Introduction: COVID-19 restrictions introduced several changes in university academic and social experience. Self-isolation and online teaching have amplified students’ mental health vulnerability. Thus, we aimed to explore feelings and perspectives about the impact of the pandemic on mental health, comparing students from Italy and the UK. Methods: Data were collected from the qualitative portion of “the CAMPUS study”, longitudinally assessing mental health of students at the University of Milano-Bicocca  and the University of Surrey (UK). We conducted in-depth interviews and thematically analysed the transcripts. Results: The explanatory model was developed from four themes identified across 33 interviews: anxiety exacerbated by COVID-19; putative mechanisms leading to poor mental health; the most vulnerable subgroups; and coping strategies. Generalised and social anxiety resulted from COVID-19 restrictions by being associated with loneliness, excessive time online, unhealthy management of time and space and poor communication with the university. Freshers, international students, and people on the extremes of the introversion/extroversion spectrum, were identified as vulnerable, while effective coping strategies included taking advantage of free time, connection with family and mental health support. The impact of COVID-19 was mostly related to academic issues by students from Italy, whereas to the drastic loss of social connectedness by the UK sample. Conclusions: Mental health support for students has an essential role, and measures that encourage communication and social connectedness are likely to be beneficial. Higher education settings can expose students to psychological and mental health distress, especially during the first year of their academic course ,2. IndeeDespite students’ perspectives on the topic have been previously investigated through a qualitative approach ,39, possThis study was reported in line with the COnsolidated criteria for REporting Qualitative research (COREQ) checklist . Data weParticipants were eligible to participate if they were 18 years of age or older and currently enrolled at one of the two universities. They were purposively sampled according to gender and age distributions, nationality, programme of study, and living accommodation to provide a variety of perspectives and experiences. Students meeting the inclusion criteria were approached by key site contacts via email and invited to participate in the study. Email invitations were repeated at reasonable intervals  for a maximum of three times until enough participants had been recruited, or the data collection period had ended. The resulting response rate of nearly 20% allowed us to reach our planned sample size.The study was approved by the relevant ethical committees of both universities (registration number: 0058642/21 for Unimib and FHMS 20-21 157 EGA for UoS), and informed consent was reconfirmed verbally immediately before the interview and evidenced by digitally signing the consent form provided by the researcher.Interview data were thematically analysed using the framework approach ,46,47. TWe conducted a total of 33 individual interviews: 15 involving students from Italy and 18 with students from the UK, of which a total of 26 (79%) were females. The sample characteristics are reported in Four themes were identified from the analysis of the transcripts, including (i) anxiety exacerbated by COVID-19; (ii) mechanisms by which COVID-19 was related to poor mental health; (iii) the most vulnerable students; and (iv) coping strategies. Themes were further distributed across different sub-themes and ordered in the text according to their frequency across the transcripts (from most to least frequent). For a complete set of participants’ quotes please see Generalised and social anxiety symptoms were widely reported by interviewees in both countries, as the most prevalent negative effects of the pandemic among students.Anxiety symptomsThe majority of interviewees (67%) mentioned anxiety symptoms as a consequence of COVID-19. Students mainly described these as exacerbated worries about the capability of dealing with a wide range of academic issues, as well as concerns for the future.“One of the biggest effects on students’ mental health was anxiety that means a lot of things, for example anxiety about work and university stuff.” UoS, M.“Unfortunately, at this moment [during the pandemic] anxiety and concern for the future, for what will come next, in my opinion are very broad.” Unimib, F.Social anxiety symptomsHowever, the perceived largest impact of the pandemic could be categorised as social anxiety symptoms. Especially considering the point of view of the youngest respondents, this condition was a likely consequence of mandatory social restrictions, finally resulting in the habit of self-isolation.“…[during the pandemic] a lot of people have been given the opportunity to lock themselves in their bedrooms and not have to talk to anyone, and they started to get used to this.” UoS, F.“I think it [pandemic] made people become more closed and more used to being online, which leads to you being more introverted.” UoS, M.Some students reported becoming more introverted, increasing time spent online, and/or feeling anxious about re-integrating with others due to the possibility of being infected.“It [pandemic] can stress some people out quite a lot and make them anxious, as well as the risk of getting COVID or that family members could get COVID. So, they want to stay at home.” UoS, F.A few students at the UoS described social anxiety symptoms as a progressive voluntary self-isolation, leading to being less comfortable in social contexts.“I think people have become comfortable staying at home and doing lectures on Teams. Now that they have to be in person, they feel a bit like forced to go back outside and this pushed them out of their comfort zone.” UoS, F.Students from Italy also described this phenomenon, tending to characterize social anxiety symptoms as a challenging return to the pre-pandemic university life, namely to in person lectures and exams (outside their comfort zone).“…this fact of going to different lectures, the university in presence and this post-pandemic situation are very difficult. It is difficult to come back to reality.” Unimib, F.“…this anxiety to interact with students, with classmates, but also the lack of desire to attend lessons in person. Now that there is the choice on the lesson in person or remotely, many students, including me too, sometimes prefer to stay comfortable at home, I don’t know if it’s for a matter of social anxiety or comfort.” Unimib, F.Few students referred to other mental health conditions associated with the pandemic, including sleep disorders, disordered eating and self-harm. Two students expressly reported an increase in depressive symptoms and only one described alcohol and substance abuse as a result of COVID-19.Six different putative mechanisms were identified, with the most prevalent being loneliness and excessive time spent online.Lonelinessn = 5). Isolation was intensified by social distancing measures and COVID-19 restrictions negatively impacted almost all participants, who described students as “being in bubbles”—bubbles was a term used by the UK Government to refer to size restricted social groups—and “being stuck in their own rooms”.Twenty-two students, equally distributed between the two universities, identified loneliness as the most common mechanism involved in the relationship between the pandemic and poor mental health. All international students spoke about loneliness, though the sample was relatively small .“Even the contact with the lecturers, beyond the lectures that could be synchronous or asynchronous, was difficult. Then, in the end everything was done in front of the computer and in my opinion it was extremely alienating.” Unimib, F.Indeed, lectures and exams held online were described as alienating and stressful, as well as favouring anxiety symptoms.“Online exams were really stressful, in particular the exams’ monitoring methods, however reliable they are. Many students were anxious or afraid to look at the screen for fear that the system will trigger the signaling for eye movements [Digital control system to detect exams cheaters].” Unimib, F.Reorganisation of time and spaceCOVID-19 restrictions and exclusive online learning frequently led to an unhealthy reorganization of individual time and space. This issue was raised equally at the two universities, by both female and male students. However, students from the UK mainly spoke about decreased opportunities to engage in social activities and the limited space to be shared with roommates for a longer time.“…you couldn’t go anywhere or do anything to take your mind off it. You didn’t have space for yourself.” UoS, F.“The pandemic has impacted students, because they had to stay with each other for such a longer period of time that they started to notice everyone defects. So, the pandemic ruined somebody’s relationships as well.” UoS, F.“There was a habit of staying there not doing anything. You wasted your time.” UoS, F.Students at Unimib were more likely to report time and space-related issues caused by a lack of a strict division between working and spare time/space, resulting in an unbalanced predominance of time dedicated to their studies.“…it did not help that one began to depend only on the university, because that was to be done, university has never stopped, not even online. It really became an “ok I wake up, then I will follow this lesson, then this other one, then I will study for this exam, then I will go to sleep”. Time was just dictated by the university.” Unimib, F.Organization/communication with universityuniversity left just as the last thing to think about”.Failures in university organization and in communication with students during the pandemic were reported as a concern by the sample from Italy based, at least partly, on already existing communication issues. Students described feeling abandoned due to the lack of preparedness in terms of educational priorities with ““…some internal communication difficulties, have come to light more clearly [during the pandemic].” Unimib, F.“University was left just as the last thing to think about, so the students felt a little neglected even with the fact that at the beginning of the pandemic, but also during the pandemic, you had no idea of how to take exams, find books, or get the information on the timetables. Many of those things happened for months. No one knew how to handle these things.” Unimib, M.Interviewees reported a deep distance between students and lecturers following an inappropriate arrangement of online lectures and exams.“I missed going to the exam and seeing the lecturer, therefore breaking a barrier that was physical. With online exams and teaching, the distance between the figure of the teacher and you as a student persisted.” Unimib, F.“[One of the sources of poor mental health was] the distance between students and lecturers in the pandemic period. Almost a surreal situation.” Unimib, M.Low motivationLow motivation was identified by five students from Italy as a consequence of the pandemic restrictions leading to poor mental health. In the most part, this was reported as a struggle to approach study, poor concentration, and withdrawal from studies.“There were many withdrawals from study attributable to demotivation [during the pandemic].” Unimib, F.“…perhaps also due to the COVID period, I personally felt a difficulty precisely in approaching studying, in concentrating, with low motivation, certainly linked, in my opinion, to university workload and also other things that I have had to face at the same time.” Unimib, F.One of the students from the UK shared their opinion about low motivation, mostly referring to a decreased desire to devote time even to sport and social activities.“I do a couple of sports and you can tell that during COVID obviously we were unable to do that and now, even though we still show up to training, we are less motivated.” UoS, F.UncertaintyDuring the pandemic, isolation and poor communication with the institutions fed the sense of uncertainty about the future and growth opportunities, both in Unimib and UoS students’ opinion.“During COVID-19 there wasn’t anything defined or certain, you know, circumstances were always changing.” UoS, F.This was mainly experienced by those living at home with their parents, who referred to having a lower sense of independence and self-determination.“…uncertainty about the future was exacerbated by COVID.” Unimib, F.“During COVID, the perspective is always kind of much grayer than it was before. Will I be able to go abroad to have an experience? I do not know.” Unimib, F.Moreover, sharing negative work experiences  with relatives might be considered as a possible moderator of the uncovered sense of uncertainty.“…some students, as well as their relatives, lost their jobs, and they felt a sense of uncertainty.” UoS, F.Freshers, as well as students living far from home, and subjects on the extremes of the introversion/extroversion spectrum were described as most at risk of poor mental health during the pandemic.FreshersLoneliness and more time spent online decreased social opportunities, especially among first year students. They were considered to be the most vulnerable subgroup by several interviewed students (33%). Indeed, it was widely expressed by students in the UK and Italy that an essential part of the academic experience is the chance to meet new peers during the transition from secondary school to university.“A big part of university, especially in the first year, it is to meet people, and it was not possible during the pandemic.” UoS, F.“I was quite affected because the first year is when you make all your friends and get to know people and you couldn’t do that. It’s because it was first year that the pandemic made it like ten times worse.” UoS, F.Two young students also spoke about the impact that COVID-19 had on their high school education, making them less ready for university.“Obviously COVID prevented freshers from going to school for so long and doing so many things. I think it could be quite a quick transition [from high school to university].” UoS, F.“…in particular, during COVID, they found themselves going from high school last year to university and were catapulted into the university world without knowing anything. They could have bad impression about the relationship with teachers.” Unimib, M.Moreover, Unimib students highlighted for freshers a more challenging return to normality after the pandemic, including a poorer relationship with the institution.“Many freshers told me about the effort of having started the university path [course] alone and that even loneliness makes them very anxious, the fact of not being able to compare with anyone, they struggle so much with this.” Unimib, F.“Freshers are not used to the environment, and they may have some problems in starting in person lectures.” Unimib, F.International/off-campus studentsInterviewees, mainly from the social degree programmes, identified students living far from home  as a vulnerable population during the restrictive measures, given the likely sense of loneliness. This scenario was exacerbated by the feeling of being in a foreign environment.“I am really far from home, and it was a problem for me especially during COVID, because I felt very lonely, and I have to do a lot of things alone also at home. I had a lot of responsibility.” UoS, F. [international student].“…when we restarted to go out a little bit, I had a hard time making friends, because in any case everyone was in their own house. We never really found a moment to be together, to get to know each other better. Thus, in my opinion it was worse for off-site people because, in addition to being far from home, they didn’t even know the city they lived in.” Unimib, F.Students from Italy also raised practical issues in terms of barriers during the pandemic when looking for medical support and trying to access health services.“…to be an off-site student during the pandemic was a bit problematic. I have discovered that in Lombardy to be able to book a specialist visit to the hospital you need the regional health card. Moreover, there have been some guys who have had problems in the sense that they were in contact with [COVID] positives, they called the healthcare system, but they didn’t get any information. Thus, during COVID it was really difficult for off-site students also from a practical point of view.” Unimib, F.Introverted vs. extroverted studentsSince socialisation was described as an essential aspect of the university experience, opposite social skills, namely being an extremely extroverted or introverted individual, were seen as a possible source of vulnerability during the pandemic. According to some students, introverted people, who might take advantage of class time to socialise, were likely to be more vulnerable to pandemic restrictions as compared to their counterparts.“Some of the more outgoing people might have tried and find a way to socialize also during the pandemic, but maybe people who were relying on meeting people through lectures weren’t able to do that because everything was online.” UoS, F.“…especially the more introverted suffered during COVID because they tend to stay more closed.” Unimib, F.Similarly, according to some interviewees, students at the other end of the spectrum  were identified as a vulnerable target as well, since they were considered as less used to being alone.“The pandemic affected me in a way that wasn’t ideal. I don’t like being alone. I am a true extroverted person.” UoS, F.“The pandemic really took a turn on the mental health of people. Especially people that are a bit more extroverted and who like being outside and being with friends. They felt lonely because they couldn’t do what they did before.” UoS, F.Respondents described a variety of coping strategies that could help university students to overcome the negative effects of the pandemic.Time for oneselfReorganization of time and space produced a greater amount of free time. Both UoS and Unimib students, especially women, recognised that taking advantage of leisure time helped in coping with the pandemic. Students from the UK suggested using time to explore new hobbies and interests, as well as to reunite with family, when possible in line with national directives, since campus life is generally distant from their hometown.“It [pandemic] gave me the time to sit down and reach out, ask for help and actually work on myself.” UoS, F.“…COVID had a negative impact for some of students, but not for me. When COVID started, I flew home, and I was home for almost seven months, and I really enjoyed it because being away from home was something I haven’t really got used to. And I had time to do a lot of things, activities for myself.” UoS, F.For Unimib students, the pandemic meant additional time to devote to study since there are no distractions at all, thus benefiting students who also had a job.“I have conflicting ideas [about the effects of the pandemic on mental health]. Paradoxically, the first period, especially the first lockdown period, therefore March-April-May 2020, helped me a lot because, having no commitments that took away my time to study, I was able to attend courses and take exams. It was a very good semester from that point of view.” Unimib, F.“…on the other hand, among the benefits, there were for those working students, who still continued to carry out activities during the pandemic or even considered their opportunity to review online lessons in order to better understand them.” Unimib, F.Family supportStudents, mostly from Italy and in particular those who lived far from home and reported a good relationship with relatives, specifically recognised family support as an effective strategy to cope with the pandemic challenges.“I was lucky, because anyway I was at home with my family during the first lockdown. I’ve never been alone, and it is important for mental health.” Unimib, M.“I was blessed to live in a peaceful environment with healthy relationships within the family. For example, from this point of view, I was lucky because I had the opportunity to go home. I returned home, I live in a very large house, we are five, I have a brother and a sister, so I didn’t go through the lockdown alone but with my family support.” Unimib, F.Mental health support during the COVID-19 pandemicMainly, students enrolled in scientific programmes considered crucial university strategies for mental health support, regardless that these were actually provided to cope with the impact of the pandemic. In particular, one interviewee spoke about helpful interventions delivered by the university in the form of informative webinars.“During COVID there was a series of events related both to how to carry on the career during the pandemic, and in general to mental health support. It was really useful.” Unimib, F.Other students focused on unmet needs, stating that the university should have done more during this challenging period.“You were not in university all the time because of COVID, and you were isolated and therefore maybe the university would have needed to organize more discussions with students about the support of mental health and explain exactly what the support is.” UoS, M.“…to arrange some online session to meet with other people and speak about mental health. It could be useful especially in relation to COVID.” UoS, F.Despite most of the sub-themes were shared by students from both universities, some differences emerged when comparing Italy and the UK.At Unimib, students identified academic worries and the not entirely adequate organization of the university system as one of the main mechanisms by which COVID-19 was related to poor mental health. Conversely, UoS students described the impact of the pandemic on mental health as due to the loss of social connectedness, seen as an essential aspect of the academic experience. Moreover, students based in Italy, who usually share their accommodation with parents, highlighted the challenging management of individual space among other potential mechanisms leading to anxiety symptoms.Finally, differences in terms of coping strategies as regards the pandemic were detected across the transcripts. Students from Italy identified family support and being able to dedicate more time to study as beneficial, while the UK sample devoted the greater amount of free time to personal growth.To our knowledge, this is the first cross-country qualitative study on the impact of COVID-19 on the mental health of university students. The findings provided a model for understanding how—and for whom—COVID-19 restrictions were likely to result in poor mental health. Specific factors, mainly loneliness and more time spent online, were identified as putative mechanisms underlying the relationship between the pandemic restrictions and mental health. Generalized and social anxiety symptoms were described as the main conditions reported by students, with freshers, students living far from home, as well as those who were more extroverted or introverted, being considered the most vulnerable subgroups. Our findings corroborate previous research that described an increased likelihood of reporting anxiety symptoms during the pandemic, mainly in higher education settings ,19,20,21On the one hand, virtual networks and communities on social media platforms were often deemed appropriate by higher-education students for self-disclosure or help-seeking possibly encompassing warnings on different stressors affecting psychological wellbeing during outbreaks ,55. On tDespite differences in the lockdown restrictions between Italy and the UK , studentDespite most patterns were shared between the two countries, some differences emerged when comparing students from Italy and the UK. At Unimib, the impact of COVID-19 on mental health was explained as foremost resulting from academic worries and not the entirely adequate organization of the university system. Evidence showed that university students routinely experience academic pressure ,76. ExamFinally, strategies for coping with the pandemic from the interviews might have been similarly influenced by the specificity of the cultural environment. Students from Italy, mostly living with their parents, identified family support and being able to dedicate more time to study as beneficial, while the UK sample devoted the greater amount of free time to personal growth. Both strategies, family support, and time for oneself, have previously been identified as adaptive behaviours in response to stressful events ,87,88,89Our findings should be interpreted with caution considering some methodological limitations. First, although we attempted to diversify the sample to include various groups of students in terms of sociodemographic characteristics, male students were under-represented, thus preventing a proper gender-based comparison. Despite this, there was an appropriate distribution across age, degree programmes and living conditions, interviewees might be students who were already well engaged, to some extent outgoing, and interested in mental health topics. Although generalizability is not an issue inherent to qualitative research, this scenario may suggest an additional potential selection bias with overestimation/underestimation of the condition of interest. Second, the principal investigator’s education and background might have influenced the interview contents and subsequent interpretation, through a possible restricted focus on mental health issues. Nevertheless, interview questions were research-based, and piloted before the start of the study to ensure understandability and face validity in relation to topics covered, as well as maximum relevance.Finally, due to some difficulties encountered in online recruitment, the interviews were conducted over a relatively long interval of time (from September 2021 to April 2022), thus potentially undermining students’ feelings and perspective about the pandemic issues also in terms of recall bias about past exposure or outcomes. However, the interviews were held in a private setting, which has been shown to minimise worries about privacy and anonymity, thus allowing participants to freely express themselves and take their time to explain their perspective .The current study highlights the likely psychological burden among university students during the pandemic and the key role of mental health support in university settings. Our findings add to the existing evidence supporting the need for measures to improve communication within educational institutions, as well as to encourage social connectedness, as one of the elements of university experience. The complex relationship between stressful events, such as a pandemic, and poor mental health, advocates interventions aimed at strengthening positive coping strategies, especially targeting vulnerable students. Further research is needed to provide additional insight into this field, taking into account also national cultural specificities.


This study focuses on the vocational interests of trainee teachers for kindergarten and primary school, investigating whether the RIASEC-interest dimensions are related to teaching preferences in the Swiss subject of Nature–Human–Society, which is characterized by its multidisciplinarity. Interests are a source of individual differences in people and important to study since they influence intrinsic motivation, and thus, behavior, effort, and occupational decisions. The results of the conducted survey, composed of the Nature–Human–Society questionnaire and the general interest structure test (AIST-R), show, in a sample of 220 participants, that trainee teachers’ vocational interests were partly related to their previous experiences in the specific content domains of Nature–Human–Society and slightly differed by gender. The RIASEC interest dimensions of social, investigative, realistic, and partly artistic evidence significant correlations with preferences in the teaching topics of the Nature–Human–Society subject. It became clear that trainee teachers with high realistic and investigative interests and low social and artistic interests tended to prefer thing-related teaching topics, while pronounced social and artistic interests with low realistic and investigative interests were associated with teaching preferences for people-related topics in the subject of Nature–Human–Society. The dominant role of Prediger’s people- versus thing-related interest orientation could thus also be confirmed in the choice of favorite teaching topics, signaling that teachers feel comfortable with those topics that match their interest structure. Interests can be considered personality-specific characteristics that are crucial determinants of individual differences. People differ in their preferences for certain fields of knowledge or activities. Such individual interests can influence the direction, vigor, and persistence of human behaviors, as interests directly affect intrinsic motivation ,5,6,7,8.The RIASEC model is arranged as a hexagon see , suggestHowever, usually, only the three highest expressions of the interest dimensions are used and pronounced in a three-digit Holland code, for example, SAE, which means that a person has the highest expression of interest in social, followed by artistic, and enterprising. This code of interest, SAE, is particularly common among kindergarten and primary school teachers. In Holland’s theory, the working environment of kindergarten and primary school teachers is also characterized by social, artistic, and enterprising activities and tasks. Accordingly, there would generally be a good fit between SAE personalities and this work environment. Indeed, people usually strive for such a work environment in which they can actively pursue their interests. Normally, they also have more pronounced competencies in their fields of interest, so they experience a good fit there ,22,23,24Holland assumed, similar to Krapp , that inPrevious studies have shown that teachers’ interests can have a positive effect on teaching and pupils´ motivation. The teacher’s enthusiasm for the content of the lesson is described as contagious to the learners. It was evidenced that primary school teachers’ interest in the subject is central to the pupils’ perception of the learning contents as exciting, important, and interesting ,32.Swiss kindergarten and primary school teachers have a bachelor’s degree and are qualified to teach a wide range of subjects in school. The subject called “Nature–Human–Society” (“Natur-Mensch-Gesellschaft” in German) is characterized by its multidisciplinarity, as it integrates a wide variety of disciplines  into one subject ,34,35. TPrevious studies with female Swiss trainee teachers have already examined whether knowledge and ability self-concepts  and the Interests as an individual difference domain are important to study since they are sources of intrinsic motivation, and thus, determinants of behavior, efforts, and decisions. The aim of this study was, therefore, to explore whether trainee teachers’ vocational interests (in the form of the RIASEC interest dimensions) are related to their teaching preferences in the Nature–Human–Society subject. In this way, this study pursues the aim of finding answers to the question of who prefers which teaching topics within the multidisciplinary subject of Nature–Human–Society. It was also investigated if there are gender differences in the individual interests of a trainee teachers’ group and to what extent previous experiences play a role in shaping interests.○RQ 1: Do male and female trainee teachers for primary education differ in their expressions of experiences with the various domains of the subject of Nature–Human–Society? If so, in which areas are there significant differences?○RQ 2: Do male and female trainee teachers for primary education differ in their expressions of vocational interests? If so, in which areas are there significant differences?○RQ 3: Do male and female trainee teachers for primary education differ in their preferences of the Nature–Human–Society teaching topics? If so, in which areas are there significant differences?○RQ 4: Is there a (positive) correlation between trainee teachers’ experiences of the Nature–Human–Society domains and their expressions in vocational interests? If so, in which areas are there very significant relationships?○RQ 5: Is there a (positive) correlation between the popularity of the Nature–Human–Society teaching topics and the expression of vocational interests among trainee teachers? If so, in which areas are there very significant relationships?The following research questions (RQ) are specifically addressed:The study intended to examine almost the entire cohort of first-semester students of the primary education program at the University of Teacher Education Bern (Switzerland). In the academic year in which the study was conducted, the overall cohort was composed of 83% women and 17% men. No exclusion criteria were defined, to obtain a sample as representative of reality as possible, to ensure that the study had high external validity.A total of 220 students participated in the entire survey. This represents 71.2% of the first-year cohort composed of 309 students. Of the remaining 28.8% of the cohort, 36 students (11.7%) did not take part in the survey at all, while 53 students (17.2%) began the survey but did not complete it in full, so they could not be considered for the sample.SD = 6.3; Min = 18; Max = 50), with 70.0% of the participants being between 18 and 22 years old. A total of 59.6% of the participants had a high school diploma , while the others had a vocational diploma, a specialized diploma, or basic vocational training and had passed an admissions exam to enroll in the study program. A total of 44.1% of the sample opted for a study focus on cycle 1 (teaching kindergarten to grade 2) and 55.9% for a study focus on cycle 2 (teaching grades 3 to 6).The sample consisted of 84.1% women and 15.9% men and had an average age of 23.26 years . The Cronbach´s alphas of the experience subscales for all the content areas of the Nature–Human –Society subject were indicated by the questionnaire evaluators ranging between 0.68 and 0.77 .N = 2496) and an occupational register with assigned RIASEC codes that characterize the respective work environment [The AIST-R (Allgemeiner-Interessen-Struktur-Test Revision in language name) is a self-report questionnaire based on the RIASEC model. The six RIASEC-interest dimensions were expressed by the participants by rating 10 items each on a 5-point Likert scale . The RIASEC-interest dimensions are realistic, investigative, artistic, social, enterprising, and conventional, and thus, capture Holland’s six personality types. The AIST-R was created by Bergman and Eder in German and is considered a validated and reliable self-assessment instrument. The Cronbach´s alphas of all the AIST-R scales were cited by the test developers as ranging between 0.82 and 0.87. The manual contains standards . In order to exclude further inhomogeneities in the sample, possible differences between participants with a major in cycles 1 and 2, as well as between participants with and without a high school diploma, were examined in a preliminary analysis. However, no significant differences were found, so these demographic variables were not considered further in the analysis of this study. For the descriptive comparability of the six vocational interest dimensions, the raw data were transformed into standard values according to the specifications in the manual. In addition, the scales for the experiences in the seven content domains of Nature–Human–Society were z-transformed in order to be able to classify which domain-related experiences were more or less pronounced in comparison to the overall experience in Nature–Human–Society.U test. To interpret the effect size, Cohen’s d was calculated for any gender difference between the variables with an interval level. To answer the research questions regarding possible correlations of the variables, namely experiences and vocational interests (RQ 4) and vocational interests and teaching topic popularity (RQ 5), the Spearman’s rho values were calculated for correlation analyses [In general, non-parametric tests were performed for variables with a rank-scaled level, but also with an interval scale level to prevent the results from being affected by a violation of the distribution. Thus, for the research questions regarding gender differences , significance tests for two independent samples were calculated using the Mann–Whitney analyses ,55,56.Cronbach´s alphas for the experience scales, composed of three items for each Nature–Human–Society domain, ranged from 0.794 to 0.869. In U Test was carried out to determine if there were gender differences in the seven Nature–Human–Society domains of the experiences scales. There was a statistically significant difference in the social–ethical experience between the groups , as well as in the physical–technical experience  and the economic experience . Compared to males, females had significantly higher scores in social–ethical experience, while females’ physical–technical and economic experience scores were significantly lower than those of males. The results of biological experience , cultural–religious experience , historical–political experience , and geographical experience  did not indicate significant differences between females and males.A Mann–Whitney To make the experience scores of different domains comparable, standard values were calculated and are shown separately in The RIASEC subscales produced Cronbach´s alphas between 0.785 and 0.858. U tests were performed to evaluate whether the RIASEC interest dimensions differed between females and males. The results indicate that females had significantly higher social and artistic interests than males . Additionally, there were significant gender differences in realistic and conventional interests . Males had significantly higher scores in realistic and lower scores in conventional interest than females. Non-significant differences between both groups were evidenced for investigative and enterprising interests .Mann–Whitney The results of the individual RIASEC scales were converted into the general norm scores and are presented in In U tests were used to evaluate whether the selection of the popularity of teaching topics differed between females and males. Two statistically significant group differences were evident: Compared to males, females expressed less popularity for the teaching topic “Technology, electricity, and inventions”  and more popularity for the teaching topic “Thinking about oneself” . There were no significant group differences in the popularity ranking of other teaching topics: “Being with others” , “Religions and traditions” , “How products were produced” , “Life in earlier generations” , “My hometown” , “Earth, and how people live in other places” , “Animals, woods, fields, ponds, and flowers” , “Sun, moon, stars, and universe” U = 2898.000, Z = −1.091, p = 0.275), “Water, air, weather, and stones” , and “Substances and their properties” .Mann–Whitney The graphs in If the sample is divided by gender, the popularity corresponded in all cases except for two specific topics. The graphs describing the “Technology, electricity and inventions” topic illustrated that only half as many male subjects as female subjects disliked this topic and that, in contrast to females, there were also more male participants who favored this teaching topic. Furthermore, the graph of “Thinking about oneself” indicates that this topic was nearly equally popular and unpopular among female trainee teachers, while the graph of the male subgroup clearly points in the direction of unpopularity.Overall, it must be noted that the sample graph of all participants is, in all cases, more similar to the female graph than to the male graph because the female subjects are represented in the whole sample with a larger proportion. In addition, it is noticeable that most graphs show the highest percentages in the middle range of the popularity of the teaching topic.Spearman’s rank correlation was computed to assess the relationship between the experience variables in the seven Nature–Human–Society domains and the RIASEC interest variables. As shown in Spearman’s rank correlations were also calculated between the RIASEC interest variables and the teaching topics’ popularity variables see . The popThe outcomes of this research provide insight into trainee teachers’ vocational interests and demonstrate their relationships with prior experiences with the Nature–Human–Society content areas, as well as with current teaching preferences in the Nature–Human–Society subject.Starting with the results of the experiences (RQ 1), it can be stated that male and female trainee teachers for primary education had quite similar experiences with the content areas of the Nature–Human–Society subject, except for social science, economics, and physics–technology, where the former experiences were more positively pronounced in women, and the latter two in men. The effect sizes of these differences could be interpreted as low to medium. Generally, it was noticeable that the experiences with biology and geography were generally positive and above average, while those with economics and physics–technology were below average compared to the overall experience scale of the Nature-Human-Society subject. The experience outcomes of the female subsample were essentially consistent with those of another sample of Swiss female trainee teachers , althougExploring the question of whether male and female trainee teachers’ vocational interests differed (RQ 2), the general answer is yes, except for the two interest dimensions of investigative and enterprising, where no significant differences were found. The social interest was highest for both genders, indicating a good fit with the teaching profession. In previous studies, social interest was also described as the best predictor for entering the teaching profession ,23. In tRegarding the question of whether gender differences were also evident for teaching preferences in the Nature–Human–Society subject (RQ 3), it can be said that more similarities than differences were found. A gender-specific effect could only be demonstrated for the teaching topics of “Thinking about oneself” and “Technology, electricity, and inventions”, where the former topic can be classified as people-oriented and the latter as thing-oriented. Consequently, it is not surprising that the former was preferred significantly more often by women and the latter by men, especially since it was also shown that the men subsample had a significantly higher realistic (thing-orientated) and a significantly lower social (people-oriented) interest than the female subsample. For the other topics, there was reasonably clear agreement in terms of likes and dislikes, in which there is a tendency for people-related topics to be more popular than thing-related topics. Thus, thing-related topics or topics of inanimate nature  were ranked at the bottom of the popularity scale. However, at the top of the popularity list, there were also not clearly people-related topics, but topics that refer to animate nature in general, such as animals and plants, or mixed topics, such as “Earth, and how people live in other places”, which is attributable to both physical and human geography. Immediately after those favored topics in the ranking, however, come people-related teaching topics such as “Life in earlier generations” and “Being with others”. The teaching topic favorite list of this sample is broadly consistent with the teaching topic favorite list of female teacher candidates from a previous study .p < 0.01 or p < 0.001) are interpreted.In the following, the correlations between the participants’ vocational interests and previous experiences (RQ 4) and their current teaching preferences (RQ 5) are discussed in more detail. To this end, it must first be noted that here, in the analyses of the correlations, only those significant scores that turned out to be very or highly significant (We start with the connections between experience and interest (RQ 4), which, according to the literature, should generally be given . The strIn the last section of the discussion, we will clarify the question of whether very significant relationships can also be found between vocational interests and teaching preferences in the Nature–Human–Society subject (RQ 5). The vocational interest dimensions of social, investigative, realistic, and artistic evidenced strong correlations with some teaching topic preferences in the subject of Nature–Human–Society, while the interest dimensions of enterprising and conventional did not. Prediger described enterprising and conventional interests as typically relevant for data-related work tasks ,50, and It is important to note that our results are based on the voluntary participants of one trainee teacher cohort. Therefore, the generalizability of the conclusions of this study is limited. In particular, it would be desirable to enlarge the male subsample with additional cohorts, since gender differences turned out to be significant in this study, and men were represented with a rather small proportion. This means that the statements about the male group in this study are extremely sample-dependent and must be interpreted carefully. However, the underrepresentation of men in teacher training for kindergarten and primary school is typical, and the characteristic gender ratio of these trainee-teacher cohorts is well reflected in the sample, so the sample can be considered representative .All in all, it can be concluded from the study that the importance of vocational interests in teacher education should be recognized and that positive experiences should be provided in teacher training that can foster trainee teachers’ interests in teaching all topics of the Nature–Human–Society subject. The study has in fact made clear that prospective teachers generally prefer to teach people-oriented topics than thing-oriented topics. This decision-making behavior carries the risk that thing-oriented topics are not addressed as frequently in everyday teaching of Nature–Human–Society subjects and, consequently, pupils cannot gain as many learning experiences in these areas as in people-oriented areas.Nevertheless, it is encouraging that the social interest of trainee teachers, independent of gender, has been identified as the highest. Thus, it is an inner need of trainee teachers to work with other people, in this case, specifically to teach children and help them learn and grow. In teacher education, trainee teachers take on a change in role, away from the role of the student to the role of the teacher. In this way, teaching topics are also grasped from a different perspective, not only from a subject-specific perspective but also from a subject-didactic perspective . This alSince people-oriented topics are known to be more popular with trainee teachers than thing-oriented topics, a connection can generally be made between these areas by embedding thing-oriented topics in personally and socially significant contexts. By showing trainee teachers the fields of application of thing-oriented topics and thus the benefits for people, the learning and teaching of such topics can become more interesting and meaningful ,63,64.Ultimately, it is important that teacher education awakens a situational interest in trainee teachers for teaching a wide variety of content, especially for topics previously classified as unpopular. Teacher educators, therefore, need to create appealing and practice-relevant learning situations that evoke positive responses and a sense of competence in trainee teachers ,7,8,28. Overall, it can be stated that prospective teachers should develop a professional understanding of their future professional role during their training and understand that teaching is not about their personal interests, but that teaching and learning in kindergarten and primary school must be oriented towards the interests of children in the different educational areas that the curricula specify.


Healthcare organizations are increasingly exploring ways to address the social determinants of health. Accurate data on social determinants is essential to identify opportunities for action to improve health outcomes, to identify patterns of inequity, and to help evaluate the impact of interventions. The objective of this study was to refine a standardized tool for the collection of social determinants data through cognitive testing.An initial set of questions on social determinants for use in healthcare settings was developed by a collaboration of hospitals and a local public health organization in Toronto, Canada during 2011–2012. Subsequent research on how patients interpreted the questions, and how they performed in primary care and other settings led to revisions. We administered these questions and conducted in-depth cognitive interviews with all the participants, who were from Saskatchewan, Manitoba, Ontario, and Newfoundland and Labrador. Cognitive interviewing was used, with participants invited to verbalize thoughts and feelings as they read the questions. Interview notes were grouped thematically, and high frequency themes were addressed.Three hundred and seventy-five individuals responded to the study advertisements and 195 ultimately participated in the study. Although all interviews were conducted in English, participants were diverse. For many, the value of this information being collected in typical healthcare settings was unclear, and hence, we included descriptors for each question. In general, the questions were understood, but participants highlighted a number of ways the questions could be changed to be even clearer and more inclusive. For example, more response options were added to the question of sexual orientation and the “making ends meet” question was completely reworded in light of challenges to understand the informal phrasing cited by English as a Second Language (ESL) users of the tool.In this work we have refined an initial set of 16 sociodemographic and social needs questions into a simple yet comprehensive 18-question tool. The changes were largely related to wording, rather than content. These questions require validation against accepted, standardized tools. Further work is required to enable community data governance, and to ensure implementation of the tool as well as the use of its data is successful in a range of organizations.The online version contains supplementary material available at 10.1186/s12875-023-02173-8. The social determinants of health (SDoH) are the conditions in which we live, work, and play that impact individual and population health . Our incAccurate SDoH data that is linked to, or part of an individual’s health records is essential to identify opportunities for action to improve health outcomes and address health inequities. For example, care teams can help address patient needs through referrals to relevant community resources . AccuratThe objective of this study was to refine, validate and standardize a tool for the collection of robust social determinants data, building on previous work, and to conduct cognitive testing with a large group of diverse individuals through in-depth interviews.Research ethics approval was obtained from Unity Health Toronto (#20–241), the University of Manitoba Health Research Ethics Board (#HS24204), the Newfoundland and Labrador Health Research Ethics Board (# 2020.259) and the Saskatchewan Behavioural Research Ethics Board (#2373).An initial set of questions  on social determinants for use in healthcare settings was developed by a collaboration of hospitals and a local public health organization in Toronto, Canada during 2011–2012 . QuestioOne hundred and ninety-five (195) participants were recruited from four provinces in Canada: Saskatchewan, Manitoba, Ontario, and Newfoundland and Labrador. Data collection was conducted from April 2021 to January 2022. Study advertisements were circulated using social media, through classified advertising websites, using collaborator distribution lists, and with posters placed in waiting rooms in health centers and community spaces. Study advertisements were in English, French and the top three non-Indigenous languages spoken in participating provinces according to the latest national census , 26: Arathink aloud, by sharing their immediate thoughts on each question. Participants then selected their answer choice. Minimal unscripted concurrent probing was done by interviewers, except to prompt participants to continue to think aloud throughout the survey. Interviewers recorded the thoughts of participants for each question. Interviewers were trained to look out for: issues related to question wording, issues related to unclear question objective, questions with redundancy or repetitiveness, issues of burden or length of the survey, and questions that lacked response options participants that frequently want to select [Cognitive interviews were conducted by five members of the study team  and two research assistants, who all identified as female. All interviewers had moderate to extensive experience with conducting qualitative interviews, but most were new to cognitive interviewing. Cognitive interviewing is a technique used to gain insight into learners’ perceptions in which individuals are invited to verbalize thoughts and feelings as they examine information . In thiso select .The analysis was conducted by the five members of the study team who had conducted the interviews. Informal analysis of the cognitive interviews was conducted as described by Willis .Using thThree hundred and seventy-five individuals responded to the study advertisements and 195 ultimately participated in cognitive interviews: 125 (64.1%) from Ontario, 25 (12.8%) from Saskatchewan, 24 (12.3%) from Manitoba, and 21 (10.8%) from Newfoundland and Labrador. Although the study was advertised in other languages, all interviews were conducted in English, as no non-English speaking participants contacted the study team. Participants were diverse: 148 (76%) identified as non-white, 71 (36%) indicated not being born in Canada, and 38 (19.5%) noted they had difficulty making ends meet at the end of the month. Although the majority of participants reported a college or university degree , 8 (4%) individuals indicated they did not complete high school and 9 (5%) individuals had high school or equivalent  participants indicated they could make ends meet some months (frequency) or could regularly make ends meet a year ago but not currently (timeframe). To address this feedback, we updated the questions to include a specific timeframe  and, in some cases, updated answer options to include frequency .For many questions about social needs, participants expressed confusion concerning the timeframe for and frequency of the social need they were being asked to indicate. For example, with the question, For questions that had ‘not applicable’ as an option, a large number of participants were confused about the difference between ‘no’ and ‘not applicable’. For example, 19 (10%) participants were unclear how ‘not applicable’ was defined for the employment question, and 14 (7%) participants that were unclear for the medication question. Therefore, we qualified the ‘not applicable’ option with a short phrase. For example, for the question about paying one’s rent or mortgage on time, we replaced ‘not applicable’ with ‘not applicable, I do not have to pay rent or mortgage’.For certain questions, such as those concerning whether the participant was born in Canada, sex at birth, gender identity, and sexual orientation, several participants noted they may be unwelcome or uncomfortable to complete. To address this concern, the research team included a ‘prefer not to answer’ option to all the questions in the final survey.Based on feedback from study participants, research staff, patient partners, advisory committee members, and other subject matter experts, additional domains were added to the questions on social needs, including questions on food security, and phone and internet access. Ethnicity and religion were added as optional questions. These optional questions should be used at the discretion of healthcare leaders if feel that they are necessary for use at their respective healthcare organizations.“If it could be arranged, would translation into another language be helpful at your next appointment?”, was unclear for only seven (3.6%) participants. Five (2.6%) participants were unsure if the question was referring to a healthcare appointment or any appointments. To clarify, we added ‘healthcare’ to the updated question. In addition, to reduce data entry error, we added a list of optional drop-down answer choices for language preferred.1The wording of the question concerning language needs, Among 71 (36%) participants that were not born in Canada, three participants could not recall what year they arrived in Canada. Given that this question is aimed at determining newcomer status, we revised the answer options to include ‘less than 5 years’, ‘5 to 9 years’ and ‘10 years or more’ instead of an open-text field. This reduces data entry error and addresses recall issues. It also fits with Statistics Canada’s definition of a recent immigrant or newcomer.In this paper, we have not reported cognitive interview results from study participants on this question as we believe that the reporting of these results should be governed and led by Indigenous communities. We have included in the descriptor a statement that this data must be collected with engagement with local First Nations, Métis, and Inuit governance bodies in accordance with the First Nations OCAP, Métis OCAS, and Inuit Qaujimajatuqangit data governance and sovereignty principles.3The race question includes a preamble intended to explain why race is being asked about at a healthcare appointment. Twelve (6.1%) participants indicated that the preamble was too technical or overwhelming or requested simpler language. Eight (4.1%) participants noted that ‘not based in science’ is technically incorrect or unnecessary  to the concept of race, and some noted that ‘not based in biology’ is a more appropriate phrase. In addition to suggested edits to the preamble, eighteen (9.2%) participants requested examples of countries or regions for each race category in the answer options, which we have now included. Fifteen participants wanted the ‘White’ and ‘Black’ option to be separated into different “types” of White or Black people. For example, participants suggested splitting the ‘Black’ option into African, Afro-Caribbean, African American etc. However, based on the definition of race and ethnicity, which we describe in the newly added descriptors, “types” of white or black people would correspond with ethnicity. The revised SPARK Tool provides an optional ethnicity question to address this topic. Eight (4.1%) participants indicated preference for an ethnicity question instead of a race question. The participant feedback on this question was valuable, informed the creation of, and changes to other questions. However, we did not edit this particular question as changes to the race question itself were not strongly indicated in light of the cognitive interviews and the existing question aligned closely with existing national standards for race-based data .“In general, do you experience any of the following due to a physical, mental, or emotional condition?”, and its answer options were seen as too broad and subject to interpretation. For example, ‘difficulty communicating’ may refer to a speech impairment or language barriers. Some participants  were unsure if a difficulty they experienced should be included. More specifically, there were 12 participants (6.1%) who were unsure if they should say they have a difficulty if it could be corrected with assistance . Based on the feedback we received, the study team revised the question to include ‘due to a severe and persistent physical, mental or emotional condition’. Additionally, the study team revised the answer options based on participant feedback. For example, it was unclear what ‘self-care’ meant to 19 (9.7%) participants, so we changed that option to ‘personal hygiene’. Including examples in the answer options and adding a descriptor helped to clarify that this question is intended to identify conditions that are severe and disabling. Eleven (5.6%) participants felt the options provided were limited and did not account for difficulties associated with having a mental health condition. The addition of answer options to include ‘difficulty with activities for daily living’ captures difficulties mentioned in the cognitive interviews that were not present in the original answer option.For 38 (19.5%) participants, the disability question, “What was your sex assigned at birth?”, six (3.1%) participants noted that ‘intersex’ status is not necessarily always ‘assigned’ at birth, therefore ‘assigned’ was removed from the question.For the question, “What is your current gender identity?”, based on feedback from subject matter experts, the term ‘current’ was removed from the question as it was deemed redundant or unnecessary for answering the question. Nine (4.6%) participants felt the options provided for gender identity were limited. Based on feedback from the participants as well as from subject matter experts, additional options, including ‘transgender woman’ and ‘transgender man’ were included in the question. For five (2.6%) participants, the difference between ‘sex at birth’ and ‘gender identity’ was unclear, and hence, the descriptor includes an explanation.For the question, Two additional options, ‘demisexual’ and ‘asexual’, were added to the sexual orientation question  as 17 (8.7%) participants felt that the original options were too limited, and a few participants specifically mentioned those options should be included. This change was supported by the study team’s review of the literature and consultations with subject matter experts. We removed the definition in the ‘heterosexual’ option  based on feedback from 16 (8.2%) participants who felt it was unnecessary, some of whom found it offensive. ‘Queer’ and ‘pansexual’ were separated into two different options as 9 (4.6%) participants highlighted that these terms are not synonymous. Some participants  indicated that they felt that gender could be represented by more than one answer option , therefore individuals can now select multiple options.“What is the highest level of education you have completed?”, three (1.5%) participants and a patient partner on our study team felt that the phrase ‘highest level of education’ in the question was un-inclusive, hierarchical, elitist, or offensive, so the term ‘highest’ has been removed. Twenty-one (10.8%) participants mentioned that the education answer options were too limited and, in some cases, confusing. Therefore, several options were added or revised including replacing ‘trades certificate/diploma’ and ‘college/university degree’ with ‘college, CEGEP or other non-university certificate or diploma’, ‘completed registered apprenticeship or other trades certificate or diploma’ and ‘undergraduate degree’. Examples were added to clarify the term ‘postgraduate’ as 14 (7.2%) participants, many of which spoke English as a Second Language (ESL) or completed their education outside of Canada, were unfamiliar with the term. We clarified or removed the word ‘some’ in the options and replaced with ‘ongoing’ in most cases. One limitation to the updated question is that participants are not able to select more than one option for their level of education as requested by 9 (4.6%) participants. For example, in instances where a participant has attended both college and university and considers both education levels to be equivalent, they are forced to pick just one. Multiple choice selection was not added to this question as its purpose is to ascertain literacy level indicated by education level.For the education question, “Do you have difficulty making ends meet at the end of the month?” to “Do you currently have difficulty paying for basic needs?” as 26 (13.3%) participants, many of whom were ESL speakers, found the term ‘making ends meet’ difficult to understand. For 7 (3.6%) participants, it was unclear how to define a basic or essential need, so we included clarification in the descriptor. One limitation to the updated question is that it does not capture people who are able to pay for basic needs like food, shelter, clothing, but still have serious financial difficulties. This concern was identified by 7 (3.6%) participants. This brief question may not accurately capture every aspect of a person’s financial situation. However, it has been validated as a good predictor of poverty and identifying individuals living below the “poverty line” or low-income cut-off (LICO) [We changed the question from f (LICO) .Three (1.5%) participants felt that the question about medication access  did not consider medical devices or supplies , as well as over-the-counter (OTC) medications, which may not be prescribed. To account for patients’ diverse medical needs, ‘prescription’ was replaced with ‘medication or medical supplies’.“What is your current housing?” to “What is your current housing situation?” as the previous wording of the question was cumbersome according to 6 (3.1%) participants. There were no adequate options for 35 (17.9%) participants who lived with family or friends by choice . To address this, we replaced the ‘own home’ and ‘rent’ options with ‘a place you or your family owns’ and ‘a place you or your family rents’. Some participants found the terms ‘couch surfing’ (12 participants) and ‘on the street’ (9 participants) stigmatizing, inappropriate or offensive. We replaced ‘couch surfing’ with ‘staying in someone else’s place because you have no alternative’ and ‘On the street’ with ‘Experiencing homelessness’. Nineteen (9.7%) participants felt that the options were limited and did not capture other living situations such as transitional housing or a nomadic lifestyle. We added additional options including supportive housing or group home, long-term care facility and correctional facility. We added “social housing, subsidized housing or rent-geared-to-income’ as an option to this question and therefore removed the follow-up question “Is your current housing social housing, subsidized housing or rent-geared-to-income?” from the SPARK Tool. Seven (3.6%) participants indicated wanting to be asked about their living arrangements, specifically about who they live with. For example, if they rent, to specify that they live with roommates. One participant mentioned that the ‘rent’ option is a wide category that could include living with multiple roommates or alone in a “big fancy apartment”. We added a follow-up question asking, “who do you live with? select all that apply”. For 18 (9.2%) participants, the options were inadequate and did not capture people who did not have to pay rent or people who were only able to make partial payment of the rent. ‘Not applicable, I do not have to pay rent or mortgage’ was added to address the first problem. The updated question does not yet capture participants who were only able to make partial rent payment, which is a limitation of the question.We changed the question from “In the past 12 months, did you avoid attending an important appointment because of the cost of transportation?”, it was unclear to four (2.0%) participants what type of appointment the question was referring to. This has been clarified in the updated question. The updated question was adapted from the American Academy of Family Physicians (AAFP) Social Needs Screening Tool and the PRAPARE Toolkit [In the transportation question used in this study,  Toolkit , 36.Eleven (5.6%) people were unsure what constituted a utility bill, therefore, in the revised question and the created descriptor, we provided examples of utilities for clarity. The descriptor explains ‘the specific utilities you pay for may depend on where you live’, indicating that electric, gas/oil and water bills are only examples of utility bills. There were no adequate options for 8 (4.1%) participants whose utilities are included in the rent. If these participants experienced difficulty paying a bill it would be captured in part three of housing question which asks the participant, “in the past 12 months, was there a time when you were not able to pay the mortgage or rent on time?” Further, we have expanded the ‘not applicable’ answer option to state “not applicable, I did not have to pay utility bills in the past 12 months or utilities already included in rent”.yes or no response to social support questions, explaining that they may not be able to open up all the time or may be able to open up about some things but not others. To address this, we added ‘yes, always, or sometimes’ to the ‘yes’ option. In addition, ‘family or close friends’ was replaced with ‘people’ in the question as three participants said they may be able to open up to people not in those categories, e.g., pastor, teacher, etc. For the follow-up question, ‘are you able to rely on them if you need help ?’, 32 (16.4%) participants, felt the categories or examples provided in the question were too specific. For example, participants may be able to rely on the people they referred to in the first question emotionally but not financially. We removed the examples and left the question open to any kind of help. Some of these categories, e.g., transportation, are addressed in other questions.Social support is captured by two questions, both of which were moved to follow the utilities question  as some participants found the transition from housing to social supports abrupt. For the first question, ‘do you feel you have family or close friends who you can open up to?’, 10 (5.1%) participants, many of whom were ESL speakers, the term ‘open up to’ was difficult to understand. We therefore revised the question adding ‘confide in’ for clarity . Six (3.1%) participants felt unable to provide a The SPARK Tool administered in this study included three questions aimed at identifying individuals experiencing precarious employment. However, 34 (17.4%) participants felt unable to answer the employment questions which were not inclusive of all employment situations, including full-time, permanent, self-employed, did not capture people in between jobs or working multiple jobs, and failed to capture participants that were retired. To address this, we added two questions: ‘are you currently employed?’ and ‘are you currently looking for work?’ before asking the follow up questions about precarious employment. These revisions will capture individuals unemployed and looking for employment and therefore may help connect people to employment resources. Among the precarious employment questions, the first of which asked, ‘are you employed in a casual, short-term, or temporary position?’, 12 (6.1%) participants were not familiar with the terms ‘casual’ and ‘short-term’. The umbrella terms for precarious work ‘temporary’ or ‘part-time’ were used instead. Examples of types of temporary or part-time employment were also included. Based on feedback from 4 (2.0%) participants who had multiple jobs, this question was revised to include ‘main job’ in the question to clarify that this is referring to primary source of employment. For the second precarious employment question, ‘do you feel fearful that you could be fired if you raise employment concerns?’, the phrase ‘raise employment concerns’ was confusing for 4 (2.0%) participants. To clarify this, we added examples of types of employment concerns. The question has also been modified to simplify the language. Based on feedback from research staff, ‘fired’ was replaced with ‘negatively affected’ in the question to account for people who may not be fired but endure negative consequences if or when they raise concerns. For the question about income instability, ‘does your pay vary a lot from month to month?’, we replaced ‘vary’ with ‘change’ for 12 (6.1%) participants who wanted the question reworded. Several of these participants also mentioned that their pay may change a lot due to other factors unrelated to precarious employment such as self-employment or shift work . This is a limitation that the updates have not addressed.In this study, we conducted cognitive interviews with 195 diverse individuals from across four Canadian provinces to refine and develop a standard tool for collecting data on social determinants within primary care settings. For many participants, the value of this information being collected in typical healthcare settings was unclear, and hence, we included descriptors for each question. In general, the questions were understood, but participants highlighted a number of ways the questions could be changed to be even clearer and more inclusive. The findings from this study led to numerous ways to refine the questions.Our findings are similar to other research on collecting sociodemographic data and screening for social needs in healthcare settings. Several previous studies have found that it is essential to clarify the reason for collecting data on social determinants at the outset –39. Our The SPARK Tool fills a gap for a validated, national standardized SDoH tool for use in health care settings in Canada and beyond. The SPARK Tool is designed to be self-administered by patients, allowing patients to share their own social needs and therefore, improving the quality and validity of the SDoH data collected. Other standardized SDoH tools such as the PRAPARE Tool, which was developed for the United States context, is being implemented in health care settings across the United States and includes a wide range of SDoH domains . One of In addition to making the tool easier to understand and complete, two other goals were top of mind as we interpreted participants’ cognitive interviewing data and made adjustments to the tool. First, to make the questions inclusive and inviting so that all respondents see themselves and their needs and circumstances reflected, and second, to offer sufficient information in the questions and descriptors to convey the relevance and importance of collecting SDoH data in healthcare settings. By accomplishing all three objectives in our revisions to the tool, we believe patients will better understand its purpose, be more receptive to it, and more inclined to complete it. Patient perspectives on the collection of SDoH data, including their thoughts on how it is explained and the questions that are asked, were also collected during in-depth interviews that followed the cognitive interviews. Those results will be presented in forthcoming manuscripts. Moreover, the SPARK Tool is currently undergoing further validation through psychometric testing, including concurrent validity through comparison against other standardized tools. Finally, an ongoing study in which the SPARK Tool is being implemented in five clinics, one in each of Saskatchewan, Manitoba, Ontario, Nova Scotia and Newfoundland and Labrador, is examining the feasibility and acceptability of administering the tool in active primary care settings and will offer additional insight into potential for this tool in identifying and addressing SDoH in healthcare. This study is nearing completion and results will be published soon.required to have their cameras turned on, a few opted to not appear on video and non-verbal cues during their cognitive interviews may have been missed by the researcher.A limitation of our study is that all interviews were conducted in English, despite advertising in numerous languages and offering translation services if required. Future research is needed to determine whether translations of these questions perform well or elicit new or different concerns from patients. The exclusion of cognitive interview results for the Indigenous identity question in this study is a limitation and a gap remains in our understanding of Indigenous perspectives on collecting SDOH data in healthcare settings. As noted above, because the research team did not have established relationships with relevant Indigenous leaders and groups in the various participating provinces, and had not adequately engaged them in the design of this study, we decided to omit these results in keeping with the guidance put forward in First Nations OCAP, Métis OCAS, and Inuit Qaujimajatuqangit data governance and sovereignty principles –32. To rIn this work we have refined a set of 16 sociodemographic and social needs questions into a simple yet comprehensive and inclusive, 18-question tool that can be used in healthcare organizations to collect data on sociodemographic and social needs. The changes that were required were largely relating to wording, rather than content and demonstrated that consensus can be achieved. These questions require further validation against accepted, standardized tools, and a future validation study is planned. Further work is required to enable community data governance , and to Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2


It is unknown that whether frailty is a risk factor of influenza and the hospitalization among older adults, although it has been shown that frailty was associated with poor recovery from the hospitalization among those. We examined the association of frailty with influenza and the hospitalization and the effect by sex among independent older adults.We used the longitudinal data from the Japan Gerontological Evaluation Study (JAGES), performed in 2016 and 2019 and conducted in 28 municipalities in Japan. The target population comprised 77,103 persons aged ≥ 65 years who did not need assistance from the public long-term care insurance. Primary outcome measures were influenza and hospitalization due to influenza. Frailty was evaluated with the Kihon check list. We estimated the risk of influenza, the hospitalization, those risks by sex, and the interaction for frailty and sex using Poisson regression adjusting for covariates.Frailty was associated with both influenza and the hospitalization among the older adults compared with nonfrail individuals after adjusting for covariates . Male was associated with the hospitalization, but not associated with influenza compared to female . The interaction for frailty and sex was significant neither in influenza nor in the hospitalization.These results suggest that frailty is a risk of influenza and the hospitalization, that risks of the hospitalization are different by sex, but that the sex difference does not cause the effect heterogeneity of frailty on the susceptibility and severity among independent older adults.The online version contains supplementary material available at 10.1186/s12877-023-03979-y. Influenza is a global public threat. The human influenza viruses usually cause moderate respiratory illness and infection of the upper respiratory tract. These patterns can result in pneumonia with progression to acute respiratory distress syndrome or in secondary bacterial infection and death because of respiratory failure. . CongestFrailty is defined as a state of increased vulnerability to stressors, which develops as a consequence of an age-related decline in multiple physiological and psychological systems, including the central nervous system, endocrine system, skeletal muscle, and immune system. , 5. ReceFrailty is associated with susceptibilities and severities of infectious diseases. Lengelé et al. showed that frail was associated with higher incidences of COVID-19 compared to nonfrail among community-dwelling older adults over 65 years.  Hewitt eLees et al. recently reported that frailty increased poor recovery in the older adults who are hospitalized because of influenza-related illnesses. . HoweverThis study had a longitudinal design and used data from the Japan Gerontological Evaluation Study (JAGES). JAGES aims to survey the social determinants of health among non-institutionalized and functionally independent persons aged 65 and older who did not receive public long-term care insurance (LTCI) benefits. This public program is described as follows: “The LTCI system was introduced in Japan in 2000 to address the demands of older persons with disabilities based on the concept of a user-oriented social insurance system with support for independence. Older people with a certification for LTCI service needs can utilize facility services, in-home services, and community-based services depending on their physical and cognitive impairments.” . This loThe baseline survey was conducted between September 2016 and January 2017 mailed to community-dwelling individuals in 39 municipalities and the data was obtained from self-reported questionnaires among 196,438 of 279,661 individuals (70.2%) responded to the survey , which was developed by the Japanese Ministry of Health, Labor and Welfare to identify older adults who were at risk for requiring LTCI in the baseline survey. . KCL wasAge was classified into two groups (65–74 years and ≥ 75 years). Educational attainment was categorized into five groups: < 6 years, 6–9 years, 10–12 years, ≥ 13 years, and others. Equivalized income was calculated by dividing the normalized household gross income in 2015 by the square root of the number of household members, and then, it was categorized into five groups: < 0.5, 0.50–0.99, 1.00–1.99, 2.00–3.99, and ≥ 4.00 million yen. Household structure was assessed by asking respondents “Who do you live with?” with the following options: “no one,” “spouse,” “son,” “daughter,” “spouse of child,” “grandchild,” “brother or sister, “father,” “mother,” “father-in-law,” “mother-in-law,” and “other.” Responses were classified into six groups: living alone, living with a spouse, living with children, living with a spouse and children, living in a three-generation household , and living in a household structure other than the above five categories. . Smokinghttp://www.dagitty.net), was used to create the DAG. The DAG analyses revealed that the MSASs to estimate the effects were age, sex, marital status, educational attainment, equivalized income, household structure, smoking status, high-risk disease, influenza vaccination, civic participation, reciprocity, number of friends met in the last month, and the municipalities. [A directed acyclic graph (DAG) was created to identify a minimal sufficient adjustment set (MSAS) of potential confounders to estimate a direct effect of frailty on influenza and hospitalization due to influenza among older adults. An online tool, DAGitty v3.0 . Frail or prefrail was associated with the hospitalization . Male was associated with the hospitalization, but not with influenza compared to female after adjusting for frailty and the other covariates, . The results of the sensitivity analysis conducted on the complete data were nearly the same as the results in the mutated data sets except for the RR of the hospitalization was higher in prefrail than frail. The association was significant neither in influenza nor in the hospitalization with male compared to female after adjusting for the covariates in the complete data. . The interactions for frailty and sex were neither significant in influenza nor the hospitalization as same with those in the imputed data sets (Supplemental Table This longitudinal study analyzed whether frailty was associated with influenza and hospitalization due to influenza among independent older adults aged ≥ 65 years. After adjusting for all covariates, this analysis showed that both frail and prefrail were associated with both influenza and the hospitalization. Male was associated with the hospitalization, but not with influenza compared to female. The interactions for frailty and sex were neither significant in influenza nor in the hospitalization. These results suggest that frailty is a risk of influenza and the hospitalization, that the risks of hospitalization are different by sex, but that the sex difference does not cause the effect heterogeneity between influenza and frailty among independent older adults.Lees et al. recently showed that frailty predicts poor recovery of older adults who were hospitalized due to influenza illness in the prospective cohort study. . Our resSeveral reports suggest a causal role from frailty to onset of infectious diseases and to their severity by showing that frailty is associated with susceptibility to and severity of infectious diseases in longitudinal studies. , 12, 30.There were sex differences in immunity against virus infections, and it affects susceptibilities to and severities of viral infectious diseases. . Human oOur study had limitations. First, the nature of the observational study did not clarify causality because of unmeasured confounders. However, this study attempted to adjust for major confounding variables from the individuals and influenza. Second, influenza infection and the hospitalization were assessed by self-reports. Therefore, we have no information that how influenza was diagnosed and the hospitalization was decided by a physician. However, it is unlikely that they arbitrarily diagnosed themselves with influenza or non-medical professionals did so and they trusted it because most Japanese citizens have good medical access due to the national health coverage and rapid diagnostic tests with high sensitivity and specificity are used to detect influenza antigens by medical professionals in all cases of suspected influenza. , 37. ThiIt was unknown that whether frailty was a risk of influenza susceptibility and severity among independent older adults. This study examined whether frailty was associated with influenza and the hospitalization in functionally independent older adults aged ≥ 65 years and whether sex difference have an effect on those incidents. Our results showed that both frailty and prefrailty were associated with influenza and the hospitalization after adjusting for all covariates, that male was associated with the hospitalization, but not with influenza compared to female, but that the interaction for frailty and sex was neither significant in influenza nor in the hospitalization. Our results suggest that frailty is a risk to increase susceptibility to influenza and its severity, that risk of the hospitalization is different by sex, but that sex does not cause a heterogeneity in the effects of frailty on the susceptibility and severity. Health care policies to reduce influenza mortality and health care providers for older adults should recognize that frailty not only interferes with tertiary prevention to recover from hospitalization for the severe illness, but also with the primary one to prevent the onset of influenza and the secondary one to prevent the severe illness among older adults.Additional file 1: