Human flourishing, the state of optimal functioning and well-being across all aspects of an individual’s life, has been a topic of philosophical and theological discussion for centuries. In the mid-20th century, social psychologists and health scientists began exploring the concept of flourishing in the context of health and high-level wellness. However, it is only in recent years, in part due to the USD 43 million Global Flourishing Study including 22 countries, that flourishing has entered the mainstream discourse. Here, we explore this history and the rapid acceleration of research into human flourishing, defined as “the relative attainment of a state in which all aspects of a person’s life are good” by the Harvard University’s Flourishing Program. We also explore the construct of “vitality”, which refers to a sense of aliveness, energy, and motivation; we contend that this has been neglected in the flourishing movement. We explore why incorporating measures of vitality, together with a broader biopsychosocial approach, considers all dimensions of the environment across time , which will greatly advance research, policies, and actions to achieve human flourishing. The Lancet have published opinion pieces underscoring the importance of “Human flourishing in a health-creating society”  family and for the community  are assured that they are well, that is, they have no disease.” He argued that the “biopsychosocial model which includes the patient as well as the illness would encompass both circumstances”  society, but also a society’s adaptation to individuals inside and out it”  in honor, comfort andhappiness, or whatever is desirable; to be increased with good things orqualities; to grow and augment; to thrive” ,69. MoreIn the late 20th century, numerous health assessment scales were developed to track well-being ,71. HoweKeyes proposed that the characteristics of flourishing can be identified as clusters of symptoms that represent an underlying state, similar to how symptoms of mental disorders cluster in diagnostic manuals . His widI am a good person and live a good life” [In 2010, Diener and colleagues developed a more specific eight-item Flourishing Scale to assess psychological well-being through measures of self-perceived success in relationships, self-esteem, purpose/meaning, and optimism. One of the eight questions on the scale harkens back to traditional philosophical and theological underpinnings of human flourishing—“od life” . It is nThe assessment of flourishing is part of a growing list of validated well-being measurements, but many of these scales lack a clear theoretical foundation and have widely differing definitions of well-being, encompassing mental, physical, and social well-being . In 2017VanderWeele’s argument that virtue is a crucial component of flourishing has been supported by an increasing number of studies linking character strengths to subjective well-being, healthy social relationships, success in academic and occupational settings, and healthy lifestyle behaviors ,84,85. BThe exact ways that character strengths contribute to flourishing are not yet understood, but it is believed that individuals who exhibit these strengths develop strong social connections, experience emotional benefits from doing good, and make life choices that increase their chances of reaching their full potential. VanderWeele proposes that character strengths are both constitutive of flourishing and causal for factors associated with well-being . Indeed,Although biopsychosocial approaches to understand the health effects of the “total” environment  are often championed, in practice, the “bio-psycho” dimensions typically dominate while the “social” determinants are neglected ,98. VandBox 2Domain 1: Happiness and Life Satisfaction.1.Overall, how satisfied are you with life as a whole these days?2.In general, how happy or unhappy do you usually feel?Domain 2: Mental and Physical Health.3.In general, how would you rate your physical health?4.How would you rate your overall mental health?Domain 3: Meaning and Purpose.5.Overall, to what extent do you feel the things you do in your life are worthwhile?6.I understand my purpose in life.Domain 4: Character and Virtue.7.I always act to promote good in all circumstances, even in difficult and challenging situations.8.I am always able to give up some happiness now for greater happiness later.Domain 5: Close Social Relationships.9.I am content with my friendships and relationships.10.My relationships are as satisfying as I would want them to be.Domain 6: Financial and Material Stability.11.How often do you worry about being able to meet normal monthly living expenses?12.How often do you worry about safety, food, or housing?that the capacity to pursue life with health, strength and energy is multi-dimensional and personal” [Levels of energy or “vitality” may be unique measures of mental and physical well-being that may not be captured through other questions about self-described health and well-being—including the current flourishing scales. Specifically, people who may score highly on measures of physical and social well-being may nonetheless report low levels of energy, and conversely, those who experience physical and emotional challenges may have high energy and vitality. Indeed, in one of the largest studies on vitality to date , researchers reported that many of the individuals that they initially expected to have high vitality levels  actually experienced low vitality . The autersonal” . It is oVitality is a central consideration of the self-determination theory, a framework for understanding human motivations and personality, with emphasis on inherent growth tendencies and innate psychological needs . The priThe omission of vitality as a core construct of flourishing may potentially weakens the value of flourishing assessments. Neither of the current flourishing indexes  within flourishing assessments is that it reflects both physical and psychological wellness. Vitality is a unidimensional construct that considers both negative and positive states; that is, the presence of energy (energy as a positive asset) and the absence of fatigue  . VitalitIn addition to physical and mental energy, vitality has been described in terms of “motivation” and “resilience” by health sciences—the desire to move toward goals and the capacity to respond to challenges, respectively ,117. In In their study of 150 languages, VanderWeele and colleagues point out that vitality could be interpreted in many different ways according to human experiences . They coI always act to promote good in all circumstances, even in difficult and challenging situations”, are most robustly connected to subsequent flourishing [It is not our suggestion that vitality is an equivalency of human flourishing. Rather, we propose its inclusion. For example, consider a socioeconomically disadvantaged person living in a marginalized community holding down two minimum wage jobs—that person could easily rate their physical and mental health as good, but if asked, could rate their energy levels as low and tiredness high. Is that person flourishing? Longitudinal research by VanderWeele and colleagues shows that meaning and purpose, social connectedness, financial security, and the single character item “urishing . Given tThere is a growing call for an integrated approach to health on all scales. This recognizes and addresses the interconnected factors that promote resilience and decrease vulnerability from the first moments of life—including the attitudes and value systems that govern these—for mutual benefits to individuals, communities, and natural systems upon which we depend ,133.The study of the total accumulated environmental exposures  that can help predict the biological responses of the “total organism to the total environment” over time is referred to as “exposome” science . ExposomTo advance flourishing research, especially to increase its relevance for clinicians and communities (through policy), an “exposome” perspective is required. When social psychologist Dr. Marie Jahoda wrote the first comprehensive review on positive mental health  in 1958, one prevailing criticism was a lack of the “biologic and physiologic components of mental health” . NotwithOne major portion of exposome science concerns the microbiome—microbes and their functional genetic materials that act to “transduce” the total environment and the context, which is so important to the definition of flourishing . InterveTaken as a whole, the emerging microbiome science challenges the idea of how the “self” is defined ,147, or The long list of personality and behavioral factors mediating the associations between flourishing and health-related outcomes—ranging from dispositional awe to parenting styles—will undoubtedly grow ,153. At Until recently, the research focus on subjective well-being and positive mental health has been on individuals and communities from affluent westernized countries. Although researchers are turning their attention to flourishing in the Global South, low- and middle-income countries, and culturally diverse populations, major gaps still remain ,155,156.VanderWeele has underscored that ‘flourishing is a property of human beings and the contexts in which they are situated’ and should be ‘understood as the relative of attainment of a state in which all aspects of a person’s life are good including the contexts in which that person lives’ . It is i“the relative attainment of a state in which all aspects of a person’s life are good including the contexts in which that person lives” [Academic interest in human flourishing has been longstanding within philosophy and theology. In the midst of declining longevity ,165 and n lives” —has ente


Parents reported facilitators to how they enacted healthy lifestyle behaviors, including family togetherness, routines, youth inclusion in cooking, and motivation due to a health condition in the family. Barriers to enacting healthy behaviors included a lack of time, a lack of access to health resources, negative role modeling, and the pervasiveness of screen media. Three major themes about the role of AI parenting emerged inductively from the interview data: “Parenting in nontraditional families”, “Living in the American grab-and-go culture”, and “Being there and teaching responsibility”. The importance of culture in raising youths was emphasized. These findings inform strategies to promote long-term adherence to behavior changes within the intervention. This study contributes to public health conversations regarding approaches for AI youths and families, who are not well represented in previous health behavior research.American Indian (AI) adolescents who practice healthy behaviors of sleep, nutrition, physical activity, and limited screen time can lower their lifetime risk of diet-sensitive disease. Little is known about how AI parenting practices influence the health behaviors of youth. The objective of this qualitative study was to explore how a group of AI parents of youths at risk of disease influenced their youth’s health behaviors after a family intervention. A secondary objective was to understand the role of AI parents in supporting and sustaining health behavior change in their youths following the intervention. Semi-structured in-depth interviews were conducted with AI parents ( American Indian (AI) adolescents in the United States (U.S.) have a higher risk of obesity, type 2 diabetes, cardiovascular disease, and some cancers, than the general population . These dParenting practices are specific behaviors parents and guardians use to teach and socialize their children. Parenting practices have been targets of past health promotion interventions in the general population to promote a healthy weight and reduce the risk of obesity-related chronic diseases among children . There ihow this group of AI parents influence and shape their youth’s nutrition, sleep, physical activity, and screen time health behaviors, with a focus on facilitators and barriers. A secondary objective was to understand the role of AI parents in supporting and sustaining health behavior change, following family participation in the AYEM-B Camp in a Box.The Achieving American Indian Youth Energy and Mental Health Balance (AYEM-B) intervention grew from a decades-long partnership between several southwestern U.S. tribes and a university multidisciplinary healthcare team . AYEM-B This study used a qualitative descriptive design; a naturalistic inquiry that stays close to the data and the surface of the words and provides a straightforward description of phenomena . Due to The AYEM-B Camp in a Box was implemented over three consecutive years , while COVID-19 restrictions were in effect and the previous residential youth summer camp was cancelled. The distanced format followed the residential camp activities, which included one week of intensive, self-guided education sessions, plus eight booster sessions. Briefly, the families were mailed the materials for the educational activities rooted in the context of AI culture. The families learned about making healthy dietary choices, increasing physical activity, getting the right amount of sleep, and limiting screen time, among other health topics. The parents were provided with information on how to engage in parenting practices that are believed to support their child toward adopting health behaviors relating to healthy eating, physical activity, sleep, and screen use ,10. All This study was approved by the University of Arizona IRB and the IRB of the Tribal partners and met the additional protections and safeguards for children and AI populations required by the IRB. Purposive sampling  identifiThe multidisciplinary research team developed a semi-structured interview script over several meetings. The questions pertained to the participant’s thoughts about parenting a youth, the successes and challenges of enacting behaviors learned as part of the intervention, and feedback about the AYEM-B Camp in a Box program. An example of a parent interview question was, “What challenges have you experienced in trying to encourage your child to eat healthy?” An example of a youth interview question was, “How, if at all, does your parent or parents influence or guide you regarding how and what you eat?”The first interviewer (CH) administered the interviews over the phone with five parents in May 2021. Following the first cohort of interviews, the interview script was modified for youth participants. A second interviewer (DD) conducted interviews in June 2022 and October 2022. All participants attended the AYEM-B Camp in a Box program in the previous year.Conventional content analysis was used because of the flexibility of the method and the lack of existing theory and research about AI parenting support for youth health behaviors . The codRigor was addressed using the criteria for trustworthiness established by Lincoln and Guba . CredibiThe research team acknowledges how researchers’ professional and personal life experiences affect the objectivity of the findings from qualitative research . The firn = five parents), 2021 , or 2022 . Eight of the eleven parents/caregivers were mothers and three were grandmothers raising their grandchildren. Some youths were hard to engage in conversation despite the use of probes and prompts. Five youth interviews lasted between 18 and 24 min, while one youth interview was only 12 min long. The average length of youth interviews was 19 min, compared to the average length of parent interviews of 31 min. Correspondingly, text extractions from the eleven parent interview transcripts were greater in number than from the six youth interviews . The findings from the youths corroborated the findings from the parents. Because of the abundance of parent-associated excerpts and codes relative to youth-associated excerpts and codes, the youth interviews did not provide any new or different information. However, the findings from the youths did corroborate the findings from the parents.The participants in this study consisted of eleven parents, six of whom had their youths participate in an interview. The eleven adult parents or caregivers  and six youths, between the ages of 10 and 15 years old , participated in the AYEM-B Camp in a Box intervention in either 2020 , the study participants were all female and mostly single parents. The women took on all the parental roles in the absence of a father figure in the household. A grandmother stated, “Well the father really hasn’t been around for these kids since they were little. You know he has been going in and out of jail, so he hasn’t really been [around] and like we’ve been trying to do both for them. Being a mother and a father”. It should be noted that when prompted to explain their thoughts on whether fathers and mothers had similar parenting roles, the adult and youth participants generally stated that the responsibilities of both parents were equally important. They described ways in which mothers and fathers individually could make different contributions to the household.Extended family played a major role for the participants. Many relied on grandparents, such as a parent who said, “It is me, and then there [are] her grandparents, which is my parents, [they] play a big role in raising her”. Other important people mentioned by the youths in the interviews were: “A nina or nino”, a parent’s “best friend”, “a godmother”, and “aunts and uncles”. One youth told of the importance of their siblings, “…because if you have older siblings, they can help you through if they’ve been through it already”. One parent commented on extended families, “They’re like the backups. If I can’t do it then, you know, I have to rely on somebody to either… take her to school, to any type of program or anything going on at school”.A grandmother participant noted challenges in raising her grandchildren. She reported support from extended family as, “Yeah. They help, especially my brothers and my sisters. You know, they always talk to the kids, and they tell them, you know, ‘You gotta help your Grandma. She’s not that young anymore. Help her do things. Be there for her’”. One mother participant commented on the growing number of families she sees who are parented by grandparents and shared her concerns that, “I think when (the youth) were in a situation that’s not good and that’s the reason why they’re being put with grandparents and grandparents are trying to do the best that they can. And they’re trying to set rules when they didn’t have rules with them before. So that’s a little bit harder for the grandparents”. The same mother suggested, “And I think if they had some type of guidance to help them along the way, too. Cause sometimes like since they didn’t have the group of kids in the home. They’re not used to making an abundance of food, or having chores done, you know separately around the house, or setting rules. Because they were by themselves”. A different parent applauded grandparents for teaching their youths, “about like cultural stuff or traditions and things like that”.Community and culture were topics that were not specifically included in the interview script but emerged in conversations as sources of strength. Three parents mentioned the importance of community resources, such as an Indian center or an Indian youth program for their youths to take part in activities after school. One mother shared how her family was learning their Indigenous language and about traditional stories and stated, “Knowing where you come from, your background. And that helps you as a person. I believe that it helps you and it makes you stronger and it makes you more proud. And you carry yourself …a lot higher when you know where you’re coming from”. She added, about traditional ways of living, “It would be nice to see that a lot more of that like in the tribal leaders”.There was evidence of other variations in family experiences among the participants. One parent mentioned living on a reservation and another shared how they visited extended family on a reservation. Both women described a connection to nature and open space, where their youths could run and ride a bike and chase their dogs. Two families described households of seven or eight members; one parent described her child with special needs who had sensory issues and a developmental delay. One parent mentioned a recent loss in the family and how their grieving affected their health behaviors for some time. Despite a diversity of challenges, the participants were perceived as positive and strong by the interviewers. Congruently, the codes and categories supported a sense of thriving in this sample of youths and parents.The participating families reported having very busy lives, which influenced all the health behaviors supported by the AYEM-B Camp in a Box intervention: nutrition, physical activity, sleep, and limiting screen media. The theme of being busy was the most common barrier to healthy nutrition and physical activity in this study. One parent stated, “We do a lot of fast food, so we aren’t very healthy at all”. Another parent shared, “So, the challenges are mostly me, I guess, …we like eating salads, but it’s having to put—you know, making the time to go and purchase all the things that we need or, you know, just to eat healthy”. Regarding sleep, one parent said, “Like how I said we have to eat dinner late, so …they’ll be tired, but I’ll tell them, like, no, you can’t go to sleep, you just ate, so let your stomach settle. And so I think that’s one of our big issues right now, is we are forced to eat dinner so late just due to our schedule”.Parents reported working late, working an evening shift, having long commutes to work or to school, and being tired. Some youths also had jobs that kept them from getting enough sleep or having family meals. Coordinating schedules for different family members was a notable challenge. Running out the door without having breakfast, grabbing fast food for lunch, and getting home too late to cook dinner were mentioned. Later dinners pushed bedtime back for a few families, affecting their sleep. Busy schedules left little time for physical activity. One parent said, “I’m always busy, busy, busy. And then, I have to go pay bills, or have to go get groceries, or I have to go—I’m always having to do something”. A couple of parents described their youths as being on their screens or phone “all the time” or “constantly”. Another parent described how it was a routine for her youth to be on the phone while in the car. Screen time was a common barrier to good quality sleep, but most parents reported some type of structure or rules around screens in the home. The interconnectedness of health behaviors was apparent.When youths were asked, “Using your own words, what does it mean to be a parent?” The youths answered with the following short statements: “Being there for me”, “Be supportive”, “Take care of their kids, provide for them and just kind of push them to success”, “Being a parent is taking care of your kids and doing what is best for them”, “Take care of your child and provide for your child and be there for your child”, and “To take care of their kids and provide for them and just always kind of push them to success”. Follow-up questions allowed for some elaboration on the theme of “Being there” and the youths added, cooking for them, taking them to school and activities, talking to them, supporting them through school, and encouraging them to go to college. The parents’ answers echoed and elaborated on the youths’ responses about parenting roles.Teaching their youths to be respectful and responsible was prioritized according to both youths and parents. Youths described responsibility as teaching “right from wrong” or “good from bad”, and teaching life skills. Parents used the words “responsibility”, “mutual respect”, “respectful”, and “helpful” to others. Chores and work around the house were important to many participants. One grandparent stated, “I’m not saying they are the best kids, but they really are good kids. You know? They help. Um like if I’m doing something and like my grandson or my granddaughter says grandma can I help you? You know, and they are really good about things, and they are very respectful”. A common thread for the majority of parents was having clear expectations and boundaries for their youths related to healthy behaviors. Most youths and parents mentioned the importance of success in school. Culture was mentioned in the context of raising youths, by one parent who said, “Setting a good example, and …just the traditional teaching, and a lot of that now, is not, it’s not really practiced, and it’s not pushed”.The last two questions in the interview script guided the interviewers to ask for feedback about the AYEM-B Camp in a Box intervention. The responses from all 17 participants were positive, highlighting the novelty and fun involved in the intervention. Positive aspects about the AYEM-B Camp in a Box included prompting families to be accountable to one another and program staff, providing a structure and schedule for activities, and bringing families closer. Youths and other children in the family  looked forward to receiving the boxes in the mail and really liked the healthy snacks and arts and crafts. Only a few participants had suggestions for improvements, while many said they would like more of a particular activity or exercise. One parent summarized, “I think you guys did a pretty good job. I think we hung on to most of the stuff. We learned a lot last year. I think, really, it’s just up to us to implement it throughout the year. And we’re off and on, but we’re trying to learn a lifestyle so, it’s just going to take longer, you know?”A youth shared, “I also think that more of the hands-on activities, like painting. Like, last year what we did was paint, like, the painted rocks and stuff. We did all that and, like, all of our family did that and it kind of just brought us, like, a lot closer, because at first we were all annoyed with each other and were all, like, getting mad at each other, arguing, but we all just kind of settled and all because of the Camp in a Box. And that’s really—that’s what really brought us together. And there was more understanding of each other”.This study extends the understanding on parenting among AI families related to helping youths maintain behaviors learned through a lifestyle behavioral intervention. Common facilitators and barriers to healthy nutrition, physical activity, sleep, and screen media use, were identified for AI families, which were similar to a 2008 study of Navajo parents of preschool children . The chaQualitative themes on parenting practices were identified. Like the existing literature, culture was reported as an important factor in AI parenting ,5,6, as A strength of this study was that it was grounded in AI culture. The literature suggests that culturally tailoring instruments and interventions in tribal research programs will improve the validity of the studies ,4,5,6,16n = 11) and youths (n = 6) completing the interviews limits the breadth and generalizability of the findings. Themes just began to emerge but did not reach saturation, the point where new themes stop emerging [The relatively small convenience sample of parents (emerging . The paremerging .The findings from this study will inform the continuing AYEM-B interventions, as the program shifts back to a residential one-week program for youths. Booster sessions will continue to engage the entire family in healthy behaviors. This study contributes to conversations regarding public health strategies and approaches for AI youths and families, who are not well represented in previous health behavior research. Our study suggests the need to consider variations in family structure, the social determinants of health, and the role of culture in future research or policy formulation.Data from interviews with parent and youth AYEM-B Camp in a Box participants offered new knowledge about parenting among AI families, facilitators, and barriers to helping their youths enact healthy behavioral change, as well as ideas about how to improve future health promotion interventions and booster sessions for AI families. The intervention was positively perceived by parent and youth interviewees, including interviewees expressing gratitude for bringing their family members closer together. This qualitative study also offers guidance for further refinement of the AYEM-B intervention to promote long-term adherence to behavioral changes. The findings provide an example of how AI parents are raising their young and supporting healthy behavioral change around nutrition, physical activity, sleep, and limiting screen media use.


In Ghana, over 270,000 people live with epilepsy, of which 70% do not receive treatment. Despite the high number of people with the condition, misconceptions exist about its causes and management in African regions. The study assessed the perceived causes and management of epilepsy among rural community dwellers in Ghana.A qualitative approach and phenomenological design were employed for the study. The population comprised community dwellers in Berekum, a rural town in the Bono Region of Ghana. A convenience sampling technique was used to sample the participants. An in-depth face-to-face interview with a semi-structured interview guide was used to collect participant data. Data were analyzed using inductive thematic analysis.A total of 15 participants were interviewed in the study, after which saturation was reached. Seven of the participants were men, and eight were women. Two categories emerged as the causes of epilepsy: socio-cultural and superstitious causes and biomedical causes. The socio-cultural and superstitious causes include “a manifestation or an influence of an evil spirit,” “family curse or disease,” “punishment from ancestors or gods of the land,” “having several convulsions,” “exposure to foam from an epileptic,” and “bites from an epileptic during seizures”, while the biomedical causes are “brain damage,” “blood group,” and “genetic makeup”. Consulting with the spiritual realm, pouring water on the person or washing the person's face, and putting a spoon in the mouth were identified by the participants as ways to manage epilepsy.The causes of epilepsy are primarily linked to the supernatural, with the results indicating that rural community residents largely attribute epilepsy to “evil spirits”. This implies that the rural communities' knowledge about the causes of epilepsy is based on the social causation theory of disease and disability, which relates diseases to the supernatural. Management of the condition was mainly seen as spiritual. Epilepsy is a chronic brain disorder characterized by recurrent nervous system disturbance resulting from a sudden excessive disorderly discharge of the aggregate group of neurons from the cerebrum, leading to disturbances of sensation, motor signals and symptoms, or psychiatric and behavioral aspects with or without loss of consciousness . The WorEpilepsy is reported as the most common neurological condition, with an estimated 50 million people across the globe living with it. A global estimate shows that ~80% of those with the condition live in low- and middle-income countries , with leDespite the high number of people with the condition, misconceptions exist about its causes and management in African regions. In ancient times, when people had no understanding or knowledge of biomedical science, epilepsy was attributed to spiritual or religious afflictions , 7, and Kassie et al. revealed a knowledge gap regarding the causes, nature, and treatment of epilepsy with varying traditional beliefs, attitudes, and practices worldwide . In AfriThe consolidated criteria guide for reporting qualitative research (COREQ) checklist  was usedThe methodological orientation employed in this study was phenomenological design. The population comprised community dwellers in Berekum, a town in the Bono Region of Ghana. The inclusion criteria were people who are from the community or lived the community for more than 15 years and aged above 18 years.A convenient sampling technique was used to sample the participants. Participants were recruited conveniently around roadsides, marketplaces, lorry stations, and churches. The purpose of recruiting participants from the area was to generate evidence on how epilepsy is perceived in the community. Potential participants were approached by the researcher face-to-face and invited to participate in the study. In all, 15 participants were recruited for this study because the saturation point was reached after interviewing this number.An in-depth face-to-face interview with a semi-structured interview guide was used to collect participant data. The guide was developed by D.G. based on the objectives of the study and revised by Y.E., the supervisor. Questions were open-ended; however, probes and follow-ups were utilized when needed. All interviews were conducted by D.G. in Akan (Twi) for 2 weeks in March 2017. Field notes and audio recordings were taken during the interviews. The duration of interviews was between 30 and 40 min. The recorded interviews were transcribed by D.G. in Twi verbatim and translated into English, which were then sent to other co-authors  for quality checks. D.G. and G.A.O. are Akan with Twi as their first language (speaking and writing).Data were analyzed using inductive thematic analysis. Notes taken during the interviews were processed together with the audio transcriptions. Data were studied carefully, and themes were developed based on participants' responses to questions. Two authors conducted the thematic analysis and coding which were reviewed and discussed by all study authors.From participants' narratives, two primary themes, each with subthemes, emerged regarding the causes of epilepsy. These encompass (a) socio-cultural and superstitious factors and (b) biomedical factors. The socio-cultural and superstitious aspects encompass notions of “manifestation or influence of an evil spirit,” “family curse or disease,” “punishment from ancestors or gods of the land,” “frequent convulsions,” “exposure to an epileptic's foam,” and “bites from an epileptic during seizures”. Conversely, the biomedical causes consist of “brain damage,” “blood group,” and “genetic composition”.evil spirit's” presence in a person's life, suggesting a connection where the spirit either possesses the individual or the person maintains a relationship with malevolent forces. For example, according to a participant,As per the study's findings, epilepsy was perceived as a representation of an “When a person or an individual is possessed by an evil spirit, the spirit manifests itself as epilepsy… therefore people get to know that this individual is possessed by an evil spirit” (Participant 2).“Some participants, however, thought that epilepsy is not just about being possessed by the “evil spirit” but a sign of being burdened by an “evil spirit”. This manifests as epilepsy if the person can no longer bear the burden. A participant explained this in the following quotation:When there is a spiritual burden on someone, it manifests as epilepsy. Thus, when the person is tired in the spiritual realm or is possessed with an evil spirit, it manifests physically in the form of epilepsy” (Participant 4).“Some of the participants believed that epilepsy is used to sabotage individuals who are perceived as having a bright future, usually by a witch family member, as exemplified in the following quotation:Epilepsy is a condition that someone gives to another person through spiritual means when they see a bright future ahead of them. It only affects people when the witches in their family notice that the person has a bright future and through spiritual means, they place it on that individual” (Participant 5).“Another participant added,I know that epilepsy is caused by evil spirits. When an evil spirit in a family sees the bright future of a person, then they buy it [epilepsy] in the spiritual realm for the person” (Participant 3).“Another socio-cultural notion among the participants concerning the cause of epilepsy is the idea that the condition is restricted to specific cursed families. Consequently, individuals are thought to not merely acquire epilepsy by chance but rather inherit it as a familial or bloodline curse. To them, some families are cursed to give birth to individuals with epilepsy, as stated by a participant,Epilepsy is a family disease or the result of a curse in a family that manifests within family members” (Participant 5).“Another respondent added,In some families, there are curses placed on them, and the sign of the curse is epilepsy. Hence members of the family become sufferers of it” (Participant 10).“The study uncovered that when an individual commits a transgression  against the deities or forebears of a community, the wrath and displeasure of these entities descend upon the person, and the consequence they face is the onset of epilepsy. Epilepsy, according to this belief, is acquired.When a person sins against the ancestors or gods of the land, the anger of the gods comes upon that person. The person is being punished by the gods by making him or her epileptic” (Participant 8).“Similarly,People commit some immoral acts which are against the tractions of this land, and a way of punishment the wrap of the gods comes on them, and one of wrap that comes is epilepsy” (Participant 14).“Participants also perceived that if an individual experiences numerous convulsions during their childhood and proper measures are not taken to address them, it could lead to the development of epilepsy. According to participants, certain parents underestimate the gravity of convulsions and assume that the child will naturally recover over time. Consequently, these parents do not seek timely medical attention for their child, resulting in the child eventually growing up with epilepsy. A participant explained:When a child experiences several convulsions, and the family is unable to seek healthcare for the child, it leads to epilepsy when he or she grows up” (Participant 1).“Some participants attributed frequent convulsions to excess phlegm in a person's body, which, if not cared for adequately, could later result in epilepsy. A participant noted:If phlegm's become much in a child's system, the child begins to experience a convulsion and if the family do not pay much attention, it leads to epilepsy” (Participant 1). [SIC]“As per the accounts of certain participants, it is perceived that exposure to the foam produced from the mouth of an individual experiencing an epileptic seizure could lead to the development of the condition. Consequently, people take precautions to avoid contact with the foam in order to prevent acquiring the condition themselves. As explained by a participant,During epileptic seizures, when the foam comes in contact with another person, that person also develops epilepsy” (Participant 9).“Furthermore, participants explained that one could become epileptic when a person with epilepsy bites them:When an epileptic patient bite you during epileptic seizures, you will have epilepsy” (Participant 3). [SIC]“Some participants associated epilepsy with biomedical factors, including brain damage resulting from accidents as well as incidents occurring during pregnancy and childbirth. According to this viewpoint, when an accident occurs and an individual experiences a brain injury, the person may develop epilepsy. It has been noted that when there is any injury to a child's brain during pregnancy or childbirth, the child may develop epilepsy after birth. Two participants explained this in the following quotations:Epilepsy can be due to brain damage resulting from an accident. When someone has epilepsy, it means that the person is suffering from brain damage, and during the seizures, the person becomes unconscious” (Participant 7).“Most women are careless during pregnancy, and they end up damaging the child's brain whiles in the womb. Also, during delivery, some complications can arise which can cause damage to the brain and later leads to epilepsy” (Participant 3). [SIC]“Some other participants linked the cause of epilepsy to the compatibility of the parent's blood groups. It was noted by participants that some blood groups are not compatible. Hence, when these individuals marry and give birth, the child is likely to develop complications such as epilepsy. A participant explained:There is some blood that is not compatible with others, and so when a couple's blood group are not compatible, and they give birth, the child they will give birth to may develop epilepsy” (Participant 3).“Additionally, some participants reported that epilepsy is genetic; hence, one may acquire the condition if either of the parents has it.When a parent has epilepsy, genetically their child too can acquire it” (Participants 3 and 12).“The following themes emerged in the community's management of epilepsy: “consultation from the spiritual realm,” “pouring water on the person or washing the person's face,” and “putting a spoon in the mouth”.The study's findings revealed that epilepsy is interpreted as a spiritual affliction that impacts individuals. Participants hold the view that this ailment or state cannot be remedied through medical interventions but rather requires spiritual remedies. Consequently, seeking counsel from individuals possessing spiritual abilities, such as fetish priests, witch doctors, mallams , pastors, and similar practitioners, is perceived as the most effective approach for treating the condition. Several of the participants explained as follows:Epilepsy is a spiritual disease that affects people … there is no physical cure or medication that can cure it … but it can be cured through spiritual means.”“Some participants disclosed that they would splash water on the individual or cleanse their face in order to restore their consciousness, as indicated by one participant:When I see one, I will look for water and wash the person's face till he or she comes to consciousness” (Participant 3).“Participants also noted that dousing a sleeping person with water leads to their awakening, similarly, pouring water on an unconscious individual causes them to regain consciousness. A participant elaborated:I will pour water on the person when the seizures come. This is to bring the person back to consciousness. I know that when one is asleep, and you pour water on the person or wash the person's face with water, the person wakes up from sleep, and I think when that is also done to someone who is in a seizure, the person will come back to consciousness” (Participant 8).“Some participants also reported that another way to prevent a person with epilepsy from biting the tongue is to insert a spoon in the person's mouth.I will put a spoon in the person's mouth to prevent him or her from swallowing or biting the tongue” (Participant 15).“This study was conducted in rural communities in Ghana to assess the perceived causes and management of epilepsy. Epilepsy is one of the major chronic non-communicable diseases of the brain in Ghana, with ~270,000 people living with the condition . It is tThe finding that evil spirits cause epilepsy is not new, but this old-age misconception has become deep-seated in Ghana, especially in rural areas. The findings from this study seem to reinforce this misconception about the cause of epilepsy. This finding is similar to Abasiubong et al.'s study, which revealed that in the olden days when people had no knowledge or understanding of biomedical science, epilepsy was attributed to a spiritual or religious affliction . Even thStudies have revealed that what people perceive most to be the cause of epilepsy among rural dwellers is witchcraft. In research led by Abasiubong et al. regarding how traditional healers perceive the causes of epilepsy, witchcraft stood out as the prevailing factor . In the The study findings show that the social causation theory of disease and disability is dominant in rural areas. According to Krieger, the theory views sickness and disease as the consequences of disintegration at the social level through anti-social behavior and supernatural intervention or possession . ConcernEpilepsy is perceived as a familial affliction or a generational curse that casts its shadow upon family members. The findings indicate that epilepsy serves as an indicator that a family is under a curse. It is believed that in times past, specific families maintained associations with idols and fetish priests. As these families distanced themselves from idol worship, they allegedly incurred curses, resulting in ailments meant to disgrace the family. Some members of these families now bear the weight of these curses, manifesting as various diseases, including epilepsy. Consequently, epilepsy is viewed as a condition befalling cursed families. Additionally, it is regarded as a sign alerting a particular family to their cursed state, prompting them to seek aid or appeasement from the very idols and fetish priests they once had relations with. Masia and Devinsky stated that epilepsy was seen as a curse for possessing evils, mainly resulting in the isolation of the affected person and the family .The study further reveals punishment from the gods or ancestors for sins committed as a cause of epilepsy. When an individual transgresses or violates the sanctity of the gods, it is held that the gods' wrath befalls that person, resulting in the onset of epilepsy as a form of retribution. This individual is said to experience epilepsy so that the broader community can draw lessons from it. Essentially, epilepsy is considered a means of compelling people to adhere to moral standards. Evidence from a study by Abasiubong et al.  justifieIn addition, the study identified brain damage as the cause of epilepsy. Birth complications can result in brain damage, which in turn might lead to the development of epilepsy. Similarly, accidents involving head injuries can also be a factor in causing epilepsy. Consequently, for certain participants, epilepsy is understood as a condition arising from brain damage. Notably, it is reported that 25% of epilepsy cases are preventable; however, a significant proportion of these preventable cases are concentrated in Africa due to elevated rates of prenatal and perinatal complications . Even thA bite from an epileptic patient experiencing seizures or exposure to foam during seizures was perceived as a cause of epilepsy. People believe that epilepsy is contagious . This noConvulsions and an abundance of phlegm within the body were considered responsible for the onset of epilepsy. A surplus of phlegm in an individual's system was believed to trigger convulsions, and if these convulsions were not properly addressed during childhood, they could subsequently evolve into epilepsy. Certain parents, who lack an understanding of the severity of convulsions, presume that with the passage of time, the child afflicted by convulsions will naturally overcome them. Consequently, they refrain from seeking prompt medical intervention for their child, which ultimately leads to the child developing epilepsy at a later stage. The findings support Annegers et al.'s study, which found febrile convulsions as a cause of epilepsy . Amid coAdvocates' Toolkit for making epilepsy a Priority in Africa” (Predominantly, epilepsy was perceived as a condition intertwined with “evil spirits”, thereby leading to the approach of seeking guidance from individuals possessing heightened spiritual abilities for its management. A similar finding was discussed in the toolkit “ Africa” . Due to  Africa” .The causes of epilepsy are primarily associated with supernatural factors. The findings indicated that individuals residing in rural communities predominantly attribute epilepsy to “malevolent spirits”. This suggests that the rural population's understanding of epilepsy is rooted in the social causation theory of disease and disability, which connects ailments to supernatural forces. The approach to managing the condition was largely spiritual in nature. Consequently, the study suggests the implementation of comprehensive health education programs concerning neurological and mental health conditions, given their substantial association with supernatural beliefs. Moreover, future investigations should explore the ramifications of these findings on the lived experiences of individuals with epilepsy. Finally, research is warranted to ascertain the prevalence and connections of epilepsy-related injuries.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Approval for the conduct of the study was taken from the Center for Disability and Rehabilitation Study, KNUST. The protocol was reviewed by the Head of Department and the Supervisor of the student work before the study commenced. Written informed consent to participate in the study was from the participants before their involvement.DG: conceptualization, data collection, transcription, coding of themes, interpreting the data, writing the original draft, and final review and editing. YE: supervision, coding of themes, and review and editing. TG, RT, GA-O, IO, and WM: review and editing. All authors contributed to the article and approved the submitted version.


The researchers utilized the Socio-ecological model to report the results. Participants also provided recommendations on how to improve infant care and reduce the risk of SUID. (3) Results: The confidence level of infant care among most participants was low but increased over time. Mothers’ knowledge level about the prevention of SUID was high, but poor emotional health could hurt their parental abilities. Most participants recognized medical providers as the main source of reliable information. However, a lack of emotional and physical support was reported by mothers. (4) Conclusions: Results suggested that a more holistic approach to infant care is needed. The healthcare system and communities should provide more physical, social, and mental support to first-time mothers, a consolidated approach to care before and after birth, and easy access to services at all stages of the process to reduce the risk of SUID. Infant mortality rate (IMR) is used as an overall indicator of a nation’s health. IMR is defined as the ratio of infant deaths to live births in a given year . AccordiSignificant disparities in infant mortality exist among different states. Georgia’s IMR in 2018 was 7.6 deaths per 1000 live infant births, placing Georgia at No.45 out of 50 states. Furthermore, infant mortality in Georgia has been on the rise since 2014, when it was the lowest at 6.5 deaths per 1000 live infant births [Beginning in the 1990, the United States had a sharp decline in sudden unexpected/unexplained causes of death (SUID); however, the decrease has slowed down considerably since 1999 . In 2017Therefore, what has been carried out to date to decrease SUID? The CDC’s Division of Reproductive Health (DRH) provides scientific leadership in SUID by sharing up-to-date information about SUID rates and circumstances linked with SUID and has SUID monitoring programs in twenty-two states and jurisdictions, which cover one in three SUID cases. The SAFE TO SLEEP campaign focuses on spreading safe sleep strategies and educational materials to reduce the risk of SUID and other sleep-related deaths. The “Protect the Ones You Love” Initiative was launched by CDC to raise parents’ awareness about the leading causes of child injury. “The 1000 grandmothers’ project” was an education project that focused on tribal elders to educate young native parents on sleep practices for infants . HoweverIn order to address this outcome more holistically, this study sought to explore the parental knowledge, perceptions, and confidence of mothers about the prevention of SUID and other aspects of infant care. Current study exclusively refers to the term “parental” to describe those who gave birth to the infant.In this qualitative research, the transferability , credibility, and dependability (vs. reliability) of the study were established  (234). TThe investigators conducted a literature review to identify the best strategy to reach the participants. Based on the results, the recruitment strategy utilized social media channels to recruit participants from various geographic areas in Georgia. Specifically, “moms” groups on Instagram and Facebook channels were used to recruit the participants. The PI contacted the managers of these social media groups to get permission to distribute the study’s flyer. The flyers contained information about the research project, contact information, and link to the survey in Qualtrics,  where parents could register for the study.All the survey responses were screened for eligibility, and participants were contacted by their preferred method to schedule an in-depth interview and provide a consent form. After the participants provided signed informed consent and eligibility, the researchers scheduled in-depth interviews. The provided contact information was securely stored and destroyed after the completion of the study. Inclusion criteria for the participants included first-time mothers with children under 1 year of age, female, Georgia residents, over 18 years of age, and fluent in English. Exclusion criteria included pregnant women, not first-time mothers, and women with children over 1 year of age.Prior to the interview, the researcher explained the purpose of the study, the benefits and risks of the study, and ensured confidentiality. It was made clear to participants that participation in the study was voluntary and that they may withdraw at any time. The consent form also contained the researcher’s contact information for any participant who had a question. Participants signed the informed consent document electronically and emailed it back to the investigators before the interview.A semi-structured question guide was utilized for in-depth interviews to obtain qualitative information, and all interviews were conducted over the phone. The interview guide was based on research queries and the ideological concepts of the Socio-ecological model . For theA total of 15 participants were interviewed. The first part of the interview addressed the first research sub-question. This section also explores the main source of information on infant care and prevention of SUID for first-time mothers. Finally, it addresses mothers’ concerns and feelings about giving birth and providing care for their infants.Theme: “Low confidence about infant care at the beginning but increases over time”.All participants were asked to describe their level of confidence when taking care of an infant. Many of the participants described their experience as overwhelming at first. However, as time progressed, first-time mothers felt more confident to take care of their children: “At first, I was scared when I left the hospital…we got home and we’re like okay, I guess this is what we are going to do…after the first couple of weeks I felt more confident but when I first left, I was just like afraid in general as far as the wellbeing of my child just because it’s my first time I didn’t really know what to expect”?Theme: “Breastfeeding, safe sleep, car seats, CPR training, and being intuitive are essential for first time mothers”.Participants were asked what they thought was essential when taking care of their infant. The participants perceived breastfeeding, proper car seat use, and safe sleep practices as essential: “So that’s a first, obviously anything to do with safety, in terms of sleeping arrangements for the baby, you know”.Another participant said: “Um safety is one of the biggest things, making sure the car seat is installed properly and um basically obviously making sure the child is safe is number one priority”.Theme: “Breastfeeding was important, but many women felt pressure to breastfeed”.Most women felt that breastfeeding was essential for the mothers’ and infants’ health. Also, they expressed that breastfeeding provided a chance to bond and protect their child, but many mothers felt pressure to breastfeed, and if they were not successful, many felt guilty: “While it was a little bit of pressure, which I didn’t appreciate. They were also pro-breastfeeding hospitals, which I love”.Another mother stated: “So, my breastfeeding at the beginning was not great. Um… He ended up having jaundice. And I kind of blame it on myself because I felt like he wasn’t getting any breast milk”.Theme: “Emotional journey and feeling of loneliness after giving birth”.Even though there was no specific question that addressed the emotional state of mothers during the interview, many participants felt very emotional, anxious, sleep deprived, and lonely after giving birth: “Becoming parents for the first time, the whole emotional journey and changes, especially for me, as you know, my body’s biological changes, and then my emotional changes that I go through. I guess that’s why they call it the fourth trimester, when you have a baby…and so I think that’s also part of infant care. Not forgetting about yourself, not forgetting about the dad”.The second part of the interview addressed the second research sub-question. It focused on the interpersonal level of the Socio-ecological model, which refers to social influences from friends and family on the infant care of first-time mothers.Theme: “Mothers are the infant’s primary caregivers, but partial help comes from family and friends”.We asked participants how much physical assistance they received when taking care of their infant, and the majority stated that they mostly were providing care alone. However, many identified their family, spouses, and friends as a partial support for infant care: “So, I live like three and a half hours away from my family so that’s difficult. I mean, they will come to visit but they have their own life as well”.Another participant stated: “His dad was there. He was helpful…he did work a normal 8 to 5. My mom was there. She was in town maybe three or four times a month and was helpful in the first month”.Theme: “Information provided by family is not evidence-based and “old school”.Most participants felt that the received information about infant care from family was not reliable, because it was outdated and not based on recent research studies: “I was raised, my parents back in the 80s raised me with all sorts of bumpers in the cribs and pillows and (Laughs) toys”.Participants talked to a great extent about how infant care information changes rapidly and cited that as the main reason not to trust their parents’ and grandparents’ infant care advice: “Like, my grandma came to visit him. And she put a blanket in his bassinet, which obviously like, take it out…a lot of pressure to not offend anyone. Having older, older people come in and give their advice”.Theme: “First-time parents perceive emotional and physical family and friends support for infant care as important”.As previously mentioned, most women did not trust the infant care information provided by their family because it was not scientifically backed. However, they expressed that when it came to emotional and physical support, family and friends played an essential role in their well-being: “it’s still, you know, phone calls away. Uh video, FaceTime that was nice. And to have support and love, like I said, was important for me. And for my emotional well-being”.Another mother said: “It’s so nice to have people I can trust to have him when I can’t be with him…so, it’s important to have some sort of support whether it’s family or friends”.Theme: “Virtual or in-person mom’s groups are a great source of social support for new moms”.In addition to family and friends, many participants talked about the importance of social interactions with other parents. They wanted to connect with someone who went through something similar or was currently going through the same experiences as they were. They also relied on social “mom’s groups” when they had various questions about infant care: “Like more newly moms that you want to meet… more how to find people who the same age and is going through the same thing. That would be nice”.The next part of the interview addressed the third research sub-question. This part focused on the community level of the Socio-ecological model, where questions addressed the role of social relationships and received information at that level.Theme: “Medical information in infant care was essential when compared to family, friends, and other sources”.When asked what the essential source of information was when it came to infant care, participants stated that they trusted the information provided by medical professionals the most because it was research-based and up to date: “Things that a doctor would know that’s different that a mother raising a child 10 years ago wouldn’t know”.Most participants said that the information provided by the medical professionals was easy to understand. They also felt comfortable asking questions in medical settings. Women described the medical language on infant care as helpful, clear, and easy to understand.Theme: “Participants wanted to meet the pediatrician before giving birth, because they were considered? the essential source of infant care information”.Mothers mentioned that if they had any major concerns, they would contact the pediatrician first. They felt that they could trust their pediatrician the most compared to the hospital, family, and OBGYN: “Pediatrician knows more than anybody else…could really provide information, especially when it comes to medicines or something like that, or anything to do with my child”.Participants met the pediatrician after giving birth to their child. However, most of them wanted to meet the pediatrician before giving birth to be better prepared to take care of their infant: “I asked about that. I was kind of wanting to meet them…and the receptionist was like “No, you know once you have a baby you can come in”.Theme: “The information and support provided by the Obstetrics and Gynecology physician (OBGYN) focused mostly on the female parent’s health before giving birth but was lacking after birth”.Most women described that their OBGYN support was very important during pregnancy and focused mostly on the mother’s physical health. Some OBGYNs provide information about breastfeeding and antenatal classes. However, women did not receive information about infant care: “But maybe a little more to check in and not like a follow up like hey how are you doing that’s great bye, but actually be like how you are feeling”?Theme: “Printed infant care information provided by the hospital was overwhelming, but personal conversations were very helpful”.Most of the participants gave birth at the hospital. All of them received a printed packet of flyers on infant care, some watched hospital videos, and some had one-on-one conversations about infant care prior to discharge. Many felt that the packet and provided information were quite overwhelming because it happened right after giving birth: “I was just super overwhelmed. It was a lot in the brain all at once”.However, participants found it helpful when hospital staff would take their time and had conversations about infant care, or even provided demonstrations: “When it came to informing me on things, I had questions about like him getting shots or you know, stuff like that… they were very informative and if I didn’t understand they would take the time to explain it to me. I found it very helpful”.In conclusion, mothers trusted medical information when it came to specific infant care questions. For all the other infant questions, women relied on intuition and the internet, specifically “mom’s groups”, podcasts, google, and phone applications.When asked what some major barriers are to accessing the infant care information, participants explained that even though they would like to attend more antenatal classes and workshops, they struggled with finding classes that were free of charge or have available spots: “I was taking those classes…they were like 75 dollars here 50 dollars here 40 dollars here that adds up”?Some women also talked about having more online class options, due to the lack of transportation, busy schedule, and COVID concerns: “Of course, COVID…I didn’t feel comfortable taking her anywhere near it”.When we asked participants to provide recommendations, three categories emerged: resources, interpersonal communication, and delivery of services. When talking about additional resources, mothers expressed that they would like to receive more information before giving birth on: (1) List of products/supplies, (2) link to resources, (3) more video tutorials, (4) information on car seats and breastfeeding, and (5) more classes that are affordable and easy to access.Women talked about the importance of interpersonal communication and social support. Some of the suggestions that they have provided were: (1) More verbal communication, (2) more personal interactions with the medical professionals, and (3) more virtual and in-person mom groups. Women suggested the following to improve the delivery of services: (1) More programs and/or services to support mothers after birth that are free of charge, (2) more follow-up after birth to check on mothers’ mental health, not only physical health, and (3) more information and interactions with the pediatrician before giving birth.Finally, most participants talked about the importance of technology as a method to deliver information on infant care. Many utilized Facebook, Instagram, and podcasts when they had any general questions about infant care and suggested creating a phone application that would be a “one-stop” for the most updated information on infant care, interactions with medical professionals, social connection with other mothers, and mental health services support for mothers. They have mentioned currently using applications that have small charges or free of charge but did not encompass all the aspects of being a new parent.The current study explored the individual-level factors associated with SUID prevention and infant care. Most mothers had a low confidence level when caring for their infants upon release from the hospital, but it increased over time. There is a lack of research that focuses on mothers’ confidence and infant care. However, previous findings showed an association between maternal confidence and parenting stress .According to the most recent recommendations, the main protective factors of SUID are safe sleep practices, breastfeeding, and healthy behaviors during pregnancy , which mThe current study observed that mothers were the infant’s primary caregiver. However, family and partners provided partial support, especially during the early stages of infancy. The most valued support was emotional and physical. Previous research has observed that care provided by the relative could be beneficial and positively influences infant communication and interpersonal skills .The participants also expressed the importance of social connections with mothers that were going or already went through similar experiences, which is consistent with the literature . There wThe current study also analyzed community-level support for first-time mothers. Our findings suggest that women received a large amount of information and support during pregnancy from their OBGYN but were lacking medical support after giving birth. Even though participants were satisfied with the information and care provided by the pediatrician, they expressed the need to meet the pediatrician before giving birth to be better prepared for infant care. Previous studies established the importance of expecting mothers’ thoughts and feelings about their unborn infant and future interactions with their child . FinallySome of the recommendations provided by women to be better prepared for infant care were additional resources, interpersonal communication, and the delivery of services. The preferred communication channel for the delivery of infant care information was a phone application that would contain up-to-date information, provide access to healthcare providers, and provide social interactions with other mothers. This is supported by a randomized controlled trial that observed a positive effect of mobile-based parental education programs in prevention of early childhood injuries. In addition, parents found the use of the mobile program convenient .Some of the limitations of the study include the following: most participants were from urban areas in Georgia, and mostly White women living with a partner. This is important to note because the risk of SUID might depend on multiple sociodemographic factors, and also our findings may have a limited external validity. Another possible bias was the utilization of an online recruiting strategy, which could limit generalizability. Despite the limitations, we believe that the results of the current report make an important contribution to literature on supporting mothers in caring for their infants.Current findings identified the factors and needs of mothers on each level of the Socio-ecological model. Further, findings demonstrated interconnectivity between all levels of the model. Women expressed that the provided medical services are compartmentalized. There is a large amount of attention on women during pregnancy but not nearly enough after giving birth. There is strong support for infant care provided by a pediatrician after birth, but a lack of preparation for infant care during pregnancy. For mothers to feel more competent to offer high-quality care for their infants, they need to have more emotional, social, and physical support from family, friends, and society, a more integrated approach to care before and after birth, and easy access to services and technology at all stages of the process. Finally, we hope that the results of this study will help health professionals and community organizations determine the information and support that needs to be provided for new mothers.


An ill-defined association exists between diabetes mellitus (insulin resistance) and primary hyperparathyroidism. This article explores this phenomenon while providing an explanation for such a relationship and reviewing the evidence regarding the response to insulin sensitivity following a parathyroidectomy. Primary hyperparathyroidism may increase the risk of developing insulin resistance; peculiarly, this is not present in all patients. It is likely that both intracellular hypercalcemia and hypophosphatemia alter the insulin receptor expression and response; the contribution of parathyroid hormone is less clear. Following parathyroidectomy, patients may demonstrate improvement in their insulin sensitivity, while others have no response or a detrimental effect. A varied phenotype exists among patients, and furthermore, it is unclear why certain patients demonstrate improvement in insulin sensitivity following a parathyroidectomy, whereas others fail to do so. While this review provides a broad overview of the general endocrine community, it is imperative to note that clinical applicability is limited until further studies address these remaining uncertainties. Due to the lack of understanding regarding this endocrinological enigma, the presence of insulin resistance, at this present time, should not be a criterion for a parathyroidectomy. Primary hyperparathyroidism, an endocrinological disorder characterized by high calcium and inappropriately elevated parathyroid hormone (PTH), is associated with a heightened cardiovascular risk profile. The associations that are described in the literature include an increase in body mass index (BMI), elevated low-density lipoprotein cholesterol (LDL-C), decreased high-density lipoprotein cholesterol (HDL-C), elevated high-sensitivity C-reactive protein (a marker of vascular inflammation), and impairment in insulin sensitivity (with ensuant hyperglycemia) . This laThe linkage between primary hyperparathyroidism and diabetes mellitus remains ill-defined, likely due to the limited awareness of this apparent connection in the medical community. The result of this knowledge gap is that today, much of the current literature available is posed only as ‘speculative’ reports. Due to the limited available data, as well as the significant uncertainties surrounding this topic, this article is provided as a scoping review that will analyze all available published, as well as unpublished, data, with the overall intent to collate findings conferring (or refuting) the aforementioned endocrinological relationship. An additional aim is to provide a plausible pathophysiological hypothesis. A scoping review is chosen as the method of review as it allows areas of uncertainty within the medical literature to be highlighted, and additionally, pinpoints areas that require future studies to address at a later date. Given that a narrative review provides an overview of the data, rather than an in-depth study of the subject matter, neither a risk of bias assessment nor a quality appraisal for each article is performed. It is a well-established fact that the highest-regarded bodies of evidence capable of influencing clinical decision-making are randomized controlled trials, systematic reviews, and meta-analyses. Given that a theoretical endocrine enigma is infrequently addressed, a scoping review is most appropriate to cover such less-regarded bodies of evidence. For this reason, all forms of published articles are encompassed within the article.The primary objective is to investigate the evidence denoting a temporal relationship between both primary hyperparathyroidism and diabetes mellitus (or states of insulin resistance), with the outcome of broadening the awareness of this phenomenon throughout both the endocrine and the non-endocrine communities. The secondary objectives are to review plausible pathophysiological theories for such a relationship, and, in addition, to explore whether a parathyroidectomy may improve states of insulin resistance.EpidemiologyKumar and Singh  note thaKumar and Singh  note thaEtiology and hypothesesPrager et al.  note thaAs noted previously, patients with primary hyperparathyroidism are likely to demonstrate elements of the metabolic syndrome; as demonstrated by Bolland et al. , patientIn healthy subjects (without primary hyperparathyroidism), Becerra-Tomás et al.  demonstrAl-Jehani et al.  note tha2/min/pmol/L. Røislien et al. [Certain authors, however, argue that the incidence of insulin resistance in primary hyperparathyroidism is due to the elevation of PTH, and not, as the researchers above have stated, due to the elevation of calcium. Chiu et al.  demonstrn et al.  note than et al.  further n et al.  assess pn et al.  note than et al.  additionNot all authors demonstrate a significant association between primary hyperparathyroidism and diabetes mellitus incidence; this is possibly explained by Luboshitzky et al. , who notTreatmentCertain authors, such as Kumar and Singh  and WalsConversely, Ljunghall et al.  note in Cakir et al.  analyze It remains unclear as to why certain patients with primary hyperparathyroidism develop diabetes mellitus (or overt insulin resistance), whereas others do not. The pathophysiological explanation is not fully elucidated; however, a leading theory is that of increased intracellular calcium leads to the interruption of post-insulin signaling. While insulin may be increased during primary hyperparathyroidism, it is noted that patients are likely to be paradoxically resistant. A further area of uncertainty addressed in the article is whether a parathyroidectomy leads to an improvement in ones’ glycemic profile; it is also unclear as to why certain patients may respond to this surgery, while others do not.It is important to consider the logical fallacies with the aforementioned studies; not all take into account body weight, family history of diabetes mellitus, the severity of primary hyperparathyroidism, duration of primary hyperparathyroidism, normocalcemic versus hypercalcemic primary hyperparathyroidism, or the cause of the primary hyperparathyroidism, all of which are factors that may explain the differing results above. Moreover, certain studies solely assess ‘glucose levels’, whereas others assess insulin secretion, sensitivity, and resistance, which could again explain the differing results. One further consideration is the diagnostic criteria used for diabetes mellitus, which is different among the global studies over the past decades. Currently, there is not enough data to definitively provide a recommendation, and therefore, the presence of insulin resistance should not be used as a criterion for patients to undergo a parathyroidectomy until future studies adequately address the uncertainties mentioned above.


This paper hosts the first meaningful dialogue between two important epistemic movements for criminology: zemiology and decolonisation. I identify that zemiology has a disciplinary blindness to colonialism and explain this using Gurminder K. Bhambra’s scholarship—and cognate scholarship—as a frame. Three cases—Pemberton’s Harmful Societies, Grenfell, and Border Zemiology—are selected for their critical importance within zemiology. They are used to argue that zemiology works within a standard narrative of modernity characterised by capitalist nation-states, which does not recognise the colonial foundations of both of these. Capitalist modernity is, however, a colonial formation. Recognising this allows for a better understanding for a wide range of harms. I then discuss future directions for decolonial zemiology, advocating not for expansion of repertoire, but canonical revision so that colonialism is afforded space as an explanatory frame and zemiology can better explain social harm on a global level. Bhatt : 398 refColonialism and Social Theory, Bhambra and Holmwood ask the question: ‘What does it mean to ‘decolonise’ a curriculum in which colonialism is not recognised?’ Their response is that ‘Paradoxically, if our book is to be understood as an attempt at ‘decolonisation’, it is one that has had to proceed by putting colonialism into the picture. In doing so we aim to create a different way of seeing sociology’. colonial and indigenous struggles , and to some extent Europe. This could be considered contentious, not least in that decolonization is, for some, about Relatedly, the canonical zemiology referred to above obscures analyses of social harm that do not specifically operate overtly under the umbrella of zemiology. This includes much scholarship produced in the Global South or within Indigenous communities that discuss and seek to undo harms, which do not work within European zemiological frames. Reconfiguring the zemiological canon so that it includes such scholarship, though it is a highly worthy cause, is a different project to what I aim to achieve here. As a reminder, following Bhambra et al.  and BhamWhereas other studies typically analyse one harmful phenomenon and situate these in relation to capitalist structure to explain its causes, Pemberton  undertakPemberton colonial, whilst analytically locating the gendered harms of migration within patriarchy and capitalism. Though Canning briefly notes that landscape of contemporary British border control is ‘neocolonial’ Canning : 41, ovewhy is it the case that border control is deliberately designed in this way, to be degrading, controlling and violent, stripping those who are processed of ‘their autonomy and humanity’ . Race evidently matters here, as Soliman suggests, though without an account of the structure productive of race, the aetiology of border harms remains absent. The Mediterranean Sea is not only ‘the EU’s southern border’ colonial is elided within zemiology. In all cases, however, engaging with such scholarship provides further explanation of various harms between different contexts, and works towards a fruitful decolonization within the field. With the above as precedent, this section engages with Canning and Tombs’s  statementrade in conflict minerals, tourism, racism and global inequalities. Alongside but separate to these neocolonial harms colonial as an explanation for social harm has largely been ignored within this area of study, which works within a standard social scientific account of modernity. This takes the nation-state and capitalism as the basic frames for analysis, ignorant to the colonial foundations of both. Recognising that the foundations of the present are colonial, however, and that colonial relations are variously renewed in the twenty-first century provides a greater understanding of harm, currently unaccounted for in this area of study.Overall, then, positing that future directions for zemiology could include neocolonial harms There are some efforts (e.g. Agozino Harmful Societies (between nations on a global level are obscured. The harms in contemporary Britain, though, formed through a neoliberal harm regime are necessarily indebted to colonial economies. Similarly, the harms endured in former colonies are related to their colonial past.In addressing an entire area of study, this article has necessarily had to work with specific examples. The first of these, which is discussed as a landmark study within this field (Canning and Tombs ocieties . Whilst In the case of Grenfell, it was identified that the zemiological aetiology of the fire was neoliberal capitalism. However, as Canning and Tombs have recently noted, the majority of people affected by this fire were not white, and, as this paper argues, this is not coincidental, nor an epiphenomenon of neoliberal capitalism. Rather, Grenfell was a racialised form, indebted to a postcolonial geography of the city, premised upon a moral economy of racialised personhood. Such discussion cannot be ignored in explaining Grenfell, though, within major zemiological accounts this has been elided.The third case considered was border zemiology. Nation-state borders as they exist today are a legacy of colonialism, and the policing and protection of borders reproduces coloniality. This is thoroughly rehearsed within migration studies, though zemiological analyses are all but blind to their formation in this way. That harms are administered at European borders is a matter of racial hierarchy, one produced through a colonial conceptualisation of the subject. For a discipline wishing to address harms at the border, it is entirely necessary to engage with such theorisation. This paper provides an entry point to do so, by considering how Yar’s framework of recognition can be applied to contemporary migration issues, whilst recognising the colonial undergirding to harms in this context.Though there have been recent calls for zemiology to decolonize, this call has been made in such a way that leaves the kernel of the research programme intact. This should not remain the case. There have been endeavours in other disciplines to address such core ideas in a decolonial way, which have renewed analysis and promoted the development of new knowledge. Within sociology, for instance, modernity—its foundational area of enquiry—has been excavated (e.g. Bhambra and Holmwood Through a meaningful decolonization, zemiology would be armed with means to recognise harms beyond those caused by capitalism, to meaningfully work towards post-imperial justice, as is Tombs’s  unrealisRelatedly, the purpose of this paper was not to work towards redefining harm or expanding its conceptual remit through a redrawing of canonical lines to include scholarship from the Global South which theorises harm. This, however, does deserve some comment here. Cunneen and Tauri : 377 notGacaca—a form of justice in Rwanda, which focuses reconciliation and social harmony, and focuses on collective responsibility for harm, rather than being limited to a focus on the individual (Tamale epistemic harm of colonialism involves the imposition of a ways of life—for instance, schemas of thought, perception, action, time—by settler-colonists (Tamale One initial example here is l Tamale . This fol Tamale  as the ‘l Tamale : 157. Acl Tamale : 432. Ins Tamale . Canoniss Tamale  and addrThe philosophers have only interpreted the world in various ways; but what matters is to change it. The very way in which thinking and acting are posited as oppositional, or separate categories, however, is problematic. Thinking is action, and this paper contributes to changing the world through providing a new lens through which harm should be addressed, one that responds to calls from within zemiology (Canning and Tombs As with many critical endeavours, zemiologists (e.g. Tombs ‘The point is to change the way we do theory … the eleventh thesis was not just a crude call to do away with theory and focus on the ‘real task’ of changing the world, although it has been unfortunately interpreted in that fashion by generations of Marxists Nigam : xiii.Theory is something that is done, and it can and does change the world, in terms of how others see the world and act in it. Decolonization is an ongoing process Gopal , and wha