The interventions used in cancer-survivorship care do not always address outcomes important to survivors. This study sought to understand stakeholders’ views on the key concerns of cancer survivors after treatment and the interventions needed to meet survivors’ and families’ psychosocial needs after completing cancer treatment. We conducted a descriptive qualitative study using semi-structured interviews with stakeholders  from across Canada. For the data analysis, we used techniques commonly employed in descriptive qualitative research, such as coding, grouping, detailing, and comparing the data. There were 44 study participants: 11 survivors, seven family/friend caregivers, 18 health care providers, and eight decision-/policy-makers. Stakeholder-relevant interventions to address survivors’ psychosocial needs were categorized into five groups, as follows: information provision, peer support, navigation, knowledge translation interventions, and caregiver-specific supports. These findings, particularly interventions that deliver timely and relevant information about the post-treatment period and knowledge translation interventions that strive to integrate effective tools and programs into survivorship care, have implications for future research and practice. The number of cancer survivors has risen dramatically over the past two decades, and 63% of all people diagnosed in Canada today will live for five years or more after their diagnosis . This reMuch research in Canada and globally has demonstrated that cancer survivors experience distress after completing treatment. Indeed, survivors often describe the transition from active treatment to routine follow-up care as a time filled with fear, distress, and feelings of abandonment ,11,12. SIn this study, we sought to understand stakeholders’ views on the key concerns of cancer survivors after treatment and the interventions that are needed to address these concerns. The aim was to inform future intervention research in cancer survivorship by identifying both the important outcomes and potential interventions. This paper presents stakeholders’ views on the interventions needed to meet survivors’ and families’ psychosocial needs after completing cancer treatment.We conducted a descriptive qualitative study  using seHealth care providers  and cancer system decision-/policy-makers were recruited via cancer programs/clinics; provincial and national organizations, groups, and networks ; and publicly available information from each jurisdiction . To achieve a variation in the sampling characteristics, the research team identified and contacted individuals who specialized in different cancer types, who worked in urban and rural settings, and who worked with or had a particular interest in pediatric, adolescent, and young adult populations. Snowball sampling, a purposeful non-probability sampling technique, was also used. The lead researcher [RU] initiated contact with all potential participants via email. If the participant expressed interest, the research associate [SM] reached out to the participant, provided an overview of the study nature and rationale, and arranged a time to complete the informed consent discussion and interview. A second follow-up email was sent if a potential participant failed to respond to the initial contact within one week.Survivors and family/friend caregivers were recruited by distributing study information to cancer patient, survivor, and caregiver organizations, including support groups and networks, and patient advocacy organizations. The team intentionally contacted organizations and groups that served diverse populations  or geographies . Interested persons were asked to contact the research associate via phone or email for more information. Subsequently, the research associate provided an overview of the study and its rationale, and arranged a time to complete the informed consent discussion and interview.The data for this paper are part of a larger dataset collected for a prior study . Data weTo analyse the data, the research team used methods commonly used in descriptive qualitative research, including, coding, grouping, detailing, and comparing the data . Prior tn = 26; 59.1%), with cancer survivors or family/friend caregivers representing  of the sample. The participants resided in different areas across Canada; 31.8% were from Western Canada (n = 14), 38.6% were from Central Canada (n = 17), and 29.5% were from Atlantic Canada (n = 13). The cancer types represented by survivors and family/friend caregivers were breast, colorectal, genitourinary, ovarian, melanoma, and hematologic, and more than half of these participants were between the ages of 40–64 (55.6%). More details on participant demographics can be found in  and “It’s just kind of like, ‘Good luck. Let us know if anything else happens’” [P29 Caregiver]. As a result, communication with peers about what to expect after treatment, and ongoing peer contact and support, were viewed as particularly valuable to help survivors adjust to a new normal after treatment, and to cope with ongoing and emerging health concerns. As one participant expressed:“I think that peer support is a good one. … Now after I’ve recovered, I think that that’s more what I’m seeking, is sort of to talk to people who have had a similar experience or who have tried things and that have worked and haven’t worked. Because it is such a difficult experience to share with people who don’t understand.”(P27 Survivor)Caregivers also emphasized how peer support benefits psychosocial health recovery and is different from the support of one’s family/friends:“Sharing what other people’s stories are. Because my mom really only had hers. … I think having some kind of like support group for returning to work and the struggles that you go through. Going back to work is really challenging for her. And I mean luckily, we have a very supportive family. But that’s very different than having a group of people that have been through similar things and can relate.”While peer support was more often discussed by survivors and caregivers, the importance of peer contact and support was also described by numerous decision-/policy-makers. As stated by one participant:“I think having some network or system electronically where they could communicate with each other and share their stories and provide support for each other, especially in the young adult group … So I think a lot of the patients feel that their experience makes them somehow different than their peers. And having more peer connectedness, I think would help them.”The need for navigation was discussed, of both a professional and peer-led character, to help survivors navigate the follow-up period and facilitate access to the resources and support they require, so as to manage long-term effects and optimize health recovery after treatment. This was deemed particularly important given that many of these resources and supports fall outside of the walls of cancer clinics/centres, as another participant provided:“And the navigators, I did use the navigator in the [Community X] hospital years after. And I can’t remember what it was for. But it was so good to know that here was somebody locally who knew the local community and could pinpoint where the help could come from. That would be so good.”Navigation was also seen as an important emotional and psychosocial support that can help survivors adjust to life beyond cancer, which was noted by P2:“If I could blue sky it, we would have a transition plan including navigation. It could be virtual navigation, it could be a function provided by a person. It could be peer navigation. Because we have tremendous success with all of them. And if we could blue sky it, we would have all of them for survivorship. Because people certainly choose what works best for them. … And the greatest benefit I see is how it improves people’s preparedness to cope with what they’re facing.”Many participants felt that survivors who are able to access navigation services have better outcomes than those who do not. One participant described this as:“I deal with navigational patients all over Canada… And I find the ones that have like a nurse to help navigate them through the system do far better than those that do not. So having a navigation system and points of contact where they can speak to somebody is very important.”)Among the participants, many recognised that evidence-based interventions are not integrated into survivorship care in a timely or consistent way. Consequently, all stakeholder groups discussed the need for knowledge translation interventions to ensure that interventions that are already known to be effective are well integrated into post-treatment follow-up care so that survivors benefit from these evidence-based programs and support. Many healthcare providers and decision-makers acknowledged that practice guidelines exist for survivorship care , yet they believe such guidelines to be inconsistently implemented in our health care system. Survivors and caregivers expressed this sentiment in terms of “gaps” in services and supports that are known to benefit one’s recovery, specifically as they discussed their lack of access to rehabilitation and physical activity programs, professional psychology services, and self-management programs. As one participant commented when speaking about professional mental health services, “so, there’s a huge gap, a huge gap there for depression and a lot of other issues” . Healthcare providers and decision-makers also discussed gaps in evidence-based services and supports for their survivor populations. One participant described the lack of evidence-based programs in the following way:“I think there’s a piece there too, where with exercise, we should be saying something very similar. And with nutrition, something very similar. You know, all the way through you’re promoting healthy lifestyle in people long before they’re finished active treatment and moving forward. Because I think that’s a huge gap that right now, we don’t do very much of it. They finish active treatment. They have their ongoing follow-up with the physician based on whatever the disease is that they’ve been dealing with … But they don’t have that easy access necessarily to counselling from a dietitian or counselling from a physiotherapist or somebody that’s there to help support and coach and counsel them related to transitioning back into the workplace. You know, now that you’ve got these deficits, it is going to be harder for you to do the job you did before you were diagnosed.”)Caregiver participants discussed how their experiences were different to those of the patient/survivor and how they often feel overwhelmed during and after treatment. One caregiver spoke of her emotional state in the following way:“I think, you know, I would say I experienced some trauma. Like I said, I hated that cancer centre. I went up, I was supporting [partner]. But it’s like I wanted someone to say to me, ‘[participant], I know that this is absolutely brutal.’ … It didn’t seem real to me. It just seemed, it seemed like a mechanical assembly line, quite frankly. … I mean I would see even nurses taking care of [partner], and they had a nice rapport with him, and they were, like they were very efficient and very caring. And I, like it’s horrible to say, hated them.”(P42 Caregiver)Consequently, all caregiver participants discussed the need for parallel caregiver resources and services to provide emotional support in the post-treatment follow-up period. As described by one participant:“There was a lot of like emotional things for me that I never really got any support for on how to navigate those emotions and how to kind of process that like your mom’s had cancer and had to go through the treatment. And kind of like, I think, that trauma that comes from a cancer diagnosis. So for me, it was a lot of that. I think there needs to be some sort of like, either like a program or a clinic or something that offers emotional support to cancer survivors and their families and their caregivers to navigate all of that emotional side of it once someone’s gone through cancer. Because like cancer doesn’t end when the treatment ends. Like there’s a lot of the post-cancer stuff. It changes your life forever.”Most frequently, participants cited wanting caregiver-specific informational and peer support interventions, for example:“So, there was really a lack of information for me as a caregiver as kind of like what are the next steps as far as like, you know, your cancer treatments are done. … I wish there was some kind of like follow-up appointment for the family as well where it could be like clearly indicated like this is what to expect over the next year or two years, this is what you can be watching for.”“You know, whether there was someone you could talk to, you know, as a caregiver … Or online supports … I think it’s good to see that connectivity across distance for people to be able to connect. … To apply it into a caregiver scenario would, I think, be very, very helpful.”(P44 Caregiver) This study sought to capture stakeholders’ views on interventions that are most desired and best suited to meet survivors’ and their families’ psychosocial concerns after completing cancer treatment. To do so, stakeholders from across Canada were asked to describe interventions they felt were most likely to address survivors’ ongoing concerns during the follow-up care period. The important interventions were classified into the following five categories: information provision, peer support, navigation, knowledge translation, and caregiver-specific supports/resources. This work is intended to inform future survivorship intervention research. As a starting point, researchers should use these findings to develop and test strategies to deliver more personalized and timely information to survivors, rigorously test the effectiveness and cost-effectiveness of various navigation models during the post-treatment survivorship period, and facilitate the translation of existing research into sustainable programming and practice, including caregiver-specific interventions as these individuals often undergo immense emotional distress during and after their loved one’s cancer diagnosis and treatment.Interventions to address the informational and psychosocial needs of survivors have been deemed as urgent research priorities in Canada . Indeed,Research has shown that cancer-patient navigation improves the timeliness of care and the uptake of evidence-based procedures and reduces healthcare costs ,28,29,30Participants in this study described the need for knowledge-translation interventions  to integrate effective interventions into routine practice. Implementation science, a field of science that employs rigorous methods to design and test strategies to more effectively integrate, spread, and sustain research evidence into clinical and public health practice and policy , must beRelatedly, there is a pressing need to ensure that interventions that are known to improve caregivers’ experiences and outcomes become a routine part of person-centred cancer care. In this study, all caregivers discussed the need for caregiver-specific interventions, whereas participants in other stakeholder groups did not identify this as an important area. However, we are aware that caregivers often experience a considerable physical and emotional toll while caring for a loved one with cancer. For example, they report numerous physical effects as a result of the stress of caregiving, including fatigue, insomnia, and overall diminished health, as well as psychosocial needs, including anxiety, distress, uncertainty, social isolation, and loss of identity ,48,49,50This study has several limitations. First, this study was undertaken in Canada, and therefore does not account for the desires and requirements, from a psychosocial perspective, in jurisdictions for which the health care system differs substantially from Canada. Second, asking participants about ideal interventions to improve survivors’ outcomes may be an abstract request, leading participants to describe interventions they are already aware of as opposed to encouraging creativity in their thinking. Finally, participants often discussed interventions in terms of their form and delivery modes, and less often in terms of the specific content such forms should include. Nonetheless, we interviewed a broad range of stakeholders from across Canada who had varied experiences with cancer survivorship . Therefore, the findings provide guidance for researchers and cancer programs in terms of future directions in cancer survivorship research and programming.This study identified five categories of interventions that stakeholders view as important to address important psychosocial needs in the post-treatment survivorship period. The five categories are as follows information provision, peer support, navigation, knowledge translation interventions, and caregiver-specific supports. These findings have implications for both future research and practices, namely, to develop interventions that deliver timely and relevant information about the post-treatment period, and provide knowledge-translation interventions that integrate effective tools and programs into survivorship care. Both factors are critical toward improving survivors’ experiences and psychosocial outcomes as they transition from primary treatment to follow-up care.


Mage = 39.21) completed post-intervention semi-structured qualitative interviews, including helpfulness ratings, at two follow-up assessments (10- and 14-weeks post-enrollment) to assess the acceptability, usefulness, and perceived fit of the interventions for women’s needs. Interviews were transcribed and analyzed using a hybrid deductive-inductive analytic approach. Results: While both the RISE and ECAU interventions were deemed helpful (interventions were rated as ‘highly helpful’ by 77% of RISE and 52% of ECAU participants), differences were identified in perceived impacts of the intervention, application of content, approach to patient-centeredness, and implementation recommendations. Conclusions: Findings shed light on women Veterans’ experiences and preferences for IPV psychosocial counseling interventions. Such knowledge can inform evidence-based, trauma-informed, and individualized care for women Veterans who experience IPV and may have relevance to other populations of women who experience IPV. Background: Intimate partner violence (IPV) is a significant public health problem that is commonly experienced by women and associated with psychosocial health issues. Recovering from IPV through Strengths and Empowerment (RISE) is a brief, clinician-administered, variable-length (1–6 sessions), modular, individualized psychosocial counseling intervention developed for women experiencing IPV. We present qualitative feedback and quantitative helpfulness ratings from women patients of the Veterans Health Administration who completed a randomized clinical trial (RCT) comparing RISE to a clinician-administered advocacy-based Enhanced Care as Usual . Methods: 58 participants ( Intimate partner violence (IPV), including physical, sexual, and psychological violence, is a complex population health problem. IPV is the most prevalent form of violence against women globally, with recent data from the World Health Organization (WHO) demonstrating that IPV is prevalent across the globe, with more than 640 million women worldwide who experience IPV during their lifetime . AccordiAlthough routine screening for IPV in the healthcare setting is effective in identifying patients who experience IPV , it is cThe need to understand women’s nuanced experiences of these types of IPV interventions comes at an important juncture in the fields of medicine and IPV, intersecting with the integration of patient-centered care  and survOne group of end-users that is particularly relevant to study are women who have served in the military. Women Veterans are an important population for IPV treatment research as they are at high risk for experiencing IPV, with past-year estimates ranging from 19–37% ,27,28,29The current study begins to fill the aforementioned gaps in the literature by incorporating qualitative methods along with helpfulness ratings to assess women Veterans’ IPV treatment experiences within the context of a larger randomized clinical trial (RCT) study. This RCT targeted women Veterans of the United States Armed Services who were patients of the Veterans Health Administration (VHA) and compared a new empowerment-focused modular-based brief counseling intervention (described in more detail in the Methods section) to an advocacy-based Enhanced Care as Usual (ECAU) intervention . The preWe conducted semi-structured interviews with participants 10- and 14-weeks following enrollment in a RCT comparing the Recovering from Intimate Partner Violence through Strengths and Empowerment (RISE) brief counseling intervention to an ECAU comparison condition for women Veterans VHA patients who experienced past-year IPV . The larger RCT and primary quantitative findings have been described elsewhere . In brieIn total, 60 women VHA patients participated in the larger RCT. Participants were recruited via flyers posted in the hospital, self-referrals, clinician referrals, and recruitment letters mailed to VHA patients. Flyers defined IPV and described the treatment study. Recruitment letters broadly described a Women’s Treatment Preferences study taking place at the local VHA medical center. Interested women were screened by phone for eligibility criteria, in which a trained research assistant (DS) administered a five-item IPV screener that has been validated with women Veterans  and asken = 50) received sessions and assessments in person at a local VHA medical center as was intended with the original study design, and 10 participants received one or more sessions and/or assessments via telehealth due to the COVID-19 pandemic. There were no significant differences in pretreatment sociodemographic characteristics for the ten participants who had telehealth sessions versus those who did not as part of the larger study . The study’s randomization procedures remained the same following the onset of COVID-19 and resulted in an even distribution of participants to each of the two intervention conditions. Participants completed follow-up assessments 10- and 14-weeks following enrollment, which included semi-structured qualitative interviews at each time point. Participants were compensated $25, $50, and $75, respectively, at each of the three assessment timepoints. The compensation was commensurate with the amount of time required to complete the assessments and was approved by the Institutional Review Board. Participant flow throughout the study is shown in The recruitment, intervention, and analysis team included trained individuals from a variety of educational backgrounds. More details are provided throughout the manuscript. For the RCT, trained bachelor-level research assistants and a doctoral-level clinical psychologist conducted screening, consent, and assessment procedures. Women who were eligible following a phone screening scheduled an in-person enrollment session, and those who were ineligible were provided with appropriate alternative resources. At the enrollment session, women provided written informed consent and filled out a packet of questionnaires for their pre-treatment assessment. They were randomized to receive RISE or ECAU, which they received immediately following their pre-treatment assessment  . Most paRISE is a variable-length, modular-based, survivor-centered and trauma-informed intervention that ranges from 1–6 sessions and was administered over the course of 10 weeks in the current study. RISE is rooted in principles of Motivational Interviewing  and empoECAU is an advocacy-based intervention that incorporates best-practice recommendations for addressing IPV in VHA. Participants in the ECAU condition received a one-time, 60-min intervention with a provider. At the start of the session, participants were given VHA’s IPV educational brochure to provide psychoeducation about different forms of IPV, prevalence rates of IPV, and the effects of IPV on physical, mental, and social health. ECAU provides information about safety planning, including an optional brief safety plan that can be completed with the provider. Participants in the ECAU condition receive information about local and national resources, including both VHA and community resources, and have the opportunity to connect with these resources and receive referrals as relevant and requested by the woman. Interventionists were VHA clinical providers, including one social worker and three clinical psychologists, with relevant clinical experience and expertise in trauma-informed care; all were women. Providers delivered both interventions within a primary-care setting and an outpatient mental health clinic. Providers participated in weekly consultation with the RISE intervention developer, and both RISE and ECAU sessions were reviewed by the study principal investigator (KI) and discussed to ensure fidelity to the respective treatments. Semi-structured audio recorded interviews were conducted at the 10- and 14-week post-treatment assessments by qualitatively-trained study staff. The interviews were conducted at both timepoints, as it was possible that women’s perspectives or recommendations could be different at the 14-week assessment because they have had more time to try out what they learned in the interventions. Author AH, a medical anthropologist and implementation scientist, provided oversight and overarching guidance for data collection and analysis. An interview guide was developed based on the treatment development and implementation literature, and Veteran and clinician stakeholder input. Interview questions were semi-structured in nature, with a focus on elucidating participant experiences and attitudes about their respective intervention. Of note, the interview guide had been piloted and refined during a pilot study . All intInterviews were analyzed using a hybrid deductive-inductive analytic approach, following an established multi-step approach for efficient and effective identification of key findings from the interviews. The analysis team was trained and led by AH and consisted of two doctoral-level clinical psychologists and a bachelor’s level research assistant . The multi-step approach followed common rapid analytic methods in intervention development and implementation research ,46. FirsNext, the team compiled the summaries into matrices, one matrix each for the RISE and ECAU participants, and used matrix analysis  to displn = 1 did not complete either the 10- or 14-week assessment and n = 1 did not complete the interview portion at either assessment point, resulting in n = 28; ECAU: n = 2 did not complete 10- or 14-week assessment but because these were different participants, there was interview data at one of these timepoints for all 30 ECAU participants). p-values > 0.05). Three interviews were not transcribed due to recording not being feasible and two interviews from each condition were accidently deleted prior to being transferred and transcribed. In these instances, we relied on memos and written notes for these participants. Of the 60 participants from the RCT, 58  participants completed the interviews at the 10- and/or 14-week follow-up assessments and are included in the analysis (RISE: n = 30) received a one-session intervention. In the RISE condition (n = 28), 23 women (82.1%) completed at least two sessions, 21 (75%) completed at least three sessions, 17 (60.7%) completed at least four sessions, 14 (50%) completed at least five sessions, and nine (32%) completed all six sessions. The percentage of RISE participants selecting each module were as follows: Improving Coping and Self-Care (75%), Education on Health Effects of IPV and Warning Signs (57.1%), Enhancing Social Support (57.1%), Connecting with Resources and Moving Forward (57.1%), Making Difficult Decisions (50%), and Safety Planning (35.7%).In the ECAU condition, all participants , none of the participants reported less than adequate levels of perceived helpfulness . The majority of RISE participants (76.9%) and just over half of ECAU participants (51.7%) rated the intervention as ‘highly helpful.’ The remaining participants in both groups rated the intervention as ‘somewhat helpful’ (23.1% for RISE and 48.3% for ECAU). Similarly, qualitative results indicated that all participants, regardless of their condition, were appreciative of having an intervention available to them; the majority were not aware of other alternative counseling interventions for IPV. Both interventions were perceived as generally acceptable, although several differences were identified in terms of perceived impact, application of content, patient-centeredness, and recommendations for implementation.Women in both conditions reported that they found the intervention to be helpful, but the specific ways in which the interventions were perceived as helpful tended to differ between the two conditions. RISE participants shared more positive impacts on emotional health and psychosocial well-being, whereas the ECAU participants tended to highlight more practical impacts. Specifically, women in the RISE group reported the intervention impacted the way they felt about themselves, including feeling more empowered, confident, and independent than when they started the intervention. For example, women in RISE shared that they felt more confident to think about their relationships and their personal needs differently and take a more active role in improving various areas of their life, including their relationships, and prioritizing their physical and mental health. For instance, a RISE participant described, RISE has empowered me to take much more control over the interpersonal relationships in my life ”.“While discussing making the decision to leave her relationship during the study, another participant shared, It’s definitely made me realize and get some self-worth back and feel more empowered by my decisions ”.“Similarly, another woman in RISE shared that, I didn’t realize I wasn’t taking care of myself or advocating for myself much. RISE gave me that confidence to start doing that ”.“Confidence and independence were increased through independent thinking and decision-making. As noted by a RISE participant when discussing her desire to be more financially independent, In the past I wanted to be separated from him, but I realized I couldn’t do that. Now I am working towards that financial independence ”.“These types of benefits were not typically noted among women in the ECAU group. In terms of potential mechanisms of these changes, women in the RISE group, many of whom opted to participate in multiple RISE sessions (mean sessions received was 3.8 sessions), shared that reflecting over time with their RISE provider and engaging in exercises within specific modules, setting goals related to the module, and practicing between sessions helped them acknowledge their strengths and restore self-esteem, opened my eyes and after every session, I would think about what the session was about. When I’m driving or when I have a quiet period, I would realize, ‘oh yeah, I do have this quality’ or ‘oh yes, I’ve been able to handle this problem.’ So, it made me see that I wasn’t as awful as I thought I was or as inadequate as I thought I was. It made me realize I’ve accomplished a lot more than I had realized ”.“[RISE] Women in the ECAU group described the intervention as having helpful impacts too, particularly in terms of increasing their overall knowledge about IPV and the variety of resources they could potentially make use of now or in the future. In terms of knowledge, multiple women discussed the value of learning about and paying homage to the different forms of IPV and their impacts on health, which helped them to validate their IPV experiences. One woman stated, covered all bases including every aspect of abuse in a relationship: physical, sexual, and emotional. I feel as though emotional abuse can be more detrimental than physical sometimes ”.“[the intervention] Another woman noted, It impacted me by teaching me that I’m not responsible and I don’t deserve specific treatment, like abuse. Whether it’s physical, emotional, mental ”.“This information was typically perceived as normalizing and helped women understand they were not alone in their experiences. Notably, the ECAU participants consistently commented on the impact of the breadth of information provided within the brochure that was used to help facilitate the information sharing and elicit discussion during the session, The wealth of information and contact information for resources in the pamphlet I took it home, and I poured over it for days. I googled every single thing, whether I thought I needed it or not. Stuff like that. But that whole thing made me feel not alone in this ”.“The intervention and brochure in particular led this participant to seek out additional information and resources. Participants in both conditions reported that they applied tools and resources provided through the interventions. However, women in RISE endorsed more active changes in their daily lives through incorporating self-care, activating social support, and being more assertive in relationships, whereas women in ECAU applied tools specifically from the informational session and brochure, such as accessing IPV-relevant services and increasing awareness of IPV-related health impacts. RISE participants identified several topics and handouts that they directly applied and utilized in their daily lives. Some notable applications were self-care, using decisional balance exercises from the Making Difficult Decisions module and applying strategies from the Enhancing Social Support and Safety Planning modules. For example, when asked about intervention applications, one participant shared, I still have and use the handouts, especially the self-care handout. Sometimes it’s hard for me to do self-care, but with handouts it reminds me that I don’t have to do anything major. It can be something simple, like aromatherapy. Even if I don’t have the funds to go out. Just little things. It definitely adds up ”.“Another participant described utilizing an exercise that is part of the Making Difficult Decisions module after participating in RISE: I have been weighing my pros and cons sometimes before I make difficult decisions ”.“Increased skills around making decisions led to more confidence in her ability to make good decisions for herself.Moreover, other RISE participants elaborated on the importance of social support as a mechanism of coping and maintaining safety. During and following the receipt of RISE, women engaged with social support, noting: led me to reach out to a couple people just to make sure we were covered in case I had to use my safety plan. For me, that was a little bit more of going outside of my norm to ask for help, especially for the relationship situation ”.“[RISE] Likewise, another woman described utilizing content and concepts from the Education on Health Effects of IPV and Warning Signs module to improve her physical and mental health, noting: really impacted my physical health so much. I try to make plans to workout more or exercise or do things that were more towards my physical wellness. Emotionally, RISE kind of helped me to stabilize my emotional roller coaster on some days ”.“[RISE] These examples of applying RISE concepts, resources, and skills emphasize some of the RISE intervention’s unique mechanisms of helpfulness, appropriateness, and usability.Participants in ECAU also provided examples of applying what they had learned from the intervention, although the applications were somewhat less concrete and mostly involved the information and resources discussed in the session and the associated brochure. An ECAU participant noted, I liked that she gave me the pamphlet and went through it with me during the session. It was helpful. She gave me resources to help me and places to go in the VA for certain things ”.“She elaborated that her provider helped connect her with case management, and she had since been utilizing their services which she found valuable in moving towards practical goals. The sentiment that the pamphlet was a helpful tool resounded amongst many participants in ECAU. Another ECAU participant echoed that, just to have that information was comforting ”.“This participant emphasized that the statistics about other women experiencing IPV, as well as the normalization of common reactions and health consequences of IPV, also played a role in providing social connectedness, as it made her feel comforted and not alone. Participants in both interventions often disclosed that they did not fully comprehend the seriousness of the abuse in their relationship or that they were not to blame for the abuse. Similarly, another ECAU participant poignantly appreciated the brochure and gave credit to the intervention for impacting the decision to leave her partner, stating: I felt like I had resources within the brochure. You gave me a lot of resources to use to feel better and get help to leave. So that was good ”. “Participants in ECAU utilized the pamphlet to better understand their situation: I’ve been evaluating my situation more clearly with information from the brochure ”. “This participant reflected that the validating nature of their provider helped normalize her IPV experiences and therefore enabled her to be more open to recognizing the corresponding health impacts.Participants in both the RISE and ECAU conditions expressed appreciation for the patient-centered nature of the interventions. Further, RISE participants noted that they appreciated the flexible yet structured and contained nature of RISE, I liked that we had a menu. Every week I got to pick because then I don’t have to sit there and wonder, ‘okay, what do I want to talk about today.’ She gave me options. If I didn’t want to deal with the feelings today and instead deal with coping with stress, that option and choice was very good for me ”. “Similarly, another participant described how selecting the focus of her session was empowering because it gave her agency in her own treatment, noting: I got to pick the topic based on what I was going through. That was very good. It helped me to think, ‘okay do I need to focus on this area a little bit more or that area.’ So, I liked that I was choosing myself but talking to somebody with expertise at the same time ”. “Another RISE participant echoed this sentiment, stating: I liked the menu items in the beginning that we covered. It gave me a chance to figure out where I was currently at in my mental state, and where I am at in that relationship. So, I really liked that. It definitely catered to what I needed instead of, this is what we are going to do today regardless of what I feel. So, I liked that ”.“In both groups, participants liked that the interventions were tailored to them as women Veterans who experienced IPV. In particular, they valued that the interventions had general resources as well as specific resources related to their identities as women and as Veterans. An ECAU participant further describes this in reference to a referral that she was provided to a Post-9/11 social worker: It is tailored to us, which is more specific, it’s more beneficial than just some random [other resource]... oh there’s an actual office just for Veterans like me, and you should go there ”. “The participant reflects how targeting women Veterans specifically and individualizing the intervention to assist in their explicit needs contributed to her high level of satisfaction with the intervention. This may encourage women to feel more comfortable utilizing follow-up services as they reflect on their individual needs. Another ECAU participant emphasized the value of utilizing a women’s space within the VHA. She stated, I wasn’t aware there was a space for us women with partner issues. I was very happy that I was able to get that information because I want to say that I haven’t received that anywhere. Then, after the session, I felt like I had a space to do so ”.“Participants were asked to describe any changes they would make to how the intervention was delivered that would have improved their overall experience with the intervention or that might help other women experiencing IPV. Across both conditions, there was a desire for more sessions; however, this desire was more common and pronounced for ECAU participants, and the rationale for wanting more sessions differed between groups. The RISE participants who wanted more sessions indicated a desire to continue to further their progress, as they had experienced initial positive impacts from the intervention, and they wanted to continue their growth. For example, one woman in the RISE group shared, I wish that it could have been more thorough and longer. Like if it became a permanent thing, I am sure that would fix the problem, but just the one a week and because it did have such a big impact on me, there wasn’t enough of it because now here I am, and now I’m on the other side of that, and there’s still a lot of work that needs to be done ”. “This suggests that RISE might be more impactful if participants had the option to engage in more sessions. Later in the interview, she described in detail why it would have been helpful for her to have more sessions, I wanted to do all the topics and there were six, but there were only six sessions. I wish it could have been longer. Some weeks I really wanted to go back over one topic, but then I wouldn’t be able to, I’d have to cut one out ”. “Another RISE participant indicated that she wanted several more sessions because that really helps you set goals and then it helps you keep them. To go back and look at the first goal that you set, you know, 20 weeks prior, would be extremely helpful to kind of just remind yourself like you made this progress, don’t let go of it. Just to kind of build habits so it is not like something that you do once, and you move on and you don’t do it again ”. “This suggests that including more RISE sessions might further instill the skills and applications implemented in RISE. more time to process things ”. The ECAU participants wanted more sessions because they wanted the opportunity to further reflect on their IPV experiences and gain more in-depth benefits from the intervention. ECAU focused primarily on providing information and resources, validation, and safety planning. Although the intervention was generally deemed acceptable, many ECAU participants expressed that they wished they had a designated time and space to reflect on their IPV experiences and its impact on their lives in more detail, and wished they had more sessions to reflect on things that arose or were triggered during their ECAU session. One participant stated that she would have benefitted from “This participant went on to mention that having more sessions could have strengthened the impact of the supportive messaging that is part of the intervention: I feel like if I had more sessions, the more stuff would stick. Just being reassured that things weren’t my fault or things like that would stick more ”. “Although ECAU participants appreciated and utilized the informational and resources-based intervention, a number of participants reported feeling emotionally triggered or overwhelmed by the extensive information provided in a single session: I think that the brochure she showed was really good, but with the brochure, I noticed after being here, I had a really hard day after that, and the day after. I think it was because of the brochure and how simplified it was ”. “This participant recommended that some women may appreciate an offer for a scheduled phone or in-person check-in following the session to validate, problem solve, and answer questions. Another ECAU participant echoed, Just, it just seemed a little overwhelming. I actually feel like, hmm, maybe to have a couple more sessions so you don’t feel so stressed ”. “This participant recommended breaking up the ECAU intervention into multiple sessions to give participants the opportunity to consume the IPV information at a more manageable pace, hence reducing their stress and enhancing their ability to benefit more from the intervention. Another ECAU participant voiced that having multiple sessions would have helped her feel more comfortable and open with her clinician. She stated, I definitely would have said maybe a couple more sessions to get it all out to that one person and see that one person a few times and start to kind of build a relationship ”. “This participant suggests that having more sessions might have facilitated a stronger therapeutic relationship which might have led to higher acceptability of the treatment. An additional domain related to implementation recommendations was the desire for telehealth options. Prior to the COVID-19 pandemic, both interventions were delivered in person. Due to the COVID-19 pandemic, RISE and ECAU were converted to telehealth for the final 10 participants in the study. Before the COVID-19 pandemic, women in both interventions consistently expressed interest in utilizing telehealth as an option to limit barriers to care that are common among women with recent IPV experiences. As detailed here by a participant in the RISE group, Maybe doing telecommunication or skype videos. Cause I think that would have a greater impact...you could reach a lot more people. If they can’t get to you, they can literally just use their phone or computer and still talk to that person as long as they are in a safe space. And maybe they don’t feel comfortable [in the medical center] and they feel comfortable in their house talking ”. “Once the interventions were adapted to telehealth, interview questions were modified to inquire about their experience of receiving an IPV intervention during the pandemic. One woman who transitioned from in-person RISE sessions to telehealth suggested that telehealth was a better option for her as she could more easily attend sessions , I almost think it’s better over the phone because I am in my own comfortable space. I am not rushing to get into a hospital. Getting through traffic. I was resistant to doing therapy over the phone, but now, I have adapted to it, and I actually prefer it more ”. “Another participant in the RISE condition shared that she experienced an unanticipated problem with telehealth related to privacy: I was completely comfortable with telehealth. The only time I wasn’t was when I was at my boyfriend’s mom’s house. I was like in my car doing it. It was my own fault for forgetting that I had the session, but my window was down, I think someone might have overheard me. But normally if I am home, I am completely comfortable ”. “Although some participants were hesitant to participate in teletherapy originally, as some had difficulty locating a private space, most women ultimately found it more palatable and feasible since it cut down time constraints and other barriers to care. Women who have experienced IPV and seek IPV treatment have a variety of unique needs and preferences ,48,49. TOur findings add to prior qualitative work investigating IPV survivors’ experiences with disclosing and discussing IPV in general mental health contexts ,50 by adInterviews in the current study revealed that the additional flexibility during the COVID-19 pandemic  across both interventions was important, feasible, acceptable, and safe. Trauma-informed telehealth strategies  were applied to bolster women’s privacy, confidentiality, safety, and comfort addressing IPV via telehealth ,54. We aWomen across both intervention conditions shared during the interviews that they utilized a number of additional resources and services as a result of direct linkages from the intervention. IPV screening and response literature confirms the importance of tangible IPV resources ,57,58,59A number of the participants across the groups spoke about the importance of the IPV interventions for enhancing a sense of social-connectedness and social support. The literature reveals that social support is instrumental in fostering quality-of-life and healing, including in the context of abuse and IPV ,62,63. WParticipants in both intervention conditions endorsed a preference for being offered multiple sessions and the perceived benefits of reflecting weekly and engaging in exercises/practice between sessions . Participants in previous studies have emphasized that discussing IPV-related events is highly personal and understandably upsetting ; as suchOur findings must be interpreted in light of its limitations. First, the study’s modest sample size and relatively brief and limited follow-up assessments (10- and 14-weeks following enrollment) are limitations. The brief timeframe for the follow-up assessments makes it impossible to know if the usefulness and acceptability of the interventions persist over time. It is possible women may have different perceptions of the interventions’ strengths and weaknesses over time and that the 4 weeks between the two follow-up assessments was not long enough to capture such experiences. Future studies should include longer term follow-up assessments that include both qualitative and quantitative outcomes. Additionally, by design, there is variation in the uptake of the number of RISE sessions received and in the modules selected by participants. In the present study, the qualitative interviews were designed to assess participants’ experience with the RISE and advocacy-based ECAU interventions overall. The present study did not examine individual differences in how participants were impacted by the interventions and thus findings should not be interpreted to imply that all participants were affected the same by the intervention. Future studies of RISE should assess more specific feedback about the individual modules, ordering of the modules, and length of the RISE intervention. Although we found strong support among this sample for the identified themes, the findings are not necessarily universal, and the findings should not be assumed to apply to all women who experience IPV. Rather, these findings might highlight the importance of these themes as they relate to women Veterans and some themes may not be as transferrable to other clinical populations. Indeed, in addition to IPV, women Veterans tend to experience more trauma exposures over the lifespan and have additional mental and physical health needs as compared to their civilian counterparts ,66. AddiUnderstanding women’s experiences and preferences for psychosocial counseling interventions for IPV is critical to providing evidence-based and trauma-informed care for this prevalent issue. Our study focused on women Veterans. The current findings reinforce the notion that women want flexibility and a sense of empowerment surrounding the length and content of their IPV treatment. Additionally, it is important for clinicians to provide social and logistical support , which helps women feel less alone in their IPV experiences. These are practical suggestions that can be implemented into clinical practice with women Veterans who experience IPV and are likely applicable to other populations of women experiencing IPV.


This study examines the food safety beliefs of vendors and consumers in a mid-sized Nigerian city using data from in-depth interviews and cognitive mapping techniques drawn from ethnography. We examine vendors’ and consumers’ perspectives on which foods are safe, which are not, and why; the place of foodborne illness among other health concerns and motivators of food choice; and how salient food safety is as a concern for vendors. The main perceived causes of unsafe food were found to be chemicals and insects; while bacterial illnesses were widely mentioned as a cause of gastrointestinal symptoms, these were not necessarily linked to food in consumers’ minds. Respondents agreed strongly that certain foods  were less safe than others. The importance of food safety as a choice motivator among consumers varies depending on framing: when asked directly, it was prominent and closely related to visible cleanliness, but concerns about food safety competed in consumers’ minds against other salient motivators of food and vendor choice, such as price. Most vendors did not see food safety, cleanliness, or hygiene as a key trait of a successful vendor, and just over half of vendors had any concern about the safety of their food. In conclusion, we note the implications for intervention designs, particularly the need to build upon consumers’ and vendors’ current beliefs and practices related to food safety in order to make foodborne disease prevention a more salient concern in food choice. Food safety, the assurance that food will not cause harm to the consumer when it is prepared or eaten according to its intended use , is neceTransitioning lower-middle-income countries are the settings in which food safety generally reaches a critical point due to rapid economic, demographic, and dietary change amid limited (government and private-sector) capacity to manage food safety . A primeThere is thus a need to improve food safety in Nigeria. Doing so requires understanding, and potentially shaping, the motivations and beliefs that impact the decisions of consumers and food vendors, in order to enable consumers to demand safer food and vendors to deliver it ,8. WhileWhat are market vendors’ and consumers’ perspectives on which foods are safe, which are not, and why?For consumers, what is the place of foodborne illness among other health concerns and how big of a role does food safety play among other motivators of food choice?For vendors, how salient is food safety as a concern?To address these gaps, this paper examines the beliefs of consumers and vendors in three traditional markets in Birnin Kebbi, a mid-sized Nigerian city. The focus is placed on traditional markets due to their importance to consumers in LMICs  and the Answering these questions will shed light on the basic drivers of vendor and consumer behavior: their beliefs about what food is safe and how much it matters to them.This study used an adapted Focused Ethnographic Study (FES) approach. FES has been applied to various public health topics but not yet food safety ,31. FES The study focused on traditional market vendors and consumers in three markets in Birnin Kebbi, the capital of Kebbi State in northwestern Nigeria. While much of the focus was on general food safety perceptions, some questions asked about specific “focus foods”: rice, maize, cowpea, soybean, fish, green leafy vegetables , and beef. The geographic and food focuses were determined based on donor and government priorities and alignment with existing policies and programs. For the choice of the foods, nutritional value, widespread consumption, and covering a diverse range of foods were also important criteria.Fieldwork was done using trained local interviewers (four teams of two), all of whom were local to Birnin Kebbi and had experience with in-depth interviewing. It consisted primarily of in-person (face-to-face) interviews with consumers and vendors, in two phases. Consumers were defined as those who shop in at least one target market, at least once a month and have primary or shared responsibility for purchasing food for their household. Vendors were defined as those selling at least one focus food in a target market at least once a month. Both consumers and vendors were recruited non-intentionally through market visits. In Phase 1, respondents were recruited only from the city’s main market. In Phase 2, respondents were recruited from all three target markets. The sample size for Phase 1 was 13 vendors and 16 consumers. The sample size for Phase 2 was 24 vendors and 31 consumers. After being selected, potential respondents were asked a set of screening criteria to determine eligibility and willingness to participate, then selected for interviews in line with a set of quotas to ensure the inclusion of a diverse range of respondents. For consumers, quotas were set for men, women, those under age 30, and those over age 30. For vendors, Phase 1 sampling included sellers who sell each focus food, with three vendors each for the foods thought to have the highest food safety risk  and the others  having one vendor interviewee each. In Phase 2, the focus was narrowed to GLV and fish, chosen due to the potential for high food safety risk, and 12 vendors of each were interviewed. It was intended to interview both female and male vendors; however, no female vendors were available for most of the commodities.free listing, respondents were asked to name all the items in a defined domain; in ranking, respondents were asked to rank items on a scale. For certain interview questions, images of the focus foods were used to help respondents picture the food being discussed and ensure uniformity across respondents. Interviews generally lasted 90–120 min.The interview guides and protocol used here were heavily adapted from the original FES manual  that focData were collected in February–May 2021, following a specific protocol. All interviews were conducted in Hausa, audio-recorded, transcribed verbatim, and translated into English. For structured data , these were entered onto paper forms and later transferred to electronic versions. All data were treated with confidentiality, and all participants provided written informed consent. As the research took place during the COVID-19 pandemic, methods were adjusted to protect the safety of the research staff and participants.Demographic data and the responses to other simple closed questions were tabulated in Excel and/or analyzed in Stata SE15. Interview transcripts were subjected to thematic analysis either through hand-coding or using the software ATLAS.ti. Free-list data analysis used the approach described by , using VAfter discussing the demographic characteristics of the sample, we consider the following key areas of the results: how consumers and vendors conceptualize “safe” and “unsafe” foods, the relevance of food safety risk in driving consumers’ choices, and the salience of food safety as a concern among vendors.Demographic information for the interviewed consumers and vendors is given in …those that sell leftover meat have some chemicals they apply on it to prevent it [the meat] from spoiling before the next day. I really don’t know the exact name of the chemical, but I heard it is the type being used on dead bodies. So, if they are not able to sell off their meat and it happens they don’t have a fridge to keep it cool, they use such [chemicals] on it. So, you see if one buys and consumes such kind of meat, it will have a negative effect on one’s health.—C1210, a 25-year-old female consumer with secondary educationThe meat and the fish and vegetables, because of the way they keep it, it will not make me want to buy… Perching of flies on the particular product, it can bring in diseases. Let say flies perch on it, there would definitely be cholera on it. And sicknesses like typhoid and diarrhea, too.—C2201, a 25-year-old male consumer with post-secondary educationOverall, most consumers had a moderate understanding of food safety issues. The main causes mentioned for food becoming unsafe to eat were chemicals and insects. Chemicals were cited both as a general, vaguely defined concern and in relation to specific types: pesticides, fertilizers, and preservatives. Insects were named both as landing on uncovered food (transferring dirt or transmitting disease) and infesting food, though the latter was seen as more a cause of poor quality than unsafe food. Several respondents noted spoilage when food was improperly stored, dust or dirt, and poor food handling. With respect to fish and beef, animal disease and medications were both noted as causes of unsafe food. Not all responses were tied to established food safety hazards or mechanisms from a “scientific” perspective. Only two respondents mentioned bacteria; none mentioned fungi, viruses, or protozoa.[Unsafe fish] can cause severe fever and weakness of the body. I think these are what eating such unsafe fish may lead to. Some may lead to death, it can cause…is it yellow fever? I’m not sure… maybe other forms of fever and stomach pains.—C1213, a 28-year-old male consumer with post-secondary educationThe main types of symptoms named as caused by food were diarrhea, vomiting, stomachache, and upset/bloated stomach. Less commonly mentioned were headache, fever, loss of appetite, rashes, weakness, brain problems, and death. Some respondents mentioned chronic diseases, like diabetes or high blood pressure, but these were not treated in the analysis as “food safety” concerns, per se. The types of symptoms named generally did not differ across food types. Some of the respondents’ answers were clearly based on knowledge or experience of foodborne illness, while others seemed speculative:In the free listing, participants were asked to list foods they could always count on to be safe and those not always safe. The results of the listings of “unsafe” and “safe foods” are shown in Maruca vitrata), a major cowpea pest in Nigeria) or other insects (named by 14 of 16 Phase 1 consumers), and potentially unsafe chemicals were used to preserve the cowpea from weevils (12 of 16). In Phase 1, chemicals were mentioned 31 times in relation to cowpea (compared to 16 times in relation to GLV and ≤6 in relation to other focus foods). Insects were seen as an issue both at the point of purchase and in the home.[Chemicals on cowpea] come from the person that preserves it, maybe from the farmer, because if they’re preserving it, they put this chemical to prevent insects; if it’s consumed by us, the consumers, it becomes harmful to our health, it can cause sickness, even the cholera that I had talked about, it can even cause death if care is not taken.—C2202, a 31-year-old male consumer with post-secondary educationThe “most unsafe” food in the minds of consumers was cowpea, named by three-quarters of respondents, usually as the first item. Responses to open-ended questions revealed that this was for two interrelated reasons: cowpea might contain “weevils”  were named by 3–4 consumers, seldom among the first items. While there are some who see them as unsafe, they are not of high salience. Local rice and GLV were also highly ranked by vendors as unsafe. For local rice, this concern was driven by the presence of stones. It was the only food for which physical contaminants were commonly mentioned. An important distinction respondents made was between …Foreign rice, it is safe to eat. Foreign canned tomatoes, foreign canned fish, foreign salad cream is safe, foreign Bama is safe, but our own Nigerian made is unsafe…. it is not comparable with Nigerian made, foreign is higher quality. In my own opinion, [the] Nigerian Government does not care about what is produced here, while their own [foreign] government makes sure quality foods are produced for its citizens.… I do not know the reason, but foreign is better than Nigerian made. I am not in that [foreign] country, but I know [its] government makes sure and makes it mandatory to produce quality products, the company wants to maintain good reputation and maintain their customers. But here, since we don’t have a choice, anything produced will sell, consumers will buy.—V1107, a 43-year-old grain/legume vendor with primary educationIndeed, some respondents saw a general connection between foreign food and safety or quality:If one eats a bad vegetable, the person will fall sick [with] fever.… And also when one eats vegetables that has worms, it will lead to vomiting and stooling, then fever.—C1206, a 30-year-old female consumer with secondary educationYes, there is a problem when one eats those [green leafy vegetables] that were grown with chemicals or have chemicals applied on them…. It can cause harm to the body. It can cause stooling, vomiting and severe fever.—C1213, a 28-year-old male consumer with post-secondary educationFor GLV, some consumers expressed no concern; as one man noted, “I have not seen anyone that ate green vegetables and got harmed, and I don’t think they will harm anyone” . The majority, however , did have concerns related to insects  or chemicals . Some consumers also mentioned washing with unclean water or spoilage. Dirt or sand was noted as a quality issue but not necessarily a safety one.In general, consumers recognized that food safety concerns might arise with GLV in certain circumstances, but did not see them as common, and those concerns did not prevent consumption. Most food safety issues were seen as manageable with in-home behaviors like washing or cooking.The remaining foods  were named by only 1–2 people each. Interestingly, several types of food that experts might describe as a high risk for contamination  were not named, while several of those named  are generally not associated with high risk in scientific risk assessment. Aside from rice, where the potential risk was physical damage , all “unsafe” foods were associated with similar consequences—gastrointestinal symptoms and, less commonly, fever or headache—regardless of the perceived hazard.The reason why I said tinned milk  it’s because is made from the company, because it has passed through quality control before selling it out.—C1212, a 30-year-old male consumer with post-secondary educationMostly we prefer packaged foods because they’re safe… I prefer packaged foods than open foods because [of] how they are being treated and being preserved. When you get packaged foods, you can actually get it anywhere, it is the same thing. But when you go to a particular customer  to get vegetables or fish, they are open foods…. You [must] have trust with someone you will know that, that person [is] clean and neat.—C2201, a 25-year-old male consumer with post-secondary education[Instant noodles are] made by companies, so they wouldn’t sell something of low quality.—C2219, a 46-year-old male consumer with post-secondary educationFor “safe foods” , grains,However, a few named packaged/industrially processed foods, particularly Semovita (blended flour) as foods of concern due to chemicals or prolonged storage.always safe but rather that with the respondent’s care and attention, safe versions can be identified. Similarly, vendors made a separation between the risk associated with certain foods in general and risk they attached to the same foods when sold by them, offering explanations like “I only sell the good ones”.Surprisingly, fish, beef, and GLV all also appeared on consumers’ “safe foods” lists. For GLV, this is with slightly less salience than as an “unsafe food”, suggesting divided opinions, whereas for beef the salience is considerably lower. The appearance of cowpea on both lists is also surprising. The respondents’ commentary indicates that this reflects not that cowpea is The different types of hazards associated with each of the seven focus foods are shown in Salmonella typhi, Vibrio cholerae); a similar vagueness in definition may also be the case for malaria for how neat it is and the surroundings for the entire products I am going for, that is what I normally do.—C1215, a 37-year-old male consumer with post-secondary education [emphasis added]I check the quality of what I want to buy and then the price…. I will visit 2 to 3 shops and then go for the cheaper one. For me, though, I go for quality before I make a purchase, and I look The choice of a vendor was also driven largely by price (13 of 16 Phase 1 consumers), including discounts or free goods. Credit provision was mentioned by one quarter of respondents. While not a key concern for all shoppers, credit was an important motivator for some, particularly in a context of often increasing and unpredictable prices, and could lead to ongoing vendor-shopper relationships. Beyond price, the main characteristics motivating the choice of a vendor related to interpersonal qualities: niceness, politeness, good customer relations, and patience (which consumers described as related to a vendor’s willingness to bargain and discuss). Four (of 16) Phase 1 consumer interviewees brought up vendor cleanliness unprompted when asked about general criteria relating to vendor choice. This was usually presented as one criterion among several, but a necessary one:When the topic of foodborne illness was broached more explicitly in Phase 2, respondents were much more likely to mention cleanliness as something they sought in a market or vendor (26 of 31 respondents). Moreover, when asked to rank five potential ways that a vendor could attract customers, cleanliness was commonly rated first .To gauge the importance of food safety to vendors, we asked them to list the qualities they believed were required for success in vending food. “Cleanliness” and “having a washed/clean product” were the only responses with a direct bearing on food safety that the listing exercise produced, each named by less than 10% of vendors and appearing at a low position on the list, suggesting low salience. Far more salient are aspects of vendor character  and competitive pricing. In Phase 2, vendors were asked to rank cleanliness  as a way to attract and keep customers, as compared to other qualities that were noted in Phase 1 as being important aspects of being “a good vendor”. The results are shown in One of the ways to be noticed and selected by customers is that–imagine that this is my table and there are very fresh vegetables laid out on the table. Naturally, the freshness of the vegetable is one of the things that affects customers. Even before they ask the price, the goods are what will first of all captivate them… One of the things a shopper expects from a trusted vendor is good quality product. Then, after that, we can talk about good price.—V2113, 35-year-old GLV vendor with primary educationInterviews also explored the topic of food safety through exploratory, open-ended questions about vendors’ own food safety concerns and the concerns expressed to them by shoppers. Five of 13 vendors stated that the safety of their own foods for sale was not an issue that concerned them. Among those who acknowledged a concern, the issues identified were familiar from the consumer interviews: chemicals , stones and dirt (soybean), and animal health (beef). In general, vendors intermixed food safety with food quality, which they construed in general terms as “freshness”. While freshness may be associated with food safety , safety-enhancement was not the main benefit associated with freshness by vendors. Instead, a fresh product was perceived to be easily recognized and appreciated by shoppers, making it an effective way to maximize sales. This was particularly important for GLV, for which apparent freshness was seen as an important motivator for consumers. Some vendors gave freshness primacy, even above price, reasoning that fresher food permits vendors to start the price conversation with shoppers on a different footing:Nine of 13 vendors stated that shoppers sometimes raise food safety issues, but their accounts of these encounters make it clear that much of this consumer concern is directed not at food safety strictly speaking, but rather food quality. Averaging the estimates made by vendors, less than a third of customers were said to ask questions about either the quality or safety of their food. Women were cited by some vendors as being more likely to have concerns or be more discerning, as were urban salaried and educated shoppers, whereas the poorer consumers were noted as less concerned. Regarding specific foods, vendors did note that safety-related issues shaped customers’ choices for certain foods, primarily cowpea  and rice (free of stones). For beef, two vendors noted the importance of a clean sale environment and a clean vendor in communicating safety/quality and encouraging customers to purchase, which was not the case for any other focus foods. As one beef vendor noted, “Meat with dirt is not healthy … because the business requires neatness. From where we buy up to where we sell, needs to be clean” . However, some vendors (particularly of fish and maize) saw safety as an unimportant issue for shoppers.In sum, while vendors were aware of food safety in a general sense, it appeared to be an issue of, at most, moderate concern.This study has examined the food safety beliefs of vendors and consumers in a mid-sized Nigerian city, painting a rich, in-depth picture and offering insights for the design of interventions. Regarding the first research question, on vendors’ and consumers’ perceptions of what causes unsafe food and which foods are safe and unsafe, a fairly clear picture emerges. The main perceived causes of unsafe food, at least among consumers, were chemicals  and insects. Less commonly named were spoilage, dirt, and poor handling. Few respondents mentioned bacterial contamination or explained in detail the mechanisms through which it could occur. While bacterial illnesses such as typhoid were widely mentioned as a cause of diarrhea and vomiting, these were not necessarily linked to food in consumers’ minds. There was also some conflating of foodborne illness with other food-related aspects of health . Respondents agreed strongly that certain foods were less likely to be safe than others, with cowpea , beef , GLV , and local rice (due to stones) being commonly named. The main consequences of unsafe food mentioned were gastrointestinal symptoms and, less commonly, fever or headache. The chief food safety concern among consumers was clearly chemical contamination or weevil infestation of cowpea, though this was not a main concern among vendors.Taenia solium), poultry, and beef, as well as fruit and vegetables, due primarily to bacterial contamination  [Contamination of cowpea in Nigeria with organophosphate pesticides is a documented issue, potentially causing health issues and leading the European Union to suspend dried bean imports from Nigeria since 2013  ,37,38. HE. coli) . The priE. coli) , such asE. coli) ,44,45,46E. coli) . This maE. coli) . Indeed,E. coli) ,50. Be tAn additional finding of note under the first research question was the prominence of processed and packaged foods among the foods listed as “safe”, as well as the tendency for some respondents to equate “foreign” or “industrial” foods with being safer than “local” or unprocessed foods. Similar findings for packaged foods have been identified in other LMICs . The asswhen the topic was not specifically primed or prompted. However, once consumers were asked directly or had been primed on the topic, it was much more prominent, with the majority of consumer respondents opining on the importance of vendor and market cleanliness and naming strategies to avoid unsafe food. In general, however, consumers’ concerns about food safety did not seem to be overriding, i.e., they recognized that food safety concerns might arise with certain foods in certain circumstances, but not commonly, and those concerns did not prevent consumption of that food. Most foods were seen as safe, and it was rare that consumers reported avoiding consumption of a specific food due to safety or quality issues. Moreover, while unsafe food was associated with gastrointestinal diseases, it was not seen as the only cause of any gastrointestinal symptoms, which people also associated with malaria and unclean water. Respondents had rather vague and flexible ideas about types and causes of illnesses, including foodborne ones, and surprisingly few reported direct experience of getting sick from food.Turning to the second research question, the results give a somewhat ambiguous answer regarding how important food safety is as a concern and motivator of choice among consumers. The study found a fairly low level of salience compared to other concerns Jointly, these results align to findings from lower-income countries that food safety is rarely a dominant concern of either the public or policymakers . From anIn addition, food safety will always be competing in consumers’ minds against other salient motivators of food and vendor choice . In partRegarding the final research question, salience of food safety among vendors, we found that most vendors did not see food safety, cleanliness, or hygiene as a key trait of a successful vendor and that just over half of vendors had any concern about the safety of their food. Similarly low prioritization of food safety, despite documented risks, has been found among meat sellers in Tanzania . VendorsVendors also did not consider cleanliness to be a top way to attract customers and estimated that only about one-third of customers asked questions about either quality or safety. Whether this directly reflects that only one-third of customers are concerned about quality or safety is not clear. Customers may still have evaluated it through visual inspection, they may have been skeptical of whether vendors would be knowledgeable or honest about food safety , or they may have prioritized bartering on price over discussing quality. Indeed, research in Ghana has noted that customers are hesitant to voice food safety concerns to vendors . For mosThis study has some limitations. First, the sample was small and not fully representative of the local population. To increase reliability and validity of our data, we used a variety of ethnographic techniques, question types and question ordering, and prompted about specific foods; however, the food safety topic may be affected by memory or personal experiences or perceived personal control over food safety, so the ambiguity of some of our findings may be due to inter-respondent variability. All vendors interviewed were male due to an inability to find eligible female vendors to interview. In addition, the consumer sample was likely somewhat more affluent than the total Birnin Kebbi population. Nigeria’s urban poverty rate is estimated at about 18%, whereas about 12% percent of this sample (using a somewhat more generous threshold) were found to be poor. Similarly, the sample is also somewhat more educated than the average for urban Nigeria, according to the 2018 Demographic and Health Survey . The popWe conclude by drawing on these insights to suggest certain recommendations for improving food safety in Birnin Kebbi and similar settings. First, the results suggest that there is some awareness of food safety and interest in avoiding foodborne disease. Interventions, such as public health campaigns, can seek to make this a more salient motivator by focusing on the potential risks of consuming unsafe food , perhaps in relation to economic costs and benefits, which appear to be a strong motivator for consumers and vendors alike. Second, education campaigns for both consumers and vendors can work to disambiguate actual “safety” aspects, and cues to identify hazards and risks, from more general “quality” aspects, as the two concepts are currently intermixed in many people’s minds. Finally, there is a critical role for government interventions at the market level that can improve food safety infrastructure. Vendors are likely unable to engage in such upgrading alone, given the costs, and it is important that it is done with minimal impact on consumer prices in order to ensure such changes are not biased against the poorest and most vulnerable.In summary, this study has offered an in-depth perspective on how consumers and vendors in Birnin Kebbi, a mid-sized Nigerian city, understand and prioritize food safety within their everyday decisions, especially at point of purchase. In short, it found that food safety was conceived primarily in terms of chemical hazards, associated with certain foods and food traits. Food safety overlapped with issues of food quality and freshness. While both consumers and vendors had some awareness and concern about food safety and foodborne illnesses, they were not top priorities for either group and tended to be intermixed with aspects of food quality or other types of illnesses. As Nigeria continues to modernize and urbanize, with food value chains lengthening and increasing consumption of ready-to-eat foods, food safety risks are likely to become only more acute, so it will be crucial to raise the saliency of food safety among vendors and consumers. To address this challenge, understanding vendors’ and consumers’ current views on food safety, and designing behavior change approaches to accommodate and build upon them, will be crucial.