Objectives: Public health interventions can be improved by understanding peoples’ explanatory models of disease. We explore awareness and perceptions of cardiovascular diseases (CVD) and options for preventative actions in young adults living in rural Andean communities.Methods: We used convenience sampling to select 46 men and women from communities in Cajamarca (Peru). Subjects participated in eight focus groups where they discussed their understanding and perceived causes of CVD as well as barriers and pathways to healthy lifestyles.Results: Fresh foods, physical activity, unpleasant emotions, and healthcare access were cited as important determinants of healthy lifestyles. Barriers to healthy diets included lacking nutritional knowledge, fluctuating food prices, and limited access to foodstuffs. Women felt particularly vulnerable to CVD and identified gendered barriers to manage stress and engage in sports. Low health literacy, poor doctor-patient relationships, and long distances prevented participants from fully accessing healthcare.Conclusion: CVD prevention interventions should consider local knowledge of these diseases and of healthy lifestyles, and harness ongoing programmes that have successfully promoted good nutrition in children and pregnant women. In concert with public-private parterships, governments should include disease prevention interventions for the entire family. Cardiovascular diseases (CVD) accounted for 20% of deaths in Peru in 2016 . DiffereIn 2004, the first National Health Strategy for Control and Prevention of Non-Communicable Diseases was published in Peru . HoweverTo address this issue, this study examined local understandings of CVD and healthy lifestyles among Andean adults in Cajamarca, Peru. Specifically, we explored participants’ personal awareness of CVD and the barriers to adopting healthy behaviours using the Health Belief Model (HBM). The HBM framework focuses on understanding personal attitudes, beliefs and practices, which is crucial for the development of intervention approaches that are culturally acceptable, people-driven and bring people closer to the health system –13.This study was carried out in the provinces of San Marcos and Cajabamba in the Cajamarca region, in the northern highlands of Peru between 1800 and 3,900 m above sea level (MASL) . These pSeveral governmental programmes are active in this area. Nutrition interventions include Vaso de Leche, which gives breakfast to pregnant women and children under 6-years-old and Qaliwarma, which gives breakfast and lunch to school aged children. People can also access conditional cash transfer programmes, such as Juntos which is intended for pregnant women and families with children under 15 years old, and Pension 65 for adults over 65 years old that live in extreme poverty . In the Screening for CVD risk factors, including blood pressure, lipids, and glucose measurements, is done at the health centre level, but it is not extended to the primary health care level in the local health posts. The screening in the San Marcos Health Centre reaches 5–7% of the population, which does not reach the Ministry of Health’s goal of 10% .We conducted focus group discussions with adults in the Province of San Marcos and Cajabamba. This research was conducted within the framework of a randomised control trial (RCT) focusing on child health outcomes . A subsaFor this qualitative study, we used convenience sampling to select participants from the larger RCT. Subjects from eight out of the 68 potential communities were invited to participate. Communities were located at different altitudes and distances to the main district .The field supervisor and a fieldworker visited the participants’ household and invited them to take part in the focus groups 3–4 days before the scheduled session. Between 5 and 8 male and female individuals participated in eight focus groups. Two focus groups were comprised of only women, the other seven included the participation of at least one man .Focus groups (FG) were held at a central location such as a school or community centre, or at a participant’s house. During the focus group, the first author acted as the moderator, and two assistants worked as observers. The moderator facilitated the discussion and encouraged all participants to discuss the questions included in the FG discussion guide .The Health Belief Model (HBM) is used to study individual health perceptions and is suitable for identifying factors relevant for the prevention of public health problems such as CVD , 12, 18.We recorded all FG discussions and two assistants took notes on verbal communication. Following each session, project staff transcribed the audio recordings, identified the participant speaking, and re-listened to the tapes to ensure accuracy. Data was organised using the Dedoose qualitative analysis software .For analysis, the codebook consisted of topics identified in the FG guidelines and emergent themes from the data. The moderator and the two observers coded the data. If differences in coding appeared, consensus was reached after a team discussion. Extracts were organised into tables, with identifiers for the focus group, the participant number, and the theme code. As focus groups included communities of different altitudes, which may influence their access to markets and healthcare, we added an identifier next to each quote “high-altitude” (> 2500 MASL) vs. “low-valley” (< 2500MASL). Additional demographic and health information for the participants was available from the larger study where this research was embedded , 15.A total of 46 participants (37 women and 9 men) partook in the eight FGs. Two focus groups lasted 30 min and the other six lasted 1 h on average. This excluded the time needed to explain the project and obtain consent. Demographic and health information of the participants are shown in In all FGs at least one participant knew a person who suffered from a CVD, but there was dissatisfaction with the knowledge that was available and accessible about the prevention and causes of CVD. Following up on why there is a lack of information, a 26-year-old woman expanded that she had not received information on CVDs from the health services, “Because the health staff in this health post only cares about the main reason of your visit. For example, child growth control. They just examine that and it’s done” . Another 34-year-old man expressed a similar sentiment, “About nutrition, about other diseases, for example, tuberculosis, human immunodeficiency virus infection, cancer. For all those … yes, there is prevention … different pamphlets, but very few about the heart” . High levels of illiteracy are an additional factor complicating understandings of CVD. As a woman in her mid-30 s stated, “The one who knows how to read, can read. But the one who doesn’t know, only observes” .While the participants expressed dissatisfaction with the level of information available for CVD and cited that they have not had in-depth discussions of CVD previously, they still expressed knowledge about the causes and symptoms of CVD. Specifically, they mentioned that symptoms of CVD included agitation, pain, weakness, and strong beating of the heart and that the ultimate consequences of CVD were heart attacks and death. In all focus groups the participants stated that anyone could develop a heart disease, no matter their weight or age.Additionally, participants identified a number of drivers of CVD, which fell into four general categories: nutrition, physical activity, emotions, and access to healthcare. We found few differences in the perceived drivers of CVD between the low-valley and high altitude communities. In the case of access to healthy nutrition and access to healthcare, distance to markets and healthcare were important limitations for communities at high altitudes. However, the availability of various foodstuffs in the local and district markets, and the availability and acceptability of health professionals at the health establishments were cited as important drivers of health in both settings.Study participants expressed that CVD is associated with being both over and under-nutrition. Interestingly, a 33-year-old woman stated, “When we have fat in the heart too, and is not necessary that we are fat” . Another woman in her mid-30s clearly articulated, “If you are overweight or you are underweight, it is equally bad.” .Participants also made direct connections between nutritional health and food. A woman in her late-20 s living in the low-valley confided, “Sometimes, we only eat to fill our belly, without realising that it is not truly nourishing us.” The same opinion was shared by a woman in her early-30 s living in a high altitude community who stated that, “Sometimes we eat things that are bad for us and we know that they are going to be bad for us. But we eat out of necessity because there is no other thing to eat.”The identification of structural barriers to adopting a nutritious diet were common and included not being able to access healthy foods, not having the economic resources to purchase them, and lacking knowledge about how to prepare healthy foods. These barriers varied across geography and occupation. More than one third of the participants were farmers, but reported that they did not regularly consume products from their crops. A man in his mid-30 s told us that, “50%  you have to buy and another 50% is produced in the field” .Participants living in the low altitude valley (2000–2100 MASL) reported that they can grow all types of food. However, community members in higher altitudes (over 2500 MASL) are limited in their crop variety and also had issues with accessing fresh food products such as vegetables, fruits, and animal protein. Barriers to obtaining these products included the cost to reach a market (which could be between 30 min and 2 h away), time spent getting there, and issues with food storage. As a woman in her late-20 s pointed out, “Food cannot be stored for a long time, maybe two or 3 days because we do not have a refrigerator, a place where to keep the food” .On the other hand, local bodegas provide constant access to non-perishable foods and drinks, which are cheaper. As a 36-year-old man quipped, “Mostly you decide what food to buy according to the economy, right?” . But even buying foods at the bodegas was complicated because food prices changed every week because of the many intermediaries involved. As a woman in her mid-30 s explained, “You know the intermediaries always have to take advantage, right? They live off that, so sometimes they sell a product at a certain price and the next week they change it. Then, in the local store, items are more expensive” . Local challenges to accessing, purchasing, and storing foods lead people to preferentially buy non-perishable foods such as rice, noodles, oil, and sugar, especially those participants living in distant communities.Participants indicated that physical activity was beneficial for their wellbeing and recognised it as a preventive measure for developing CVD. They mentioned being highly active because of their daily agricultural and farming work, which they enjoyed and kept them busy. For example, a man in his late-20 s stated that, “We get health benefits, and economic benefits…. to be useful (for field work)” . However, participants explained that recreational physical activities such as sports were often limited due to lack of time, religious and local beliefs, and gendered factors. A 37-year-old man shed light on this saying, “The word of God  has forbidden us to play football. We always bet sometimes, right? Sometimes we have anger at the partner because he is beating us. Sometimes we do not play well.” .Women appear to face dual pressures. On the one hand, participation in sport appears to be expected of mothers. A mother in her late-20 s expanded by saying, “Sometimes in the schools, in kindergartens, the moms have to participate. There is no way you do not participate. If the babies see that their mother does not want to, then they will not want too. So, you have to participate, no matter what.” . Yet there is also gendered pressure to refrain from sports as a 36-year-old woman stated that “Sometimes women are expected to stay at home and take care of their family and not spend leisure time in sports” . Gendered dynamics in CVD risk factors were also evident in group discussions regarding the perceived role of emotional stress in CVD.Participants articulated that negative emotions could contribute to heart problems and also that knowing they have health problems could produce negative emotions. A 28-year-old woman stated that, “My aunt … sometimes she suffers attacks. She has been told to avoid being melancholic, to avoid worries. Nothing, nothing. No worries, because if she is worried or melancholy she can die” . Indeed, participants connected both physical and emotional stress to strain on the heart. A young woman explained that, “Sometimes when you lose your patience. You feel that your heart beats faster at times like this. Sometimes you have anger, let’s say, it’s a moment … ” , while a woman in her late 30 s expressed a similar sentiment in relation to physical activity, saying, “When you walk and feel agitated, then you feel pain and sometimes “stitches.” Well then, you think it is the heart, right?” .These quotes indicate that negative emotions or over-exertion create heart problems, but participants also indicated that simply knowing about having heart problems can produce substantial distress. Indeed, a number of participants expressed that they would feel sad and worried if they were diagnosed with any CVD as the costs of treatment, or losses due to death, could drive economic insecurity for the entire household. Women worried about themselves and their partners saying, “If my husband gets sick, I have to spend money, I do worry” ..Discussions in the FGs revealed why women appeared to be more prone to this type of worrying. A woman in her late-20 s explained, “It seems to me, I say it is because men go to the farm, they occupy themselves there, they forget about everything. On the other hand, the women stay at home and sometimes we have worries about the children … everything, that can also be it (a risk factor of CVD) or maybe not” . A man in his late-30 s expressed a similar explanation, “Maybe … (Women are at higher risk) because sometimes we, men, go to work, it is a single job and the ladies stay at home, they work different tasks … they worry sometimes and think “There are things that I don’t have …. I do not have money” Finally, participants expressed that they would rather not know about a potential cardiovascular condition because of the stress it might cause, saying, “It is better to not know (that you have a CVD). Just stay quite during the pain, then it goes away and you forget…. if you know what you have, it is worse” . However, even for those who are interested in knowing about their CVD risk, there are substantial barriers to accessing knowledge, affordable treatment, and care at the local health posts.Participants cited costs associated with transport and food as a barrier to healthcare. As a result, they stated that they typically only went to the clinic for a pressing health issue and not for regular check-ups. A woman in her late-20 s stated, “If it does not hurt, I don’t go to the doctor. If it hurts, I will go to check what is going on. On the contrary, we should have general check-ups, for example, annually” . Appointments at the health post also needed to be scheduled in person, potentially creating two lengthy and costly trips, and creating a high initial barrier to seek care..In addition to challenges in accessing care, participants criticised the quality of patient-provider relationships. They felt that they were not treated well nor receiving proper attention because the health professionals were inexperienced and prescribed painkillers for every condition. According to a 27-year-old woman, previously, “There was a good nurse, but they relocated her to the hospital. And here, we only have trainees. This is what happens here at the health post.” Finally, she added “All the time we receive the same medicines. When we go with our children, we already know what they will prescribe to us” More problematically, participants were receiving conflicting medical advice that was not evidence-based. A 37-year-old women revealed that:“I went to the health post with my results (lipids and glucose measurements). They  told me: “No, there is no medicine, you can only take warm water before eating.” I told them I couldn’t eat in the morning. They told me that anyway I should eat a little bit …. but I should eat. They told me to start eating less but not to stop eating. They told me better to buy wine and drink a glass before going to sleep to get rid of the fat. But, I have not seen any results” .. A similar sentiment was expressed by a 27-year-old woman, “Yes, sometimes one feels bad. You can try to look for flowers, and drink flower waters, you can use also lemon, orange, custard apple” .This type of medical advice appears to be intersecting with local explanatory models for the treatment of CVD. One 32-year-old woman stated, “For example, if the heart is not well and they  tell you it is because of the fat then you try to eat things that do not affect your heart. Right? I know that you have to drink pineapple juice and because you know this is good for the heart then you drink it this is a medicine…. right? It is unclear whether these remedies were coming from healthcare practitioners, traditional healers, or fellow community members. What is apparent is that the public health messaging for preventing and treating CVD is not clear. Despite this, participants related CVD to nutrition and exercise and many participants showed an interest in adopting healthier diets and increasing physical exercise.In this paper, we explored how Andean adults in the Cajamarca region of Peru understood CVD, including the drivers of CVD risk, and perceived barriers to adopting healthy lifestyles. While the understandings of CVD were basic, study participants stated that nutrition, physical activity, negative emotions, and healthcare were important drivers of risk. Although focus groups were located at different altitudes, with differing physical access to markets and health establishments, all participants shared concerns regarding the availability of food products in markets and the capacity and availability of health professionals. We expand on these findings with particular attention to how they can inform National Health Strategy for Control and Prevention of Non-Communicable Diseases and their strategies for vulnerable high-altitude populations .Many of the participants in this study knew that CVD was potentially life-threatening and expressed a desire to be better informed. However, participants made it clear that health communication strategies via text or print-outs would not reach illiterate community members. Instead, they suggested that nutritional workshops with demonstrations of healthy cooking and nutritional discussion groups could effectively engage community members.Such nutritional workshops, if designed holistically, could address many of the barriers to the adoption of healthy eating behaviours , 22. ParWe suggest that future studies should be conducted in close collaboration with Andean women to design nutritional interventions that can improve health and wellbeing at all life stages. There are existing governmental programmes such as Haku Wiñay (“My enterprising farm” in Quechua language), which supports the raising and trading of domestic animals and entrepreneurship in small-scale agriculture . HoweverAdditionally, opportunities exist to build on public-private partnerships for CVD prevention. For example, the Peruvian national dairy company collects milk from the remotest areas of the Andes at least weekly. Considering that the company maintains this regular supply chain with remote outreach, building public-private partnerships could help in providing healthy foods to highlanders who otherwise travel only monthly or bi-weekly to local markets. However, to be feasible, such initiatives need to be linked to system-wide changes and interventions.Peru has successfully executed multi-level actions to address childhood undernutrition and anemia using a combination of programmes in the areas of health, education, cash transfer, water and sanitation, housing, and agriculture , 25. CVDTask-shifting  is anothThis study has a number of limitations, including that it was restricted to the northern Andes of Peru, used convenience sampling, and was conducted in young adults in their 30 s. Perceptions of CVD may differ in other Andean areas and in older individuals. Villagers participating in the FG also knew each other, potentially influencing their participation. However, they collectively reflected a community view, which was particularly valuable when discussing locally feasible and acceptable intervention approaches. Additionally, most of the FG participants were women, which may have biased the answers especially about gendered differences. However, as household managers and family-health knowledge-bearers with the most regular contact with health facilities, we believe they and their participating husbands closely represent the broader community perspective on CVD health matters. Lastly, sometimes participants answered our questions but referred to other disease experiences such as malnutrition and infection. Adding the sections of patterns of distress and perceived symptoms to the HBM helped in the understanding of our questions.In conclusion, this research revealed that there are many feasible entry points of intervention that can prevent Andean community members from succumbing to world-wide increases in CVD. Specifically, local women are key stakeholders who can influence their own health and the health of all family members. Therefore, they must be empowered with the knowledge and resources to enact healthy lifestyles. We see substantial opportunities for this to occur by expanding existing government programmes that are addressing child nutrition to make healthy foods and healthcare accessible, promoting healthy lifestyles and by building on public-private partnerships that can support access to healthy food for all community members.


Men who have sex with men (MSM) are at a disproportionate risk for HIV infection and common mental disorders worldwide. In the context of HIV, common mental disorders are important and are frequent drivers of suboptimal prevention and treatment outcomes. Mobile ecological momentary assessments (EMAs), or the repeated sampling of people’s behaviors and psychological states in their daily lives using mobile phones, can clarify the triggers and HIV-related sequelae of depressive-anxious symptoms and contribute toward the design of ecological momentary interventions (EMIs) that cater to the contextually varying needs of individuals to optimize prevention and treatment outcomes.This study aims to characterize the feasibility and acceptability of mobile EMA among high-risk MSM in Hanoi, Vietnam. It aims to evaluate the perceived relevance, usability, and concerns of this group with regard to the content and delivery of mobile EMA and the potential of leveraging such platforms in the future to deliver EMIs.Between January and April 2018, a total of 46 participants were recruited. The participants completed 6 to 8 mobile EMA surveys daily for 7 days. Surveys occurred once upon waking, 4 to 6 times throughout the day, and once before sleeping. All surveys queried participants’ perceived safety, social interactions, psychological state, and mental health symptoms. The morning survey further queried on sleep and medication use within the past 24 hours, whereas the night survey queried on sexual activity and substance use and allowed participants to share an audio recording of a stressful experience they had that day. At the end of the week, participants were interviewed about their experiences with using the app.Participants completed an average of 21.7 (SD 12.7) prompts over the 7-day period. Excluding nonresponders, the average compliance rate was 61.8% (SD 26.6%). A thematic analysis of qualitative interviews suggested an overall positive reception of the app and 5 recurring themes, which were centered on the relevance of psychological and behavioral items to daily experiences , benefits of using the app , worries and concerns , usability , and recommendations for future design .Mobile EMA is feasible and acceptable among young MSM in Vietnam; however, more research is needed to adapt EMA protocols to this context and enhance compliance. Most participants eagerly provided information about their mental health status and daily activities. As several participants looked toward the app for further mental health and psychosocial support, EMIs have the potential to reduce HIV and mental health comorbidity among MSM. Approximately one-third of people living with HIV worldwide meet the criteria for a common mental disorder (CMD), such as depression and anxiety -4. AmongSmartphones and other information and communication technologies have become increasingly attractive options for optimizing prevention and treatment strategies. Given their accessibility, affordability, and availability, these digital technologies promise to widen access to health care generally and specifically among vulnerable groups by lowering costs and the traditional barriers  hindering participation. Mobile health , or the delivery of interventions and other health services via digital technologies, can take the form of SMS text messages, multimedia messages, mobile apps, and social media campaigns, among other options. mHealth interventions have shown promising results in improving medication adherence ,25, healGiven the heterogeneity of risk among MSM -46, mHeawithin an individual. Comparisons of ecological momentary assessment (EMA) to retrospective approaches using calendars or audio and computer–assisted self-interviews have suggested that the retrospective approaches may contribute to the underestimation of sexual and substance use behaviors by as much as 50% and lead to distortions in specific details, including partner characteristics , I felt a lot more comfortable, as though there was nothing more I wanted to share. Whenever I can share everything I want, I will feel lighter. [My mind] still feels heavy, of course, but my mental state will feel better than if I were to just dwell on it and keep it inside.20 years, PTSD+/HIV–In some cases, the audio recording was seen as even therapeutic as it allowed participants to share distressing thoughts or feelings that they otherwise would have concealed. One of the participants contrasted the freedom he exercised in sharing details of his life in the app with the caution he felt when disclosing to friends:[I] feel reluctant to be open, to share with others. You see a lot of surveys because I shared everything I had, because in my heart, I think that, first, you’re a stranger, and second, you won’t affect my life. So, I can say all those things comfortably, and even more. But when I must talk about these issues to my friends or co-workers, it becomes very difficult, very different. You can be very close to a colleague and think of them as a close friend, but when they’re not able to keep your secret, then a second person [might know]...In their mind, they might think they’re just sharing with a close friend of theirs, but that close friend might share with another close friend, then another close friend, then a rumor circulates. So, I have this cautiousness towards those whom I interact with.25 years, PTSD+/HIV+Questions that were considered less relevant to participants’ everyday experiences were generally centered on alcohol or drug use. Although a few participants reported drug use in the past 6 months, most felt that their use was not frequent enough for either drug use or drug craving to be repeatedly sampled:I’m not someone addicted to those drugs so most of the time I won’t be affected by them. It’s only sometimes when I feel like using them, and when I do, it’s only for fun. So, I think those questions are irrelevant to my life.24 years, PTSD+/HIV+Others thought that despite their infrequent use of substances, the questions were still relevant as they were still exposed to drug-related activities in their everyday lives. Several participants felt that they should be able to document those events as those exposures can make them feel uncomfortable or increase their desire to use.hopeless or happy, several participants favored using a Likert scale ranging from negative to positive:As many questions focused on PTSD and negative affect, some participants felt that the prompts were more appropriate for someone in greater psychological distress than them. For this reason, some suggested the addition of more positive questions . Furthermore, as multiple questions measured the same construct , items were sometimes seen as repetitive and requiring a more careful read by participants. Some participants believed that the emotion measures, for instance, required them to parse their affect too finely. Instead of having items such as Questions like “happy” or “proud” are probably okay because people can separate between the two, because those emotions are different. But the questions that are more negative, [you should] reduce those because if someone is already thinking negatively and they keep reading those questions, it’ll also drag their mood down more.28 years, PTSD+/HIV+Nearly half of those who used the app said that they believed it increased their self-understanding. In particular, many believed that using the app enabled them to better understand their emotions and the individuals or situations that elicited those feelings. In doing so, some participants believed that the app made them more truthful about their emotions and what specifically they had accomplished that day:When I do the surveys, I realize that sometimes I have symptoms that I didn’t notice before; like, an hour ago I might have felt calm, I might have felt anxious, or I might have felt something else...Before I wouldn’t notice these things. Since I started doing the surveys...I [started thinking] to myself that, yes, I do have these symptoms, symptoms I didn’t notice before.23 years, PTSD–/HIV+With this increased self-understanding, a few participants believed that an additional benefit of using the app was that it enabled them to better monitor and regulate their emotions over time, that is, to identify what they could control and what they might need to change. For some, this form of self-understanding formed the basis of their desire for greater self-care:I know how to control my emotions more because if every 2-3 hours I have to answer the survey, then automatically, I have to think about whether I was happy, sad, stressed, or whatever else in the past hour. When I answer those questions (for myself), then I have to reassess how the situations were affecting my mood. So, I can control those factors better.25 years, PTSD+/HIV+Those who reported no new self-understanding or benefit often found the questions too reflective of their everyday life and therefore could not offer new insights:It’s because normally I am someone who understands themselves well already, so your app has the effect of helping me determine what I’m feeling at an exact moment. After that, I can adjust it myself so that [my mood] slowly goes back to being normal. But to say that I understand more about myself, I don’t think I did.25 years, PTSD+/HIV+Participants reported a few worries or concerns associated with using the app as they perceived the survey as similar to other questionnaires they had completed before and because of the detailed briefing they received before starting the study:Actually, [the surveys are] like a test, or an assessment. They don’t cause any problems or concerns. That’s because it’s...it’s like you’re just monitoring your health, doesn’t really concern much else.25 years, PTSD+/HIV+I mean, I already found out all the information before I agreed. For instance, if this were PrEP, even if you gave me a lot of money, I still wouldn’t. The truth is I only do the things that are good for me. I’m not going to be a test mouse. Psychological questions are fine because it doesn’t really affect me in any way, but PrEP, that affects my health.26 years, PTSD–/HIV–Others expressed privacy concerns related to the accessibility of their surveys. In particular, some participants worried that others might see their screen while they were answering sensitive questions about their sexual behavior or medication use, although only one of the participants experienced a situation in which someone had seen his responses:On one of the days [I participated], my nephew was being naughty and took my phone from me. It was also right when I had been filling out a survey. He read some of the questions and asked what I was doing, why there were questions related to marijuana, drug use, all that. I had to sit him down and explain to him that I was participating in this study at Hanoi Medical University, that it wasn’t anything serious...In this situation, I knew how to resolve it, but for others, it might create a misunderstanding.24 years, PTSD+/HIV+Participants found completing the initial EMA survey with a research staff helpful. Most participants did not experience any difficulties in navigating the EMA form. Participants struggled the most when uploading an audio file. Depending on the model of their phone, some were not able to record and upload directly onto KoBo but had to use a third-party platform to save the files. Others were also initially confused about the kinds of files they could upload and submitted photos instead.When asked whether they would use the app outside of the study, most participants said that they would but that their use would depend on how busy they were. Some emphasized that their use of the app was largely motivated by their current interest in mental well-being:It depends on the time-point. At this time-point, I’m very concerned about my mental health, and whenever I finish a survey, I always re-ask myself the questions. While I am still confronting these [mental health] problems, I will answer the prompts because they help me identify what works for me. In the future, when I no longer have these problems, I will think that [completing the questions] isn’t important, that it is fine to respond, fine not to respond. I won’t care anymore.25 years, PTSD+/HIV+When asked what features would encourage their long-term use of the app, a few said that they would feel more encouraged to use the app over a longer period if they could see daily or weekly trends in their responses or were given personalized recommendations to improve their health or general well-being . Most participants emphasized that their continued use depended less on new features than on changes to the existing study design, including the number and scheduling of the prompts:When I am available, I will do it. When I am not, then I won’t do it because it’ll be too much. But if I’m free, then what else am I doing but playing [Candycrush]?23 years, PTSD–/HIV–Others thought that their willingness to answer the prompts was variable throughout the day, depending on their mood:When I am tired, I’ll be truthful and say that I don’t want to do [anything]...There are times when I don’t want to do anything, let alone a survey taking 5-10 minutes, ticking off questions after questions. And, as I’ve said, it eventually gets boring when you have the same [set of questions] every day. I also think that [reception to] the survey will depend quite a bit on the psychological state, the mood, of the person taking it.25 years, PTSD+/HIV+) their everyday experiences  rather than strictly completing a survey. Having interactive features was also found to be critical in increasing engagement.When asked to provide recommendations to increase future compliance and better tailor content to their everyday experiences, 5 main themes emerged. First, there was an emphasis on supplementing the initial training with detailed reminders on how to use the app, as the participants reported initial confusion when completing the first few surveys on their own and having to contact the study staff for assistance. Second, the wording of the daily prompts and study questions should be made as personable as possible. Although the current phrasing was deemed easily comprehensible, it was also seen as too clinical. Where possible, the participants thought the text should be more MSM friendly, prompting people to share . Personally, I feel too embarrassed to say aloud my inner thoughts. Writing is okay, but I fear sitting alone and talking aloud like that because when I do I feel as though I’m being autistic . Singing is okay, but talking aloud like that is similar to splitting yourself in half .It’s because people feel embarrassed. Why? The audio recording is like a diary, except you write in a diary; here you have to record, retell. It’s [related to] personality type, like, you might feel embarrassed because you’re more introverted. It makes you feel autistic . This could be done by combining similar questions, occasionally changing the order of questions to make the surveys more interesting, and introducing new questions. Having access to aggregate data, particularly those that compared participants with the group average, was seen as potentially motivating, alongside receiving custom health information:[The app] keeps asking these questions, everyday these same questions. I think it needs to be a little different, so there’s enthusiasm to answer.28 years, PTSD–/HIV–This study found that mEMA is a feasible and acceptable way of monitoring dynamic interactions between mental distress and HIV risk among young MSM in Vietnam. Overall, participants found the questions pertinent to their everyday experiences of psychosocial stress and were willing to use the app in the future. Participants identified items related to PTSD symptoms, emotions, and social interactions as most relevant to their everyday experiences. Most preferred having open-ended questions to elaborate on their stressful encounters, as they found doing so therapeutic or personally informative. Some expressed concerns about data privacy. Although the number and length of EMA surveys were considered potential hindrances to long-term participation, the impersonality of the app and the scheduling of the prompts rather than their frequency were identified as primary barriers to participation. Participants recommended that the language be made more MSM friendly and that future iterations of the app include personalized end-of-the-week reports to encourage long-term use.Given that our sample was highly exposed to trauma, identification of barriers to feasibility and acceptability was important. Our compliance rate was noticeably lower than those reported previously in similar studies with MSM -73. AlthIncentivization structures can motivate compliance. Doherty et al  highlighin the wild. Most of our participants readily looked to the app for mental health and psychosocial support information, which is encouraging for digital mental health interventions. However, this inadvertent reliance on the app for mental health and psychosocial support contributed toward a second set of concerns about reactivity or when the frequency, intensity, or quality of a target measure change as a result of monitoring [Our concern that mental health stigma may lead participants to underreport experiences of mental health and psychosocial distress was largely unfounded -83. For nitoring . Specifinitoring ,86, othenitoring ,87,88. G (roughly means “autism”), which is highly stigmatizing within the country. As mHealth and telehealth approaches are becoming more widely adopted worldwide [Responses to the survey further highlighted some of the cultural specificities that might contribute to differences in the perceived acceptability of an app in different populations. Notably, our sample strongly preferred open-ended questions about their life but disliked the option to self-record as they found the behavior—when done alone—to be indicative of orldwide , the queorldwide . Anthroporldwide ,92. Thesorldwide . It is pThis study is innovative in several ways. To our knowledge, this is the first study to examine the feasibility and acceptability of using mobile technology to model the dynamic relationships between mental distress and HIV risk in a low-resource setting, and it is the second EMA implemented in an LMIC . The stuThe primary limitations of this study include the generalizability of the findings and potential reactivity. First, although the sample size was larger than comparable studies, participants were recruited from community-based organizations and clinics and, thus, present a subpopulation in Hanoi that accesses sexual health services and are engaged in care. Participants were additionally drawn from a previous study among those who had agreed to be recontacted; therefore, these individuals may be more inclined to volunteer in research. Compared with the national average, our sample was also more highly educated and had a higher income ,96. ConcOur study illustrates the feasibility and acceptability of mEMA studies among high-risk Vietnamese MSM. Participants were receptive to and invested in future studies and interventions. The findings of this study can inform the design of future EMA studies to optimize relevance, usability, and acceptability. Achievement of the Joint United Nations Program on HIV/AIDS  95-95-95


In times of crisis, communication by leaders is essential for mobilizing an effective public response. During the COVID-19 pandemic, compliance with public health guidelines has been critical for the prevention of infections and deaths. We assembled a corpus of over 1500 pandemic-related speeches, containing over 4 million words, delivered by all 50 US state governors during the initial months of the COVID-19 pandemic. We analyzed the semantic, grammatical and linguistic-complexity properties of these speeches, and examined their relationships to COVID-19 case rates over space and time. We found that as COVID-19 cases rose, governors used stricter language to issue guidance, employed greater negation to defend their actions and highlight prevailing uncertainty, and used more extreme descriptive adjectives. As cases surged to their highest levels, governors used shorter words with fewer syllables. Investigating and understanding such characteristic responses to stress is important for improving effective public communication during major health crises. During times of crisis, communication by leaders is essential for mobilizing an effective and coordinated public response. The COVID-19 pandemic presented leaders, and for the purposes of this study, specifically governors, with one of the greatest public health challenges in modern times. Communicating specific public health guidelines to the public and promoting their compliance has been central to meeting this challenge, as the actions and behaviors of individuals directly impacted pandemic spread and individual outcomes, including illness and death.1, and that specific word choice is often designed to shape public opinion2. A recent study found that after Brazil’s president intentionally and publicly minimized the importance of social distancing and downplayed the risks of the COVID-19 pandemic, social distancing behaviors in areas with strong political support for the president decreased relative to areas with weaker political support for the president3.The specific words through which leaders choose to communicate can have a direct effect on public compliance with public health guidelines such as social distancing and mask-wearing. Prior studies have shown that people’s behavior can be significantly affected by the manner in which instructions are presented5, demographic characteristics6, personal linguistic style8 and emotional state9. Speeches can also be influenced by the dynamics of the unfolding crisis9 and the underlying characteristics of the local population.Leaders employ diverse approaches to public communication. The words chosen by leaders have been found to be associated with a wide range of factors, including the leader’s political affiliations10, historical epidemiology11, historical positivity bias12, cultural shifts13, and political trends14. Applying these approaches to modern political speech, studies have variously examined the semantic content, grammatical properties15, and linguistic complexity16 of speeches by public leaders. Studies have found that the complexity of speeches declined during times of crisis19.Computer-based approaches to analyzing large corpora of texts provide a systematic quantitative approach to identifying salient patterns in the texts, which can in turn reveal deeper underlying phenomena. With the rise of computer technology and increased digitization of texts, corpus linguistic methods have been used to study a wide range of phenomena, including the evolution of languageIn this study, we assembled a corpus of over 1500 pandemic-related speeches delivered by governors of all 50 US states during the initial months of the COVID-19 pandemic. We set out to study the associations, across both space and time, between COVID-19 case rates and the semantic, grammatical and linguistic complexity properties of these political speeches. We sought to determine whether the spatial and temporal dynamics of the pandemic affected the topics that governors chose to speak about, as well as the manner in which they did so. We also investigated the relationships between pandemic intensity and characteristic linguistic markers of stress, which can undermine effective public communication strategies at the time they are needed most.We assembled a corpus of 1515 speeches, containing 4,049,146 words, delivered by all 50 US state governors. Median speech length was 1984 words, with speech lengths ranging from 100 words to 12,557 words. The number of available speeches varied by state, and by month within each state , words relating to religion such as “pray” and “God” , and words relating to extreme descriptions such as “dramatically” and “extraordinarily” .COVID-19 cases rates were positively associated with words relating to hospitals such as “ICU” and “ventilators” . They were also positively associated with negation words such as “can’t” and “no” , words relating to issuing strict public guidance such as “prohibited” and “compliance” , descriptive words relating to the concept COVID-19 cases rates were negatively associated with words relating to jobs such as “employment” and “workers” , words related to travel such as “tourism” and “hotels” , words describing formal communication formats such as “announcement” and “declaration” , and words describing helpful actions such as “hospitality” and “assistance” . Perhaps unexpectedly, words describing emergency situations such as “crisis” and “disaster” , as well as words describing specific protective measures such as “sanitizer” and “quarantine”  were negatively correlated with COVID-19 case rates.Next, we systematically analyzed all parts of speech for association with COVID-19 case rates over space and time. Figure COVID-19 case rates were positively associated with past-tense verbs such as “asked” and “did” , present-tense verbs such as “argues” and “claims” , and adverbs such as “rapidly” or “reliably” .COVID-19 case rates were negatively associated with possessive pronouns such as “his” or “your” , plural nouns such as “people” or “cases” , and base-form verbs such as “respond” or “walk,” which are typically used in future tense settings .COVID-19 case rates were negatively associated with average word length and with average syllable count, over both space and time, as shown in Figs. By analyzing over 1500 pandemic-related speeches delivered by all 50 US governors, we found that COVID-19 case rates were strongly associated, both spatially and temporally, with the linguistic properties of governor’s speeches, including semantic categories, parts of speech, word length and syllable count. Below we present possible interpretations as to how these results might be understood, recognizing that other possible interpretations also exist. For example, governors may be less influenced by changing cases and more influenced by the evolving political discourse around the pandemic, which could affect their choice of words.Some of the positive relationships identified were not surprising; for example, the increased use of hospital-related words (HOP), extreme descriptions (MST) and words related to the concept “bad” (BAD) as COVID-19 case rates increased. For example, regarding HOP, New York governor Andrew Cuomo said, “There was a global rush for ventilators and literally we have people on the ground in China.” California Governor Gavin Newsome said, “that represents a 10.7% increase over yesterday.. hospitalizations in the state of California and ICU beds again those are the numbers that I look at first thing every morning.” As cases increased, governors also used stricter words to issue public guidance (ORD), consistent with increasing urgency to promote compliance with public health guidelines.Some of the negative relationships were also not surprising: As COVID-19 case rates went up, governors spoke less about travel (TRA); travel activity slowed dramatically due to closures and lockdowns, and the relative importance of travel may have decreased in the face of an ongoing public health emergency. As COVID-19 case rates rose, governors also spoke less about words relating to jobs and employment (JOB); while increased pandemic-related unemployment was certainly an important issue, its relative importance may have temporarily decreased in the face of the ongoing pandemic.We observed a positive relationship between COVID-19 case rates and words focused on religion (REL). During the initial peak of the pandemic, when many people were falling ill and dying, governors often turned to religious and prayer-related terminology to console, show empathy, or offer hope to their constituents. For example, Governor Phil Murphy of New Jersey said, “We keep each of their memories and their families in our prayers, and please join us in that regard.” Governor Jim Justice of West Virginia said, “Only God above knows, and he’ll get us through this. I absolutely am confident about that beyond belief.”We also observed a negative association between COVID-19 case rates and words describing formal communication formats, such as “announcement” and “declaration” (COM). This is consistent with governors spending less time discussing the formalistic structure and format of their briefings, and more time focused on delivering actionable messages. We also observed a negative association between words describing helpful acts (HLP) and COVID-19 case rates, which may be attributable to governors focusing on telling people to stay in their homes rather than go out and help others.We also observed some potentially unexpected relationships. There was a negative association between COVID-19 case rates and words describing the situation in terms relating to “emergency” (EMR), consistent with governors not wanting to facilitate further panic as the crisis worsened. We also observed a negative relationship between words relating to preventative measures (PRV) and COVID-19 case rates, whereas one might have expected that governors would increasingly emphasize preventative measures as cases rose. For example, early on, Massachusetts governor Charlie Baker said, “please help us stay ahead of the virus and prevent the spread through the simple steps we have talked about before: face coverings, hand-washing, hygiene, and social distance.” One possible interpretation is that governors continued to speak about preventative measures, but also spoke more about other topics, causing the percentage of words related to preventative measures to decrease.While there was much discussion early in the pandemic around testing, personal protective equipment, and the status of the elderly, particularly in nursing homes, we did not find any strong correlations for these categories.As COVID-19 case rates increased, we found an overall shift in verb usage from future tense (VB) to past (VBD) and present tenses (VBZ). This is consistent with governors shifting from talking about what they are planning to do in anticipation of the looming crisis, to describing what they are currently doing or what they have already done to respond to increasing case rates.We observed a shift from nouns to verbs and adverbs as COVID-19 case rates rose. This is consistent with speeches becoming more oriented towards describing actions being taken to respond to the pandemic. Additionally, there was a shift away from the use of personal pronouns (PRP$), consistent with governors speaking more about what is being done rather than by whom it is being done.We observed a strong, positive relationship between COVID-19 case rates and the use of negation words (NEG), consistent with the interpretation that as case rates rose and pressure to respond to the crisis mounted, governors responded in a number of ways that involved the use of negation words. These included speaking in a defensive manner about the actions they were taking and the limits of their authority, as well as highlighting the prevailing uncertainty that they faced. For example, Governor John Bel Edwards of Louisiana said, “I don’t know when that’s going to come and I don’t know in what amounts, I don’t want to speculate beyond saying that at some point in the next couple of weeks we should have an REC meeting.” New York governor Andrew Cuomo said, “I can’t mandate personal behavior, I never could. My strategy from day one, knowing that we were going to have to ask people to do things that no government has asked them to do, maybe since World War I or World War II.” Mississippi governor Tate Reeves said, “I don’t have the authority to shut them down, therefore I don’t have the authority to reopen them. Mississippi is not China but we have to continue to be vigilant in attacking this virus.” West Virginia governor Jim Justice said, “We don’t need to hear that that’s nothing but garbage. We don’t need to hear that we know what this killer is all about and it’s everywhere, and on the other side we really don’t need to hear all the noise that says, you know, really and truly, now we’re opening up swimming pools so we’re going to kill 19 other people and everything we got to know we don’t need that noise either.”20. Saslow et al. found a decrease in linguistic complexity associated with stress, along with elevated heart rate and increased cortisol reactivity21. Buchanan et al. found decreases in word productivity to be associated with stress, increased cortisol levels and elevated heart rate22. Acute stress responses to stress-inducing speech tasks have been found to reduce function of the prefrontal cortex23, decrease cognitive flexibility24, and impair working memory25 .We also observed a negative relationship between COVID-19 case rates and average word length and syllable count. Interestingly, this association was strongest in US states that experienced the highest rates of COVID-19 cases. The use of shorter, simpler words as COVID-19 case rates surged is consistent with a characteristic response to stress on the part of the governors. Public speaking tasks have been shown to be highly associated with acute physiological stress17 and academic leaders18 declined during times of crisis19. Green et al. studied communication by US Congress members during the COVID-19 pandemic and identified increasing polarization between political parties during the start of the pandemic26. Pennebaker and Lay studied 35 of Rudy Giuliani’s press conferences over years that included two periods of crisis, including the September 11, 2001 attacks; they found certain linguistic shifts associated with crisis, including the use of negation words and shorter words, though not all shifts were consistently observed over both periods of crisis9.Some studies have looked more broadly at how leaders respond to crises. Suedfeld and colleagues found that integrative complexity of speeches by politicalTo the best of the authors’ knowledge, the present study is the first to identify the spatial and temporal relationships between pandemic dynamics and pandemic-related public communication by leaders, including examining characteristic linguistic measures of stress in response to crisis intensity. These associations can be used to guide and inform future research about the impact of the linguistic properties of political leaders’ speech on important public health communication measures such as compliance by members of the public.This study is subject to certain limitations. Though we collected over 1500 speeches containing over 4 million words from all 50 US governors, some delivered speeches were not available to be included in the analysis. Whereas we analyzed the response to a major pandemic within one level of government of one large country, responses to other crises in other locations and other levels of government may vary. We analyzed speeches at the single-word level, providing many rich dimensions of information; multi-word patterns contain further information, and are a subject for future studies. Whereas we focused on speeches during the first few months of the pandemic, responses during later stages of the pandemic may differ. The spatial analyses comparing all 50 states may be subject to potential confounding, as certain non-pandemic-related state variables such as population density and political affiliation may affect word choice. To address this, we also conducted the temporal analyses—case rates and certain linguistic features were found to move together over time as cases rose and then fell within multiple locations, eliminating many potential confounding variables  which do not change significantly on the timescale of a few weeks.As mentioned above, the content and linguistic properties of governor’s speeches may be influenced by political approach and priorities, personal demeanor and the choice of which information sources a governor chooses to rely on. Governors may also deliberately modify their speech styles to increase comprehension by general audiences. In this study, we have proposed possible interpretations describing how COVID-19 case counts may affect governor speech patterns. It may also be the case that governors’ speeches may affect COVID-19 case counts. This is another topic worthy of future study.Computational linguistic methods are a powerful tool for exploring how leaders respond to emerging crises. By assembling and analyzing a large corpus of speeches delivered by all 50 US state governors during the initial months of the COVID-19 pandemic, we found that governor speech patterns were strongly associated with COVID-19 case rate dynamics across both space and time. Several of the observed effects were consistent with responses to increased stress at the height of one of the largest public health crises in modern times. Such effects may serve to decrease the quality and impact of public health communication, or alternatively, may serve to improve it (as shorter words and greater urgency may heighten the power of the message). Analysis of similar bodies of text from other political leaders and public figures, at different levels of government including at the national level, from different public crises, and from different stages of the COVID-19 pandemic would be key to understanding if the patterns identified here are consistent across different conditions. It would also be worthwhile to study additional potential markers of stress, and to apply more advanced NLP methods. Investigating and understanding the effects of these characteristic stress responses is important for improving communication during major public health crises, both present and future.Rev; (3) the online video sharing service YouTube, and (4) the social networking service Facebook. All transcripts were curated to include only words spoken by the governors themselves. There was no apparent bias in which speeches were made available, and speeches from the governors’ offices do not appear to have been redacted in any way.We collected pandemic-related speeches delivered by governors of all 50 US states from February 27, 2020 through July 14, 2020, a period during which most states experienced at least one wave of COVID-19 cases. Transcripts of public speeches were obtained from four primary sources: (1) Governors’ offices, via public websites or direct correspondence; (2) the commercial transcription service New York Times based on data published by state and local health authorities across the United States27.For each of the 50 US states, we obtained data on confirmed cases of COVID-19 per 100,000 persons, assembled by the For each state, for each word, we tabulated total word counts for each speech. We included only words spoken by 20 or more governors, and which represented at least 0.02% of all words spoken across all speeches in at least one of the 50 US states.Words that met the above criteria were grouped by two independent raters into semantic categories. Words with multiple common meanings, or that could not be neatly categorized into a single semantic category, were excluded from the semantic grouping analysis on a case-by-case basis.Natural Language Toolkit library of Python version 3.6.2. We also calculated measures of linguistic complexity, including average word length (number of letters) per speech, and average word syllable count per speech.In addition to grouping words by semantic category, we also grouped words by part of speech using the part of speech tagger from the over space—across each of the 50 US states for the entire duration of the study period, as well as over time—across each week of the study period for a given single US state. For the spatial analyses, we normalized word counts as a percentage of all words spoken by that governor across all speeches in that state. For the temporal analyses, we normalized word counts as a percentage of all words spoken by that governor across all included speeches in that state during that given week. To ensure sufficient sample size, the temporal analyses were conducted only in states for which a total of at least 50,000 words from speeches were available.We systematically analyzed the associations of each of these linguistic features  with COVID-19 case rates per 100,000 persons. We analyzed these associations r is the estimate of the correlation and n is the sample size. For the temporal analyses, in which multiple Spearman’s Rho values were available (one from each included state), we used the standard formula for a distribution of values. As a visual aid, we fit polynomial curves to the temporal plots using the numpy.polyfit function of Python version 3.6.2, and plotted them alongside the original data points.For the spatial analyses, we calculated confidence intervals using the formula for finding the confidence interval around a single Spearman’s Rho value: where Further information on research design is available in the Supplementary MaterialsReporting Summary


However, little attention has been paid to the gaps and silences within these narratives. The aim of the present study is to interpret the silences detected in the discourse of pregnant and breastfeeding women concerning environmental risks and food safety. (2) Methods: This descriptive, interpretive, observational study was conducted according to a qualitative research paradigm and from a phenomenological and ethnographic perspective. The study sample was composed of 88 intentionally selected women, among whom fifty interviews, three ethnographies and five focus groups were conducted. Data coding and analysis were performed using N-Vivo 12 software. (3) Results: The results obtained show that the women’s discourse presented silences that reflected their minimisation of perceived environmental and food risks. However, these women were wary of food produced in the proximity of contaminated areas. Nevertheless, the participants believed they were powerless to overcome environmental pollution and the potential contamination of their own bodies. (4) Conclusions: The participants’ minimisation of the environmental risks faced and their inaction in this respect are sustained by the biopolitical practices of public institutions, which have propelled these women into a situation of learned helplessness and social injustice. Silence is a meaningful resource that adds light and shade to communicative practices and merits the attention of qualitative researchers. People communicate their ideas, values and beliefs mainly via the spoken word and non-verbal language but also through their silence. Studies have observed the importance of silence in their interpretation of discourse, in the view that “what is left unsaid” is also of pragmatic value ,2. This Social theorists have argued that silence during discourse is an affirmation of non-existence, and hence the verification that there is nothing to say, or to see, or to know, on the subject under discussion ,8. Some Camargo and Méndez ,14,15 haDiscursive silences guide inferences and reveal a special orientation towards (or sense of) the communicative act. They are markers of agreement or disagreement, intensifiers or attenuators, by deception or by concealment, argumentative, humorous or ironic. Structured silences are used to distribute communication turns, to mark non-preferred responses, to signal coordination errors, to energise the conversation, to promote changes of topic or to request attention or support . Other sThe aim of the present study is to consider the functions of the psychological and normative silences  presenteSpecifically, the silences interpreted in this study are those occurring within the narratives offered in interviews, focus groups and ethnographies of the participating women, resident either in Almanzora  or Tarragona .To provide some context for our research, these areas were selected for study due to their specific, relevant circumstances. In January 1966, in Palomares, very near Almanzora, two US military planes, one of which was carrying four atomic bombs, collided during aerial refuelling and crashed. Although more than fifty years have passed since then, the nine kilograms of plutonium spilled have not been completely cleared, so the area is still potentially contaminated by plutonium and americium ,29.The second study area is Tarragona, a city with an important petrochemical industry, which generates abundant waste, making the local air among the most polluted in the whole country ,31,32,33Specifically, in this study, we interpret the psychological and normative silences detected in the discourse of pregnant and breastfeeding women regarding their assessment of the potential dangers arising from dietary and environmental contamination. In addition, we explore the emotional and precautionary motivations that may be reflected in these individual silences during discourses on food safety and on processes of resistance to social, cultural and contextual conventions, in the view that these individual expressions may be determinants of collective silences in the assessment of environmental contamination.This study is based on earlier work conducted in two phases, in 2015 (Ref. CSO2014-58144-P) and 2018 (Ref. AP-0139-2017), exploring why and how pregnant and breastfeeding women excluded persistent toxic compounds from their diet. These investigations were descriptive, interpretive and observational and were undertaken under a qualitative research paradigm based on a phenomenological and ethnographic perspective .The study was designed taking into account previous recommendations for qualitative research . SpecifiThe health centres and the women addressed in this research were selected by intentional  non-probability sampling , taking The field work was carried out at six primary care health centres in two Spanish towns: Tarragona  and Valle del Almanzora  .The fieldwork for the first study began in January 2016, once approval had been obtained from the corresponding ethics committees in Catalonia and Andalusia, and ended in September of the same year. All participants were informed of the objectives and methods of the research, and written informed consent was obtained in every case. The three ethnographies were conducted from May 2016 to September 2017 in the two regions: the first in Tarragona city centre and in one of the neighbourhoods. the second in two municipalities in the Ribera d’Ebre area  and the third in two municipalities in Valle del Almanzora.The study population was composed of 88 women, of whom 46 were pregnant and 42 were breastfeeding. All were given detailed, extensive information about the study before the interviews, focus groups and ethnographies were held, both in written form and in a meeting with one of the researchers. The informed consent form was separate from the research information document. The protocols for the two studies were approved by three ethics committees: “Parc de Salut Mar” Clinical Research Ethics Committee (Ref: 2015/6459/I), IDIAP Jordi Gol Ethics Committee for Clinical Research (Ref. P15/135) and the Research Ethics Committee of the Andalusian Health Service in Almería (Ref: 66/2017).The two investigations were conducted in accordance with the Declaration of Helsinki .The methodological instruments employed to obtain the study data were 50 semi-structured interviews with the participating women, three focused ethnographies and five focus groups.The semi-structured interviews conducted helped ensure the discourse data obtained were of sufficient density and complexity for meaningful analysis ,41. EachThe focus groups helped promote interaction among the women, enabling them to offer first-hand information. Participation in these groups encouraged discussion and facilitated an open, flexible discourse characterised by intersubjectivity and reflexivity. Observation and analysis of the focus groups also helped the researchers identify and interpret nonverbal behaviours more comprehensively and to contextualise the silences produced .The field notes and in-depth observations compiled during the three ethnographies completed our set of methodological instruments, enabling us to triangulate methods and data and thus effectively compare the participants’ expressions regarding their preferences, norms, social representations, and food and health practices within different research contexts. This comparative approach also allowed us to analyse how medical norms and recommendations on environmental and nutritional risks are accepted, modified or ignored by the women in our study group .Previous categories were determined to codify the narratives and facilitate their subsequent analysis. The categorization was carried out following to the classification of silences according to their pragmatic functions described by Camargo and Méndez ,14,15 inThe women’s discourses were digitally recorded during the interviews and focus groups. During the latter, in addition, two of the researchers took notes and observed the participants’ non-verbal language, while a third researcher moderated the proceedings. Interviews were conducted during the ethnographic work; the researchers also took field notes that were later digitized for computer processing and analysis according to the previous categories.The interviews and group sessions were professionally transcribed and the discourses were encoded using N-Vivo 12 software.Following the analytical schemes for qualitative research recommended by Atkinson and Hammersley (1994), Ruíz (2003) and Flick (2007) ,42,43, oThe above procedure provided the basis for an interpretive analysis of discourse and silences from a hermeneutical perspective . This glThis first section presents the women’s spoken narratives, together with silences reflecting affective, expressive and cognitive dimensions of their discourse. In the context of our field work, these silences can be interpreted as emotional restraints or acts of hesitation during the participants’ reflection. Epistemological and psychological silences imply the representation of potential pragmatic functions, i.e., those related to cognition, reflection, caution, emotion, transgression or resistance.The women taking part in our study remained silent and reflective, doubting what exactly they wished to say. This silence allowed them to mentally organise their discourse about environmental risks in their surroundings.-Moderator:And in Palomares, do you work in a food-related area?-Participant:In a (…) packaging warehouse.-Moderator:In Palomares, do people talk about this issue naturally or do they keep silent?-Participant:No. They don’t speak about it naturally, but they don’t try to hide it either. If the topic comes up in the conversation, they speak with total frankness, but they say they have absolutely no worries. We still haven’t heard of any case specifically related to that, to that question. Yes, there may be, (…) it could happen anywhere.In this account, the participant pauses twice to reflect on what she wishes to say regarding her work and the risk of contamination in Palomares.-Moderator:Do you think that in your environment, where you all live, there is any biological, chemical or radioactive risk to your health?-Participant:We are in Tarragona, I mean (…). We don’t have three eyes, because we haven’t mutated yet, but (…)-Moderator:Are you all quite sure of that?-Participant:Yes.On this occasion, the participant from Tarragona hesitates, giving herself time to formulate her perception of risk via a metaphorical remark. On some occasions, the participants appeared cautious or repressed their opinions.“Those in charge tell us (…) what they want. If you like, you believe it. And if you don’t, you don’t believe it. But you don’t do anything either. So, in the end (…)”In this participant’s discourse, there were silences, holding back her opinion on the possible negligence of the institutions in protecting the environment in and around Tarragona and on the failure of civil society to react to this situation.-Moderator:Don’t the people of Palomares talk about the nuclear accident?-Participant:Yes, yes, of course. They do talk. We do, me and my friends (…). Yes, we said it might have had an effect, too. We said that this was a bit contaminated and (…). But I’d say (…). I’d say, if it was contaminated there wouldn’t be people living here. What I mean is, for example, when the plants grow (…)-Moderator:So, do you think that around Palomares there is a possibility of contamination now?-Participant:Well, I think that when it happened (…). I don’t know. I don’t know.-Participant:The thing is, maybe, in my case, I think that things like pesticides (…), maybe they do more harm to the countryside or whatever, than the radioactivity.In this example, the participant was silent at various times, holding back an opinion that might have made her uncomfortable.During their discourse, some participants were flustered and seemed emotional when talking about environmental pollution in their community, and these circumstances made it impossible for them to continue in words.“For example, I eat a lot of fresh fish, my father goes out fishing, and you can’t even trust that, because you say (…) in the water (…) the spills from the ships (…). Perhaps when it all happened there was more perception of risk, but as time went by, the thing is (…) people don’t pay any attention, it’s just something that happened in the past, it’s all forgotten now, nobody talks about it. It happened and that’s that”This participant became emotional as she tried to describe how people in Palomares today set little store in the risk of contamination from plutonium and americium.“For me, it has a direct influence, because the plants, from the rain, from the sky, and with the land contaminated, depend on it. And the animals that eat contaminated grass, or that eat, well, everything (…) everything, everything, nitrates, everything that’s in the soil, and then everything goes into the plants. And we eat all of that (…) so yes, I do think it affects us. And here, in Tarragona, especially. What’s more, we don’t know what we’re breathing (…) I think it affects us a lot”This woman, too, was unhappy and showed her distress at the potential health risks from environmental pollution in Tarragona.At times, the participants fell silent during their discourse as a sign of disagreement or rebellion in response to an argument that was mostly accepted by the group or expressed by the researchers.-Moderator:Do you grow your own fruit and vegetables?-Participant 1:Yes, because organic produce is really expensive at the shops.-Participant 2:I used to grow things in my garden, but I stopped (…), because (…) I’d say, “I live here, in Ramón y Cajal, and I think I’m eating less healthy food than if I was shopping at the greengrocer’s”. Because the cars are going past all day. And, in the end, if I am sweeping up the dirt and it all comes up black because of the pollution, then that same black stuff has been taken up by the plants. And that’s why I stopped, in fact. You can’t trust the environment.Participant 2 started speaking and then paused, implying her disagreement about the supposed benefits of food from urban gardens in Tarragona. She found it hard to believe that an urban garden there minimises the risk of food contamination.-Moderator:But there are controls on environmental pollution.-Participant:Yes, that’s what it seems (…) If it is controlled, sometimes (…) but the food industry will be manipulating the system, they do their own analyses (…) and you can also see how they’ve got around the controls. It is controlled, yes, I’m sure, I’ve seen it, I’ve seen food plants fitted (…) with waste controls. Everything is controlled, but there’s always someone who gets around it, because what comes first is always the economic interest.This participant stopped speaking on several occasions during her interviews when the question of administrative control over environmental pollution was addressed, appearing reluctant to believe that the controls are effective—she works for a food company near Palomares.Normative silences are governed by situational, social and cultural conventions, which impose a body of norms and rules that a speaking community accepts and practices to ensure harmonious interactions.Various participants fell silent during their discourse in response to the fieldwork context and format of the situation, especially during the focus groups.“In fact, I don’t know a lot of people there, but what I’m saying is that anecdotally, when we don’t agree on something, I tell them, “That’s because you’re from Palomares” (…) but no (…) I don’t think it’s that they have worse health than us living in Vera, or those who live in (…) or those who live in (…). Health-wise, they’re all much the same”The participant paused after joking about the relationship between the non-perception of contamination risks in Palomares and the potential stigma attached to the population. She then sought to justify her ironic comment and fell silent again, realising that in the current situation and context (the discussion within the focus group) it was better to remain silent.-Moderator:And do you think that the environment also affects food, can it affect your food and your health?-Participant:Of course. Just go there, look at the refinery, see the trees that aren’t even green, the leaves are brown. Even so (…), we’ve eaten vegetables and things grown here and, for now, we’re OK. Touch wood, right? But a little, I think, it must have an effect, like everything else. But neither do I think there’s much difference between living here and living in the centre of Barcelona. Everywhere you go (…).In this example, a woman from Tarragona, after remarking that contamination is visible in the form of soot impregnated in the trees, then fell silent so as not to be so explicit, and even sought to minimise the impact of her comment. She understood that the focus group is not the right situation in which to talk about these matters, as it might cause discomfort and fear in other women who were pregnant or feeding their babies.Some silences arose from the asymmetric relationship between the participants and the moderators/researchers, who were viewed as experts in health and environmental issues.-Participant:Then, they also blamed (…) with so much internet, they said there was an array of solar panels for internet. They blamed the panels more than (…) than that, than contamination, which was a lot.-Moderator:Do people in Palomares think that these foods could be radioactively contaminated?-Participant:Well, I don’t know about that. But where I was, in the company where I worked (…) they said (…) that yes, that that could also have an effect. That it was a bit contaminated by (…). But I said (…) I was thinking, if it was contaminated, there wouldn’t be anybody living here.This participant had certain qualms about expressing her opinion. In the social context in which the focus group took place, she may have felt she was exposed to judgment. She also may have considered that in this context it was not appropriate to relate private conversations with her workmates about the environmental risks in Palomares.-Moderator:And to finish, the last section is the issue of chemical substances in food. Whether you think that food contains these substances.-Participant:Yes, but I don’t know to what extent (…), I’m totally unaware, that is, at what level, what effect it might have, do they remain or do they disappear? I don’t know what to say (…)-Moderator:To simplify, do you think these chemical substances accumulate or not?-Participant:I believe that if you (…) They don’t disappear if you regularly eat stuff that contains it (…), isn’t that right?-Moderator:In other words, for you, they do accumulate, you’d say.-Participant:They accumulate because you don’t have time to clean them out if you’re always eating products that contain them. But if you don’t eat them, then yes, they will, because your body is healthy. But if you eat, if you eat them (…)-Moderator:You accumulate them, over time.-Participant:I don’t know if accumulate is the word! Or… Yes, you do. I can’t explain scientifically how it works. The truth is that (…) I really don’t know.This participant was insecure and fell silent several times during her intervention. Her speech was not spontaneous, and she excused her ignorance on several occasions, probably because she felt she was being judged in the social context of the focus group.The participants’ discourse frequently features culturally motivated silences, expressing local beliefs and taboos about the potential risks of environmental contamination in their neighbourhood.-Moderator:Do you believe that environmental pollution affects food?-Participant:Yes, I’m sure it does (…). It would be the same as the food. In other words, at the legal level, everything is controlled, but really, they could be doing anything, which isn’t (…)The moderator asked about one of the “taboo” topics in the Tarragona area, namely the potential contamination of food grown in the area due to environmental pollution. After she started speaking, the participant first paused after saying that environmental contamination affects food. She then mentioned the culturally motivated lack of confidence among people in Tarragona regarding the levels of contamination and its control by the authorities.-Moderator:And what do people think in Palomares about the possibility of potential contamination from the nuclear accident?-Participant:They [the people who live in Palomares] (…), well (…), they are totally confident, they say they’re planting their crops, they say it’s been many years since it all happened, they haven’t seen any diseases related to it, or paid much attention to it or heard anything alarming. They’re totally confident, they regularly eat local products.The woman remained silent at first and then reproduced the official discourse among the inhabitants of Palomares that has been culturally established since the beginning in dealing with the nuclear accident.This study shows that psychological and epistemic silences can be highly significant, indicating the cognitive and emotional state of the participants in a communicative interaction. The social orientation of our analysis also highlights the importance of normative silences, i.e., those that are motivated by situational, social and cultural conventions. As observed by Méndez (2016) , silenceOur discourse analysis reveals evidence of the denial of environmental and food risk by pregnant and breastfeeding women who live in two highly contaminated areas of Spain. The first area, Tarragona in NE Spain, is contaminated by chemical emissions, while the second, Palomares in SE Spain, continues to be affected by radioactive compounds (plutonium and its decay into americium).According to our interpretive analysis, the types of silence most commonly presented by these participants were psychological or epistemic , reflectAlthough in both study areas our participants discounted the possible impact of contamination, concerns were expressed about potential health risks, about inadequate administrative controls on environmental pollution and about the possible transfer of contamination to the local foods consumed. Previous work by our research group has shown that, in general, pregnant and breastfeeding women place greater trust in homegrown foods  or foods purchased from small businesses that source their products from local farmers ,19,48. HThe women who took part in our study repeatedly stated that potential food contamination related to environmental degradation was unavoidable. This outlook was corroborated by the psychological and epistemic silences produced during their interviews and focus group interventions. Thus, several participants paused significantly during their discourses, after which they continued, “we couldn’t eat anything” in reference to the quality of the local food or “we’d have to live in a bubble”, remarking on the impact of environmental pollution. In other words, these participants acknowledge that they are unable to alter their diet and lifestyle and are resigned to accepting the situation and not attempting to change their reality. This pattern of behaviour is what Seligman  called lAnother aspect examined in our analysis is that of normative silences , when paIn Tarragona, the normative silences detected in the narratives of the participants are culturally and socially based on prevailing economic interests, as the petrochemical industry is the main employer and source of financial wealth in the area. The petrochemical complex is estimated to account for around 30,000 jobs, directly and indirectly . AccordiIn our view, both in Tarragona and in Palomares, the authorities have failed to inform the population properly about the potential dangers to health from environmental contamination; instead, they have fostered silence and passivity among civil society. According to Foucault (2007) , this apIndustrialisation and modern lifestyles are known to produce adverse effects on the environment. In turn, pollution and environmental degradation can have a negative impact on public health. For this reason, governments legislate to protect their citizens from these potential sources of harm. In contrast, however, they sometimes minimise the potential health risks of environmental and food contaminants.Our study shows that both in Palomares and in Tarragona, discourses of official truth were generated that minimised or denied the existence of environmental risk, creating a “spiral of silence” about the risk to people’s health. Our analysis of the psychological and normative silences produced in the narratives of the study participants shows that most of these women are cautious in their words and minimise the risk of contamination present in their environment, thus reproducing the institutional discourse. Nevertheless, these women are doubtful of the quality of their environment and the food that is produced there.Despite the evident problems, the populations of Palomares and Tarragona have for many years remained passive, doing little to defend their rights and health. In contrast, the US government recently acknowledged that some of the soldiers who had worked in Palomares during the recovery of the four nuclear bombs and may have been exposed to plutonium had subsequently contracted cancer. On the other hand, none of the cases of local inhabitants who have suffered from cancer in the last 55 years have been linked to plutonium contamination, despite the fact that their potential exposure has been much longer lasting than that of the American soldiers. In Tarragona, although the incidence of cancer there has risen in recent decades and is now the second highest in Spain, to our knowledge no judicial decisions have corroborated any causality between contamination and the presence of cancer among the general population. Recently, however, the High Court of Justice of Catalonia ruled in favour of a worker who fell sick with cancer after being employed in one of the leading chemical companies in Tarragona. This court associated the presence of the disease with the worker’s lack of protective equipment and his consequent exposure to ethyl, benzene and other chemical derivatives.In conclusion, we believe that the populations considered in this analysis present the phenomenon of “learned helplessness”, a condition in which people believe that no action is possible to reverse the degradation of their environment and the potential contamination of the food they consume. This condition has arisen from practices of biopolitics and biopower long exercised by public institutions, which have generated situations of grave social injustice for the populations in question.This study provides a valuable and introductory study on precautionary attitudes and minimization of environmental risk of pregnant and lactating women who live in potentially contaminated places. As a limitation, we want to highlight that the influences that the immediate context and social agents  have on the narratives and silences of women have not been studied in depth. In this way, the results emanating from this study should be considered basic material for future research that studies the influence of the close context of women in the interpretation and assessment of environmental and dietary risk during pregnancy and lactation.