MHFA training outcomes reported in the literature, such as the improvement of students’ awareness, knowledge, and literacy about mental health, as well as the development of empowerment to act , 23, 24.Academic Medicine to advocate the urgent inclusion of MHFA training in medical curricula, with the same parity as the physical first aid training , 39 were pharmacy students (23.5%)- only 16 were in nursing sciences (10%), 4 in physiotherapy, 6 in midwifery and 5 in odontology. Further studies should focus on each healthcare profession to explore the specific aspects non-covered by our results.Yet, we consider that we were able to reach data saturation among this specific, concerned, population. Third, subgroup analysis of male students and women students did not reveal any differences between them in relation to the results, although gender differences have been described in terms of prevalence of mental disorders and mental health risks , and proThese results of this study directly question the need to develop a specific MHFA training course directly addressing students’ mental health issues and related issues, such as gender-based and sexual violence as well as educational format better aligned with students’ level and healthcare training modalities. When delivered to future healthcare professionals, this course should be integrated into the curriculum and the internships so students can apply and use MHFA skills not only as citizen with their friends, family, and peers but also as healthcare professionals with patients. This would enable a better transfer of learning and at the same time participate to reduce stigma of mental illness among healthcare professionals. In practice, based on our findings, we would recommend to, first increase the amount of mental health and psychiatric courses given during the first years of healthcare studies; then to integrate into the curriculum, during the first or the second year, as an optional course this 2-day MHFA course with an adaptation of the content closer to what students are experiencing in order to improve self-protection and help among peers; and finally to create a level 2/advanced MHFA course specifically tailored for present and future healthcare professionals.The raw data supporting the conclusions of this article will be made available by the authors, upon reasonable request.Ethical approval was not required for the studies involving humans because the research complies with French regulations governing observational research involving students . The study was conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.JS: Conceptualization, Formal analysis, Investigation, Methodology, Writing – original draft. PE: Formal analysis, Validation, Writing – review & editing. TB: Formal analysis, Funding acquisition, Validation, Writing – review & editing. YD: Investigation, Validation, Writing – review & editing. M-AP: Formal analysis, Methodology, Supervision, Validation, Writing – review & editing.