Although parents of triplets experience substantial mental distress, research about this increasing population has primarily focused on physical health risks of triplets and mothers, failing to capture the subjective wellbeing of parents. Accordingly, this study aimed to understand first-hand experience of parents of triplets, using thematic analysis of semi-structured interviews participated by eight parents . Six themes were identified: (1) Negative and (2) Positive experiences of raising triplets prenatally and postnatally, (3) Social, psychological, and material support, (4) Experiences and challenges specific to mothers and (5) fathers, and (6) Advice for future parents. These themes suggest that being reassured and accepting support from others are particularly essential in reducing stress and anxiety. Self-compassion interventions were recommended to support the wellbeing of parents of triplets. Our findings will help parents of triplets, their social circles, and healthcare workers to develop effective approaches to reduce the mental health difficulties that this under-researched population experiences. Parents of triplets experience increased anxiety and stress related to triplets’ and mothers’ health and financial concerns.Parents’ positive experiences included a sense of having a big family and of feeling magical to encounter the unusual phenomena.Mothers’ challenges were internal , while fathers’ were external (stability of job and finances).Being reassured and accepting support from others are particularly essential for reducing stress and anxiety in this population. The occurrence of higher order gestations or multiple births, consisting of three or more foetuses, has been rapidly increasing over the past three decades in developed countries . Purposive and snowball sampling techniques were used to recruit the participants: an initial announcement about the study was shared through the lead author’s social media accounts. The parents who responded to the announcement received an invitation to the study and a consent form, which explains the rationale and details of the study. Participants who agreed to take part in the study completed the informed consent form electronically, which was sent back to the researchers.In order to gather detailed information and allow participants to convey their experiences of parenthood, we employed the semi-structured interview method Woods, . Semi-stPre-designed interview questions were formed to provide some guidance and sent to all participants in advance of the interview. Our questions focused on parents’ pre- and post-natal experiences of having triplets, the challenges and positive impacts of parenting, advice for future parents of triplets, other people’s reactions (Appendix 1). Although we interviewed parent couples, we conducted separate interviews with each father and mother to observe variations in idiosyncratic experiences specific to different parent roles. Since our participants were based at different countries, we conducted video interviews via Skype. The interviews were recorded (with the participants’ prior consent) and transcribed verbatim, which were later confirmed for accuracy by the participants.We used the thematic analysis method to analyse the interview data. Thematic analysis is a method used for systematic identification and organisation of patterns of meaning (themes) across a dataset  Positive emotions when finding out about having triplets, (2) Last chance to have children, (3) Confidence about childbirth, (4) Concern and worry from other people, (5) Judgment about having more than one baby, (6) Financial and domestic worries, (7) Feeling ‘full of baby’, (8) Mother’s feelings of boredom and restriction, (9) Receiving family support, (10) Feeling guilty about other children, (11) Having a big family as a joyous experience, (12) Positive mindset, (13) Support from nurses, (14) Being happy about healthy babies, (15) Accepting help, (16) Not allowing bad statistics impact your experiences, (17) Triplet personality differences, (18) Concern when finding out about having triplets, (19) Concern about mother’s health, (20) Encouraging triplets to be individual, (21) Positive experience of growing up with many siblings, (22) Support from family and friends, (23) Being treated differently by others due to having triplets, (24) Feeling scared by doctors about having triplets, (25) Lack of psychological support for postpartum depression, (26) Recognising each other’s strengths as a couple, (27) Feelings of inadequacy as a father, (28) Poor communication from medical staff, (29) Feeling that something is abnormal, (30) Closeness between triplets, (31) Feeling like a ‘human incubator’, (32) Providing a holding environment, (33) Seeing parenting as a relationship rather than a job, (34) Using Internet and Facebook to find other triplet parents, (35) Feeling special as parents of triplets.Using Braun and Clarke’s  mind mapOnce the distinct themes were established, a second stage review process was conducted to check whether the themes relate to the entire data set , useful support in raising triplets (Theme 3), experiences and challenges specific to mothers and fathers (Themes 4 and 5), and advice for future parents of triplets (Theme 6).The data sets from Theme 1: Negative experiences of raising triplets prenatally and postnatally, revealed parents’ struggles in adjusting social, psychological, and material aspects of their lives to accommodate the triplets’ needs. Unsurprisingly, these adjustments are experienced as intense and demanding in multiple births, often requiring drastic changes in parents’ careers as well as domestic and social lives. In contrast, Theme 2: Positive experiences of raising triplets prenatally and postnatally, demonstrated parents’ happy moments, both prior and after birth. Many positive expressions and experiences relate to the idea that triplets are a special and rare phenomenon, which is interesting for many people outside of the family circle. In Theme 3: Social, psychological, and material support that was useful in parenting triplets, parents revealed the different support networks that were useful both prior and after the birth of triplets. Theme 4: Experiences and challenges specific to mothers of triplets, and Theme 5: Experiences and challenges specific to fathers of triplets, draw differences between fathers’ and mothers’ experiences of parenting triplets. Finally, Theme 6: Advice to future parents of triplets conveys some of useful tips on how to overcome the challenges of parenting triplets prenatally and postnatally, such as allowing themselves to accept support.Participant 2: First emotion was [that of] a concern because it’s an unusual situation. Economically, this means it’s another three children. [It adds to] financial and medical concerns.Participant 6: We came out in car, broke into tears. The news was great, being pregnant is wonderful, but being pregnant with triplets was… massive. … How are we going to afford everything, cope financially, [and] not give up jobs and still care for children?Participant 7: I was so shocked. … I felt emotionally overwhelmed, a bit like, “oh my god, I just can’t believe it”. Day after that, I panicked, and I was afraid for a long time, thinking if [the triplets] were going to be okay. […] I wouldn’t have money to support them, [and] I had those fears all the time.All study participants revealed that they had immediate financial and domestic concerns once they learned that they are having triplets.Participant 3: At the 8th week, doctor told us that we are having twins, but I felt that is manageable. At the 12th week, they said we are having triplets. That was shocking. As a working nurse myself, I knew a lot of statistics associated with risks [of having triplets]. I was happy with being pregnant, but anxiety started to grow, worried about babies’ and my health. Worried about whether they will be born healthily.Participant 5: My husband and I went to the hospital and got a scan. They asked if I have taken fertility drugs, [and I said] no, of course not. Radiographer then told us that she sees three bodies. I said: “Pardon?” My first thought was abnormality. Three babies? She got somebody else to check. I was upset, I wasn’t prepared, and we were both worried. What about complications?Participant 6: As young parents, we were worried. The radiographer brought a colleague in and said we should get a senior radiographer. They were talking to each other but saying nothing to us. Then, the senior radiographer said, “oh my god, we can see three heads”. At that time, we thought we have one baby with three heads. They haven’t explained it well at all. For scared people who are not familiar with the [medical] system, it was poor communication. It set up negative feelings that there is a problem or something that needs to be sorted out.Many of these concerns were coupled with health worries relating to both mothers and triplets. Several participants noted that the initial communication from doctors and other medical staff was unclear and made the parents feel as if something was wrong or that there was an abnormality with the pregnancy.Participant 4: All of our [his and his wife’s] attention had to go to the triplets, so our daughter felt our love for her was stolen. It seems to me that she has become more frequently angry, and sometimes she behaves like a baby. We weren’t, probably still aren’t, certain how to approach her. We have just been trying to have a one-on-one time with her.For a family with another sibling, care for the mental health of that child is another important issue.Participant 2: [There] is a huge change in your life after birth. The ability to go to a park for a walk is now [replaced] with feeding and wrapping the babies and getting them into car. […] All out of sudden, there are other things to think about. I couldn’t just flip myself and say, “I will be there at 8 o’clock in London.” I may not get enough sleep, so getting a 6:30am train was not even an option.Participant 8: I was at Uni, working full-time. I remember this excruciating feeling of “why can’t they just have a day off?” […] Babies get up at 4am, and “it’s your turn, my turn” kind of argument [with my wife]. Saturday morning, I want to be slow, but they are up, and there is no slow time.Finally, many participants noted the physical exhaustion and difficulties in managing time after the birth of the triplets.Financial concerns, health worries, physical exhaustion and limited time were noted as primary negative experiences by the participants.Participant 1: It was my last chance to have children. My husband was worried; we had to undergo fertility treatment with our [firstborn], and I didn’t want to get the treatment again. I wanted to have four children, and I had a massive feeling that it will be alright. We were astounded when we heard the news. Immediately, the [medical staff] told the scary stats. They pushed, but I took the risk.One participant was particularly positive and confident about giving birth to triplets. Differently from most participants, the dataset revealed that one couple in particular struggled to have children and had to undergo fertility treatment with their firstborn. This has made the mother feel more confident and positive despite negative statistics associated with multiple births:Participant 1: We created a big family, and that’s why our mindset was positive. […] Having them was busy but it was also so joyous. They were healthy, and nurses felt privileged to be there, [witnessing] three healthy babies. It was a novelty for them, it brought so much happiness.Participant 2: I had a positive experience being raised with four siblings. […] The shift toward becoming family-focused was natural. […] We’ve been lucky with all the kids. They have an effect on everyone, everyone loves them. You really think, “wow, this is what it means to have a family”.Two participants referred to the importance of having (and being part of) a big family as a positive factor in parenting triplets.Participant 6: The triplets were communicating and laughing between themselves. I remember those mornings, taking a picture of them, it was amazing. We were listening to them and bringing them to bed, and they would all go to bed at the same time. Some real wonderful experience in the early days. They learn the concept of sharing very early on, and do things together.Participant 8: We became famous. When we left [our town], the security and people were smiling, crowding around us. […] People were asking questions even if they don’t know you. […] [Life] with triplets becomes funny. When triplets used to crawl, I would lie in the living room, and they’d crawl all over me, in circle, same direction. It was magical and fun.Lastly, several participants noted the special bond between triplets, which has been likened to witnessing a unique phenomenon both by parents and strangers outside of the family circle.Participants reported a sense of a big family, and strong bonds among themselves as positive experiences.Participant 5: My care was amazing. Medical staff were very careful, sensitive, and nice. I had lots of scans, and I developed a great relationship with the consultants. There was a team for each baby. […] I was in a special care unit, which also had [cared] for postnatal depression. It could be because of the separation factor [since] the triplets were in an incubator. It was a strange emotional [experience].Participant 7: My girls were born in private hospital. I felt relaxed, they were well looked after, had a room just for them. There were three incubators, I could sit and be with them. [I was not] able to hold them yet because they were too small.All participants noted the importance of having support from the medical staff and hospital, both prenatally and postnatally. This includes not just support for mothers’ and triplets’ physical health and wellbeing but also psychological support.Participant 6: Never had any negative reactions. Everyone was lovely: family, friends, neighbours. They ensured we had everything we needed. Just knocked on the door, and they were lovely. Very few people gave guidance. […] Our circle of friends grew. We didn’t lose anybody. All friends, same age, with babies, we got to know people who are also multiple birth parents.Participant 8: At the most basic, what helps is having a supportive partner. I’m sure it’s the other way around too. Also having [family] support, that’s huge help. We received financial help from my [partner’s] family. The triplets got beautiful clothes and were well dressed. […] With financial support, we were able to go out as a family with our babies.Two other factors that played an important role in overcoming parenting-related challenges were financial support and help from family and friends.Participant 4: We were kind of hoping that our parents will come to help us. My mother in-law came to help us for a few days, but she didn’t agree with how we take care of triplets, so had an argument with my wife, and left. We were left alone to take care of triplets and a four-year-old. As we had hope up, it was physically and mentally challenging to adjust to the reality that we are alone.Participant 8: You don’t get things for free, but my hope is that people will realise that going from one to three children is something rare and expensive, and everything comes in three at the same time. [I remember] when we flew back from London, we needed help getting off the plane, but no one helped for 45 minutes. Eventually, someone helped us from the airline. On the other hand, when we flew on Christmas, [the staff] took care of all babies, for ten minutes they walked around with the [staff], while we got breakfast.Some participants highlighted the value of external support by referring to an experience where they did not have such support.Participants reported that more support is needed for parents of triplets, and the felt value of such support was immense to them.being and feeling pregnant) with triplets. In comparison to interviews with fathers, mothers frequently discussed their prenatal and postnatal experiences as internal rather than external, without necessarily clearly differentiating between themselves and the babies .Participant 7: I was a human incubator for babies. I was there for them. I struggled with my hormones a lot, I felt nervous. If someone was annoying me, I would rush out easily. I felt I had to deal with my emotions, to be calm and provide for the babies […] because I knew it would have an impact on them.Participant 1: My mom was worried, my sister was confident just like me. Most people said, “oh my god” or “as long as you have one baby”. But I was happy. […] I felt full of baby.Interviews with mothers included many expressions and thoughts that pertained to experiences of pregnancy , we had to strike a deal with them again, and pay two and a half fees.Participant 4: When we found out we are having triplets, I thought I should quit my job to help my wife. But then we won’t be able to survive financially. … [After triplets were born] I worked really hard, but on reflection I sometimes feel regretful that I could have taken more days-off back then to support my wife.In comparison to interviews with mothers, fathers more frequently stressed financial and domestic concerns, and work pressures.Participant 1: Stay calm, don’t look too far into the future. Try to enjoy. Accept as much help as possible.Participant 5: Try not to be too anxious. People offer help, just accept help. Look out for the community and friendships, not just for yourselves as parents but also for children. See this as a social experience.Participant 3: I have become less ashamed to express my emotional distress to my friends, “I am stressed”, “I’m depressed” and so on. Then they suggest we go to the park or shopping together. This was helpful. I found that not being alone, being with someone very helpful.Interestingly, the main advice from all participants was to learn how to accept different forms  and sources  of help. This implies that there may be an initial psychological difficulty or anxiety felt by new parents of triplets in being supported by friends or family, as well as discomfort in receiving support.Participant 2: Try to find people who had similar experience or are interested in triplets. When [my partner] told me about this study, she was excited. First thing I said was that I wish we had known someone [like us] at the time. As much as your immediate family supports you, someone who has gone through can give you better advice. So, first bit is to find someone with same experience, whether virtually, on social media, etc.Participant 5: Recognise each other’s strengths. It’s easy to blame partners. […] Try not to be resentful, communicate; it’s okay to be angry, but you need to talk about it. We could have easily divorced but we went through this because we were on it together.Participant 5: You have to be in a community […] instead of closing off others from yourself. Respecting other people, but also [inviting] them to your [space].Other advice included finding other people with multiple birth experiences, recognising each other’s strengths as partners and parents, being part of a supportive community, and meditation.Participant 7: Meditation. People struggle all the time. I wanted to have a profession, to bring money in… But you don’t have time when raising children, you are so busy with three babies, then it all starts to hit you. […] Meditation really helped me. I felt serene. I am now a Buddhist myself, […] I focus on meditation, breathing, and self–monitoring.One participant reported a specific intervention to address stress.Acceptance of support and stress reduction exercises such as meditation were noted as advice for future triplet parents.This study qualitatively analysed semi-structured interviews with eight parents of triplets , reflecting on their pre- and post-natal experiences. Six themes were identified: Negative and positive experiences of raising triplets prenatally and postnatally (Themes 1 and 2), useful support in raising triplets (Theme 3), experiences and challenges specific to mothers and fathers (Themes 4 and 5), and advice for future parents of triplets (Theme 6).One original contribution of this study was an appraisal of the first-hand experiences in parents of triplets to address the lack of mental health care for parents of triplets Bricker, . ConsistOur results also revealed that, after the birth, parents had difficulties forming a firm bond with each child, as reported previously Akerman, . Additiointernal, concerning their and triplets’ physical and psychological health and wellbeing, which aligns with previous research . Mothers’ challenges were generally described as Bricker, . This fiBricker, . For Winexternal factors such as their job and finances. Indeed, the health risks are high and thus are often the main concern in triplet pregnancy  can offer practical and helpful information, with self-compassion as one approach to protect their mental health. While triplet research so far has focused on risks and challenges associated with delivering and raising triplets, our analysis identified what is helpful for parents of triplets, which can help develop psychological resources such as resilience and self-compassion . As such, these findings may not apply to the general population of parents of triplets. Though recruiting parents of triplets is difficult due to the limited number of samples and limited time they can devote to research, more diverse samples should be recruited to develop more generalisable findings. Relatedly, one couple in our study was from Japan, while the remaining three were from the UK. Although we did not find any significant difference in data, considering the cultural differences in parenting (Bornstein, The number of parents of triplets and the demand for resources to support them are on the rise, however, targeted support for parents of triplets remains to be evaluated. Although our study features a small sample, we were able to identify first-hand experiences of parents of triplets, and possible interventions to support their wellbeing, which correspond to unique idiosyncratic experiences revealed through semi-structured interviews. Our findings will help parents of triplets, healthcare workers and communities to develop effective means to reduce the mental health difficulties that this under-researched population faces.Appendix 1 Triplet Study


The spread of the SARS-CoV-2 virus has transformed many aspects of people’s daily life, including sports. Social networks have been flooded on these issues. The present study aims to analyze the tweets produced relating to sports and COVID-19. From the end of January to the beginning of May 2020, over 4,000,000 tweets on this subject were downloaded through the Twitter search API. Once the duplicates, replicas, and retweets were removed, 119,253 original tweets were analyzed. A quantitative–qualitative content analysis was used to study the selected tweets. Posts dynamics regarding sport and exercise evolved according to the COVID-19 pandemic and subsequent lockdown, shifting from considering sport as a healthy bastion to an activity exposed to disease like any other. Most media professional sporting events received great attention on Twitter, while grassroots and women’s sport were relegated to a residual role. The analysis of the 30 topics identified focused on the social, sporting, economic and health impact of the pandemic on the sport. Sporting cancellations, leisure time and socialization disruptions, club bankruptcies, sports training and athletes’ uncertain career development were the main concerns. Although general health measures appeared in the tweets analyzed, those addressed to sports practice were relatively scarce. Finally, this study shows the importance of Twitter as a means of conveying social attitudes towards sports and COVID-19 and its potential to generate alternative responses in future stages of the pandemic. In December 2019, the first cases of pneumonia of unknown origin were identified in Wuhan, China  is unthinkable for athletes”. Later, it progressively moved to emphasize the increasing risk of infection and difficulties involved in ensuring proper training, despite the fact that the International Olympic Committee (IOC) urged them to continue preparing .Concerning some sports, particularly football, tweets talked about the immediate career consequences for some professionals because of the difficulties and changes encountered in the transfer procedure. As a tweet pointed out, “The coronavirus crisis will not only resize the transfer market downwards but will also change the perception of figures that we have handled so far”.The coronavirus outbreak also provoked a major economic crisis because, without sport, the industry faced major losses as a result of the lack of direct earnings from sports events that were now canceled and indirect earnings from media rights that were suspended as a result. Some spectators demanded reimbursements for “everyone whose made & paid for travel & tickets” and wondered if they had “any chance of getting any money back”. However, several tweets soon showed how the coronavirus outbreak had left “many clubs and organisations struggling financially” because incomes fell abruptly and some “club’s insurers remove[d] pandemic cover[s]”.To overcome this challenge, professional clubs required sportspersons to take pay cuts . They were accepted widely because they allowed non-sporting staff to avoid being fired .A few tweets on women’s sports referred to the dramatic economic consequences of the pandemic because of the weaker economic nature of their field, unlike men’s sports. “Women’s sport must be safeguarded because coronavirus” and “huge economic impact” “threaten [its] existence”, especially in football, as recent international advancements are under threat.Economic problems were also observed at amateur and community levels; thus, “Many clubs already rely on retired volunteers, who may be in the ‘at risk’ category and need to stay safe”. These organizations received economic support from sports authorities in different countries to help overcome these challenges. For instance, a total of “£195 million package to help sport and physical activity through coronavirus” and “£20 million Community Emergency Fund available immediately for local club and community organisations” were provided by Sport England.Finally, economic consequences also affected TV, specialized sports channels, and media houses, which offered reductions in their sports packages .In the initial days of the pandemic, tweets tended to minimize the effects of the disease because “people who got the virus had mild symptoms and returned to good health” or attributed the most severe effects of COVID-19 to “older” or “weak” people: “I hate the Coronavirus, not for the fact that it can kill me, but for the fact that it kills weaker people”. In contrast, sports practice was presented as a protection factor, assuming that sport and exercise made people “strong”, “healthy”, and implicitly resistant to COVID-19: “people that dies to the coronavirus are older people that doesn’t really do much sport at all and already has a bad heart”.Tweets pertaining to safe sport practices and protection measures to be taken in the course of practice exercises were relatively scarce. For instance, in our search, we found no tweets focusing on safety, using masks, or other hygiene measures in sports practice. Only a commercial tweet that referred to a specific mask for cycling was identified: “Buy WEST BIKING KN95 Antiviral Coronavirus Sport Face Mask With Filter Activated Carbon PM 2.5 Anti-Pollution Running Cycling Mask”.Most sports celebrities’ testimonies were related to general public hygiene measures, such as “stay at home”, “stay safe”, “social distancing”, and “Look out for each other” instead of anything particular to sport practice during the pandemic. However, as the pandemic progressed, some tweets mentioning the importance of the safe and secure practice of sport emerged: “WE WILL GET THROUGH THIS TOGETHER! Golf and sport will bring us all back together, but ONLY when it is safe”. Revival of sports practice is seen as a sign of personal and social renewal and as an important means for personal and social wellness. “We do not know what sport will look like when this is over. We have to hope it looks the same—without forgetting…”. “It’s only when something disappears that you realize quite how much you miss it”. “In this current dark reality, sport doesn’t matter, but it does”.According to the last tweet, sport and physical activity can matter for health issues pertaining to COVID-19, particularly as a strategy for overcoming stress due to lockdown. As confinement and sporting cancellations spread, tweets referring to becoming active rose both in number and significance. Governmental and private sports organizations as well as individuals and media wrote many messages promoting physical activity and sport among the population and suggested links that people could use to join exercise programs online .The COVID-19 pandemic has affected the daily lives of people the world over, as seen in the tweets analyzed in this study. Our results show that since late January and early February, the number of tweets published on COVID-19 and sport began to increase until a peak was reached in mid-March. Singh et al.  examinedMuch detected traffic came from online newspapers, which have accounts on Twitter where they show a part of their digital content. This presents a bidirectional phenomenon as Twitter is both a site for the publication of news and a source of information for traditional newspapers ,50,51,52The most repeated words in all these tweets were those that generally refers to the type of virus, “coronavirus”, and the disease it causes, “COVID-19”. However, both the name of the virus  and how the press should refer to the disease were areas of controversy in the initial days among health authorities. Several historical precedents show the importance of disassociating the name of certain diseases from their place of origin  because it can generate significant stigma on people from and living in the place in question . For thiFrom a sporting perspective, the words “league”, “due”, “player”, and “football” were most repeated on Twitter during the period of analysis. European football had a prominent presence in this social network during the study period, although the word “football” was used to refer to different sports in English . The word “NFL” , which is associated with American football, appeared in the 596th position of the world ranking. From this, we can deduce that the impact of the coronavirus on US events was discrete during the study period. Future work should focus on other periods during the pandemic to establish the impact of COVID-19 on American football, and by extension, on American professional sport.The word “olympics” also had a prominent place in many tweets. The fact that the pandemic began in Asia, and Japan was one of the first to be affected, fostered the appearance of many tweets on the possible impact on the Tokyo 2020 Olympics at the end of January 2020. The Olympic Games are the largest economic, political, and social sporting event in the world and decisions on this macro-event can affect many other sporting events.The quantitative results also showed that words related to prevention had a relatively low presence. For instance, the word “mask” hardly appeared in our analysis. Early doubts about its usefulness  may haveMost users mentioned the news from particular newspapers. However, only very few tweets mentioned the URLs of national or supranational institutions that were not related to sport . This suThe qualitative results indicate that the pandemic has affected many facets, persons, groups, and organizations at different levels in the sport system. Tweets under study in this paper focus especially on the social, sport, economic, and health impacts, as seen in the main themes identified in the analysis.The tweets studied to prove the powerful role that sport plays in the lives of many people. They realize it when the sport is snatched from their lives, breaking their daily routines abruptly. Many of them realized sport provided the excitement they needed to endure their routinized ordinary lives, as identified by figurational sociologists ,61. ThisSome tweets emphasized how the pandemic had disrupted their main ways of socializing with other people and establishing ties with their family and peers, as Parnell et al.  identifiThe cancellation of sporting events and the lockdown to contain the spread of COVID-19 had short- and long-term consequences, especially for athletes and coaches. Twitter referred to the stress on their health and the uncertainty it provoked in their careers. For instance, users referred to the transfer process that was affected at the professional level and the broken expectations that prevailed at the grassroots level because young athletes are in the early stages of their career. This is an important issue that Evans et al.  highlighOur results indicate that the sporting industry and the economic consequences of COVID-19 received important attention on Twitter. Reimbursement of money after the postponement and cancellation of sporting events and the lack of revenues were emphasized in some tweets. A recent study showed how the Big Four League in North America supposed a potential revenue fallout of 6bn dollars if they did not collect any gate receipts until the end of the season . HoweverThe sport appeared in many early tweets in the form of an intrinsic factor of protection, a sort of magic shield that protects people from serious health problems. Previous research has revealed that this attitude is typical of male, young, sporting bodies facing illness . It alsoThe first limitation of our study is directly related to the language used for the search. We chose to collect tweets in English alone. Although English can be considered the lingua franca on Twitter , this deBeyond these limitations, future work should focus on athletes and sports institutions with a significant presence on Twitter. Particularly, it would be desirable to track the news published about COVID-19 in the accounts of professional athletes and the sports newspapers with a presence on Twitter.This paper presented how COVID-19 has affected most facets of the sport, such as governmental organizations, clubs, athletes, managers, coaches, and fans, as well as the sporting community on the whole. The quantitative dynamic of posts on Twitter concerning sport evolved according to the pandemic and lockdown to contain its spread. However, many of these tweets were created around most media sports events  generated in the news agencies and newspapers. Our quantitative and qualitative analyses show that Twitter focused mainly on professional sport and mass entertainment events, whereas grassroots and women’s sport was relegated to a residual role despite the adverse impacts of COVID-19 on those areas, the career development of the athletes involved, social advances, and health consequences. No tweets referred to other vulnerable groups, such as immigrants, the homeless, and refugees, and potential groups segregated under virus risk . This shows how COVID-19 had spurred new forms of economic and cultural inequalities that should be considered if the pandemic continues to spread.The economic impact has devoted important attention to the messages on Twitter, as has happened in the economy in general, coming to dispute with the preservation of people’s health messages during the initial sports decisions on postponements and cancellations. These disputes and tensions were softened at the time when the athletes, coaches, and young fans were not as invulnerable as Twitter users expected them to be. Messages on sport shifted from considering this social practice as a healthy bastion to an activity exposed to disease like most other activities.However, the counting of tweets on sport exhibited that neither the media nor Twitter users focused on general hygiene measures. The qualitative analysis showed the resistance among Twitter users in the early stages to adopting health-related measures in mass events. Although sports celebrities participated in prevention campaigns and cancellations contributed towards reducing the spread of COVID-19, it is doubtful whether Twitter helped gain awareness on the health protection measures. This is especially dramatic as sports is a universal practice with a worldwide audience. However, our qualitative analysis showed that people were mainly worried about how to fill the gap left behind in the wake of the cancellation and postponement of sporting events and to address the boredom ensuing as a result, rather than being concerned about protecting their health. Health authorities should take advantage of the opportunities offered by sport for communication through media and social networks to transmit information on health protection and prevention measures in the future. In particular, the enrollment of most media sports persons could play an important role in the dissemination of messages about preventive measures. The practical implications of our study point in this direction. Our results may suggest that Twitter and, specifically, sports-related tweets can be a vehicle for the dissemination of messages on the pandemic, using professional sports celebrities as loudspeakers. The following recent tweets about the position of two world-renowned tennis players  regarding vaccines are good examples: “Murray supports vaccine in tennis” or Nadal: “Vaccine is the only solution to go through the pandemic. We need to accept it. I know some people have side effects, but the coronavirus effects are worse. I will get vaccinated if I can”. However, despite the great potential support for vaccination, these messages have had little impact on institutional user accounts. Conversely, policymakers, public health and sports professionals, and the media should pay closer attention to the possibilities of sport in Twitter for delivering anti-COVID-19 information. The next Tokyo Olympic Games this summer of 2021 offers a golden opportunity to put this strategy into practice.Finally, an important question emerged from this study for the near future: Can the interest in exercise and sport observed in Twitter serve as a new impulse for improving people’s quality of life instead of a simple confinement compensation?


Condition monitoring of rail transport systems has become a phenomenon of global interest over the past half a century. The approaches to condition monitoring of various rail transport systems—especially in the context of rail vehicle subsystem and track subsystem monitoring—have been evolving, and have become equally significant and challenging. The evolution of the approaches applied to rail systems’ condition monitoring has followed manual maintenance, through methods connected to the application of sensors, up to the currently discussed methods and techniques focused on the mutual use of automation, data processing, and exchange. The aim of this paper is to provide an essential overview of the academic research on the condition monitoring of rail transport systems. This paper reviews existing literature in order to present an up-to-date, content-based analysis based on a coupled methodology consisting of bibliometric performance analysis and systematic literature review. This combination of literature review approaches allows the authors to focus on the identification of the most influential contributors to the advances in research in the analyzed area of interest, and the most influential and prominent researchers, journals, and papers. These findings have led the authors to specify research trends related to the analyzed area, and additionally identify future research agendas in the investigation from engineering perspectives. Condition monitoring of certain devices is applied in a particular system in order to detect changes or analyze trends in controlling particular parameters, and most of all to prevent potential failures of a system. Early problem diagnosis ensures preliminary intervention for replacement of any equipment’s components before serious consequences. The term “condition monitoring” evolved—in the case of research connected to rail transport—with the development of instruments that allow the development of increasingly better measurement analyses. Such an evolution of terms, definitions, and approaches connected to condition monitoring in the case of the aforementioned mode of transport is presented in Recent decades have shown a certain evolution of approaches to the condition monitoring of various rail transport systems, especially in the context of rail vehicles and track subsystems. The approaches applied to rail infrastructure condition monitoring have evolved from manual maintenance, through methods connected to the application of sensors, up to the currently discussed techniques focused on the terms of Industry 4.0. The enormous increase in the quantities of generated data—namely, big data—requires diagnostic procedures to be automated. Such a challenge induced the need for up-to-date and improved methods of autonomous interpretation of condition monitoring data (mainly vibration methods). This has led the authors to the aim of this review paper, which is the consideration of several pieces of research focused on the scientific area of rail transport systems’ condition monitoring. The authors of this review paper took into consideration two distinct methods of scientific literature analysis: on the one hand, a bibliometric performance analysis  was carried out, and on the other hand, a systematic literature review was performed.condition monitoring techniques for rail vehicle dynamics ,applications and various soft computing methods used for condition monitoring in the context of intelligent systems ,description of onboard condition monitoring systems, methods, and devices—with a particular interest in microelectromechanical sensors, microprocessors, and transceivers—creating wireless sensor networks for freight rail transport ,methods, techniques, and applications connected to the condition monitoring of railroad switches and crossing systems ,condition monitoring systems and enabling automatic railroad track inspection ,railroad track condition monitoring with the use of inertial sensors  and GPS signals ,brief discussion on machine learning techniques in relation to rail track condition monitoring ,railway turnout condition monitoring ,53),various aspects connected to the industrial Internet of Things solutions related to condition monitoring ,various types of sensors in wired and wireless sensor networks , and wircondition monitoring associated with fault diagnosis of rolling bearings .According to the information contained in key scientific databases, nearly 20 review papers on the condition monitoring of railroad systems have been published in the last 4 decades. This is an insignificant number considering the essence of the subject matter; nevertheless, it is worth underlining that this number concerns some limited areas that will be defined later in the current article. By recalling the published review papers, it can be stated that their authors have taken under consideration topics such as :This briefly presented background allows us to state that no complex review papers connected to condition monitoring for rail transport were noted. As this can be treated as a research gap, the authors decided to consider an in-depth study consisting of a complex review of approaches to condition monitoring for railroad transport, under particular assumptions. This study is related both to passenger and freight railroad transport systems’ condition monitoring—in aspects connected to both rail vehicles and tracks.As was observed, there is a lack of review papers that treat condition monitoring of railway transport systems as complex systems composed of various facilities and subsystems, straightforwardly discussing both rail tracks and rail vehicles. This review paper’s authors have tried to fill such a research gap. Additionally, we decided to take into consideration the past few decades of condition monitoring considerations presented in numerous publications, which led us to formulate the main research aims of this publication. The research questions are as follows: RQ1: What are the current trends in condition-monitoring approaches, and how have these trends evolved over the last decades?RQ2: What are the future research directions and perspectives in the condition monitoring of rail transport systems?This paper is organized according to the following structure: The background resulted in research questions that need to be verified based on a certain methodology. The authors present the methodology of the current research in the next section. The two sections following the description of the methodology were selected based on methodological approaches, and are as follows: bibliometric performance analysis, and systematic literature review. Finally, in the last section, we discuss the main results of this study, and additionally present current research limitations and future research agendas.The type of research methodology and manner of data collection for further analysis depend on the research question being studied. Therefore, before we present our research methodology applied in the case of the current paper, we shall present potential well-known methods and techniques commonly used in the literature review context. Consequently, a proper compilation of methods and techniques is presented at the end of this section.This paper is based on coupled review methodologies—it combines a bibliometric performance analysis based on content-based analysis, and a systematic literature review as a result of the content-based analysis. The first of these methods is a form of quantitative analysis, while the second is qualitative. As a whole, this methodology adequately presents the full spectrum of publications connected to the condition monitoring of rail transport systems, both in quantitative and qualitative terms.Neuendorf  defined A bibliometric performance analysis based on content-based analysis is one aspect of the current paper, while the other is the systematic literature review. Literature review in general is characterized by certain typology, which was presented in detail in Marczewska and Kostrzewski  based onThe data searching process was limited to contributions published between 1980 and 2020 . The end date was based on the content of the scientific databases. The specific information connected to every stage of the research review is provided in the following subsections. The procedure of this research review is shown in The first stage of the search process was not limited to any period of time .“condition”* AND “monitoring” AND “railway*” AND “track” OR “vehicle”. This resulted in the return of 6115 records in total in the Scopus database . It should be mentioned that 23 publications in total were assigned to the year 2021, and these are included in this number, but excluded from the below statistics. The majority of the publications were released in English, and a significant number of them in Chinese—all of the languages of the publications are given in “(condition* AND monitoring) AND (railway*) AND (track*) AND )” allowed us to limit the number of searched publications to 5185 items . Once again, it should be mentioned that 23 publications were assigned to the year 2021, and these are included in this number, but not included in the below statistics.Since our interest was focused on the condition monitoring of railway vehicles and tracks, the following set of keywords was investigated: All of the papers in English were also filtered based on their type. As shown in i) in the mentioned research area per year (y) is presented in R2 = 0.964; this equation is noted as Equation (1). The end of the year 2020 was not excluded from this analysis; however, one should bear in mind that the number of publications will increase, considering that indexing in scientific databases is out of regulations; for example, if there was still a month of 2020 left until the end of the period between the completion of the analyzed data and the end of the year, not all of the released publications would have been indexed in the database yet.The number of publications in the research area of condition monitoring, released in English, grew annually. The number of publications , “railway”, “fault detection”, “railway track”, “vibration analysis”, “damage detection”, “failure analysis”, “railway infrastructure”, “fault diagnosis”, “vibration”, “monitoring system”, “railway accidents”, “surface defects”, “track irregularity”, “accident prevention”, “railroad engineering”, “condition monitoring system” , “track geometry”, “rail track”, “rail”, “railways”, etc. Although internal keywords such as “railroad”, “railroad transportation”, and “rails” describe more publications than “condition monitoring” terms, these are too general, and are characterized by a high degree of abstractness in connection to the particular subject matter. On the other hand, the remaining internal keywords are assigned to fewer publications than “condition monitoring”. Therefore, we assumed that the research publications of interest were hidden in a group focused on the internal keyword “condition monitoring”. Therefore, publications from the circle of this keyword are subjected to analysis in this article.A total of 617 publications assigned to the condition monitoring term were released in English between 1982 and the first half of 2020 . Most of the contributions were classified as articles and conference papers, reviews, and conference reviews; hence, these types of references were of interest to us. Unlike the sample before filtering via internal keywords, more publications in this sample were released as conference papers (54.9%) than articles (41.0%) .To satisfy the reader’s inquisitiveness, the full code applied in the Scopus database search engine is as follows:(condition*ANDmonitoring)AND (railway*)AND (track*)AND )AND )AND ).Notes and conference reviews were excluded from the research, since these are believed to be less influential in scientific terms and, thus, less relevant. For this reason, the studies to be assessed were selected from these areas, constituting a final research sample of 613 document results found with the following full code applied in the Scopus database search engine: (condition*ANDmonitoring)AND (railway*)AND (track*)AND )AND )AND )AND OR EXCLUDE .((TS=(condition* AND monitoring) AND TS=(railway*) AND TS=(track*)) OR (TI=(condition* AND monitoring) AND TI=(railway*) AND TI=(track*)) OR (AB=(condition* AND monitoring) AND AB=(railway*) AND AB=(track*)) OR (AK=(condition* AND monitoring) AND AK=(railway*) AND AK=(track*))) AND LANGUAGE: (English) AND LANGUAGE: (English) Refined by: DOCUMENT TYPES: (ARTICLE OR REVIEW OR BOOK CHAPTER OR PROCEEDINGS PAPER) Timespan: All years. Indexes: SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI, CCR-EXPANDED, IC . The search of the WoS database resulted in 473 records (checked on 8 January 2021). The majority of the WoS-indexed publications were also found on the Scopus database. Moreover, the Scopus database is characterized by a higher number of unique journals compared to WoS, as a result of which the total number of records in the Scopus database was greater than in the WoS database. A comparison of the records found in both databases is given in It is worth explaining the choice of the scientific database in these considerations. A couple of years ago, the authors of Baier-Fuentes et al.  mentioneR2 = 0.9147; this equation is noted as Equation (2).The increase in the number of publications from one year to another is different when the concept of publications is limited only to those for which the internal keyword “condition monitoring” was indicated. There is no exponential dependence as seen in Currently, the particular publication could be assigned to several subject areas, which means that publications assigned to the Engineering subject area can be assigned to several other areas as well. This is based less on the decision of a particular publication’s author(s), but more on an algorithm of the database. As can be observed, in the case of the “condition monitoring” internal keywords, most of the publications are indexed in the Engineering subject area, as is shown in Cooperation in publication and citation of the researchers cited in the case of the internal keywords “condition monitoring” is one of the most important analyses by which to present the level of researcher productivity. In order to conduct such an analysis, it was important to unify data imported from the database. The set of data connected to the published manuscripts were not given with the unique names or surnames of the selected researchers. Therefore, before analysis, the following unifications were performed: every time “Goodall R.M.” appeared in the data file it was changed to “Goodall R.”; “Weston P.F.” to “Weston P.”; and “García Márquez F.P.” to “Márquez F.P.G.”, etc. After this kind of correction, it was possible to obtain a network of cooperation in publication and citation of researchers cited in the case of the internal keywords “condition monitoring”; This network is presented in For the total number of 57 unique researchers, the total strength of co-authorship links with other authors was calculated , which were not unified, as can be observed in It is worth mentioning, despite perhaps seeming obvious, that different keywords characterize a given publication. Therefore, it is not possible to group all publications characterized by identical keywords in the text within—for example—a single paragraph; this is the purpose of As mentioned at the end of the previous section, we initially present an analysis of selected papers connected to various types of sensors used in different solutions connected to condition monitoring in railway transport The list of review papers’ specific keywords starts with “acceleration sensors” and “accelerometers”. These keywords were ascribed by the authors in both singular and plural form. In Liu et al. , two meaAcceleration sensors were also applied by Känsälä et al. he biggest challenge for condition monitoring is ensuring selection of the right technologies”, Brant and Liang .


Johannes Schmiedt  Fig.  was borndisputatio exercitii gratia), moving shortly thereafter to the Dutch Republic to continue his medical training in Leiden under the guidance of Johannes Walaeus and Otto van Huern.In his early years, Schmiedt received private tuition in Latin, German and Polish from tutors. Next, the father who had his son destined for the ministry enrolled him in the Atheneum Gedanense (an academic gymnasium), where he focused on Lutheran Theology, Greek and oriental languages. In 1642, according to his parents’ wishes, Schmiedt got a place at the University of Königsberg to study theology. However, within a few months, he changed his academic focus to medicine because it had attracted him the most. In January 1646, benefiting from a vibrant intellectual atmosphere at the Medical Faculty, he held a so-called practice disputation . Together with Johann Ernst Scheffler, he began compiling the Danzig municipal pharmacopoeia at the behest of the Council. Just a year later, its outline appeared in print [After his eight-year in print . All theSchmiedt married twice, and with his second wife, he had five children. In 1686, his only son, who was to carry on the family medical tradition, died prematurely in Helmstedt and was buried there. Having lost a male descendant, sadly the doctor broke down, his health deteriorated, and he passed away on March 3rd, 1690.Undoubtedly, Schmiedt was a prolific and capable physician with a long-established reputation. He published numerous scientific papers, documenting his daily medical practice and the experiments he carried out at local hospitals. He and his cordial friend an astronomer Johannes Hevelius sent these original case study reports to the “Philosophical Transactions of the Royal Society” and “Miscellanea Curiosa” of the Academy of the Curious as to Nature (currently the Leopoldina), whereas the “Journal des Sçavans”, the earliest academic journal in Europe, published French translations of Schmiedt’s case studies that had originally been printed in English.In the 1670 s, Schmiedt described a few cases of hypoesthesia and dysphagia in patients with nervous and mental disorders. Moreover, as a medical examiner, he always interpreted odd human behaviours as exhibitions of organic diseases like epilepsy, ‘melancholy’ and ‘hysteria’ rather than as a display of demonic possession , 5. He aplica polonica, the previously reported neurologic manifestations of the disease receded and did not recur [Schmiedt also pioneered intravenous (IV) injections and infusions in the treatment of epileptic patients and patients with neurosyphilis. In December 1665, he carried out his first experiment on a soldier with tertiary syphilis and a woman suffering from ‘falling sickness,’ after being admitted to a local hospital. In 1666, he described the successful IV therapy of two women who developed epilepsy in early childhood. In January 1668, in turn, he applied IV injections in the therapy of patients with post-stroke seizures and Polish plait. Consequently, the ‘apoplectic’ patient had no relapses of convulsive episodes. Also, in a patient suffering from ot recur . SchmiedFrom the standpoint of neurology, the crowning achievement of Schmiedt’s medical career was the IV administration of antiepileptic drugs. In a letter sent in November 1669 from Danzig to London, Hevelius wrote to Henry Oldenburg, the secretary of the Royal Society: ‘I have no doubt but that it will be a great boon to the whole human race if this therapy is adopted pretty commonly in different regions of the globe’ . And ind


Cervical cancer screening (CCS) and human papillomavirus vaccination (HPVV) are effective measures against cervical cancer (CC). Attendance in HPVV and CCS provides the greatest protection, while combined non-attendance in HPVV and CCS provides little to no protection. It is hence concerning that some large ethnic minority groups show considerably lower HPVV and CCS attendance than other women–especially women from Middle-Eastern and North African (MENA) countries and Pakistan. Little is, however, known about the reasons for this low combined attendance pattern n.To explore perceptions of and barriers to HPVV and CCS, among MENA and Pakistani women in Denmark.Focus group interviews were conducted. Data was transcribed verbatim, and analysed using systematic text condensation.Seventeen long-term resident women originating from six major MENA countries and Pakistan were included. Mean age was 36 years. We found that these women, across different age groups and descent, had sparse knowledge and understanding about CC, and their perceived relevance of disease prevention was low. Compared to HPVV, their barriers to CCS were more fixed and often linked to socio-cultural factors such as taboos related to female genitals and sexuality. Moreover, they presented unmet expectations and signs of mistrust in the healthcare system. However, at the end of the interviews, participants became more attentive toward CC prevention, particularly toward HPVV.Elements of insufficient knowledge and understanding of CC and its prevention were found among a group of MENA and Pakistani women. Their socio-cultural background further represents a barrier particularly towards CCS. Additionally, negative experiences and unmet expectations lessen their trust in the healthcare system. All of which underlines the need for new tailored CC preventive strategies for this group. Based on our findings we suggest that future studies develop and evaluate interventions aiming to improve HPVV and CCS, including user-involvement. Cervical cancer screening (CCS) has considerably reduced cervical cancer (CC) incidence and mortality , 2. New Two universal and free-of charge services aimed at preventing HPV induced CC are on offer to residents of Denmark: a gender-neutral childhood HPV vaccination (HPVV) programme targeting all children aged 12–18 , and a CTo be best protected against CC, both HPVV and CCS are required. It is therefore concerning that HPVV and CCS attendance are substantially lower among some larger sub-populations, such as those with lower socio-economic status (SES) and ethnic minority background, particularly those from Middle Eastern and North African (MENA) countries or Pakistan –11.Currently Denmark consists of 800,000 individuals with ethnic minority background, corresponding to 14% of the total Danish population; by 2060 this proportion is predicted to reach 21%. The largest and fastest growing minority group have migrated from non-Western countries, such as MENA and Pakistan, where the present number of immigrants (persons born outside Denmark) is 357,466 and descendants (persons born in Denmark with two immigrant parents) is 165,174 .Ethnic minorities may face specific barriers, contributing to their relatively low degrees of HPVV and CCS attendance. European based qualitative studies, including one Danish study, investigating ethnic minority women’s barriers to CC prevention, have suggested that apart from practical, cognitive and lingual barriers, women from non-western countries may also face emotional or socio-cultural barriers to CCS and/or HPVV influencing their attendance –17. ThesHowever, only few qualitative studies have investigating the interplay between HPVV- and CCS-specific perceptions and barriers among ethnic minority women in a post HPVV era , 17–19, The aim of this study was thus to explore perceptions of and potential barriers to HPVV and CCS among a group of ethnic minority women from MENA countries and Pakistan in Denmark.To address our aim, we applied a qualitative approach in accordance with the COREQ guidelines , that inThe inclusion strategy was to include ethnic minority women from countries known to have the highest degree of combined HPVV and CCS non-attendance in Denmark, which in this case was MENA countries and Pakistan . FurtherInclusion criteria were thus women aged 23–65, with fluent Danish language skills and an ethnic minority background. Participants were either immigrants (born abroad) or descendants (born in Denmark), with parents originating from MENA and Pakistan, previously found to have the highest degree of combined non-attendance .quality of the data provided by the participants. In studies with relative narrow aims, high quality communication between participants and interviewer, furthermore in studies which include participants with high level of knowledge and experience regarding the topic in question, relative few participants can be sufficient to secure high information power.The sample size was in accordance with Malterud´s concept of Information Power , a methoEligible participants were recruited through snowball sampling  in DenmaThe recruitment process involved assistance from key community informants, and prior local collaborators, such as “neighbourhood mothers” . As well as bilingual healthcare professionals in the field of gynaecology. Furthermore, we posted advertisements to attend the project in country-specific Facebook groups (e.g. “Moroccans in Denmark”).Potential participants were approached by Sara Badre-Esfahani (SBE) face-to-face or via telephone, and introduced to the aim of the study, and the framework of FGI´s. Once verbal agreement to participate had been given, all the participants received a short-written presentation of the study prior to participation.Four Danish spoken FGI´s were conducted by SBE and supervised by Lene Seibæk (LS) between August and December 2019. A semi-structured interview guide was developed based on a priori knowledge on the field and used to guide the interviews .Before the interviews, each participant filled in a background questionnaire that included information on socio-economics, demographics, and HPVV and CCS status of themselves and children, if relevant, combined with a form of consent  Files.Participants were then introduced to the FGI setting, and encouraged to share all aspects of their thoughts and perceptions, and to discuss their opinions and disagreements with each other. Initially, to frame and focus the FGI´s, the participants were presented with simple diagrams, based on previous results , illustrThen they were asked to share their knowledge and understandings of CC and its prevention. Approximately halfway through each interview, a second time-out was introduced, where the participants were given a short presentation, based on simple on set hand drawings, illustrating the natural history of HPV-derived CC and the biomedical logics of HPVV and CCS. The purpose of this time-out was to build a “common ground” of knowledge concerning HPV and CC for further discussions.The FGI´s were audio recoded with permission from all participants, on one condition that only the first and last author had access to the data. After each FGI these audio recordings were transcribed verbatim by SBE. All transcripts were then read systematically by SBE and LS, while listening to the audio recordings, to check the quality of the transcripts and gain an “overall impression of the data”.The data were then analysed according the Malterud’s systematic text condensation (STC)  which isgenerating an overall impression of the data and defining preliminary findings,de-contextualizing the transcript into small elements called; meaning units, and coding these in groupsre-contextualization these elements to a multi-vocal first-person narrative and, finally,developing an analytic text and reaching a novel understanding of the research topic.The initial steps of the STC analyses were conducted after the first two interviews, by SBE and LS, and the attention of the final two interviews was focused according to these preliminary findings. After the last interview, in-depth STC analyses were performed for all transcripts and findings discussed thoroughly by SBE, LS and co-author Camilla Rahr Tatari (CRT). As CRT had not participated in the FGI´s, nor had access to the raw data; her involvement at this point ensured transparency of the analysis process and validation of the findings. Finally, these findings were critically discussed among the entire author group.Due to the sensitive nature of the topic, and the risk of revealing the identities of the participants, we fully anonymized the identities of the participants using solely identification numbers (P1-P17).Because the FGI´s were expected to alter the participants’ perceptions of CC prevention, potentially creating new awareness and perhaps worries, the participants were offered a debriefing by telephone at the end of the study period by SBE. At these phone conversations SBE initiated by personally thanking the participants for their contributions, subsequently SBE asked each participant whether any questions, concerns or worries had a raised during or after the FGI, they need to discuss with SBE.All participants filled out a written informed consent stating that the participants had received both verbal and written information about the study, and that background information and participant statements may be presented anonymously; it also specified that participants at any time had the right to withdraw their consent  Files.The study protocol was reported according to the EU’s General Data Protection Regulation (article 30), and listed in the record of processing activities for research projects in Central Denmark Region (J. No.: 1-16-02-400-16). The Regional Committee for Medical and Health Research Ethics were also contacted in line with local legislation  and founFour FGI were conducted, participants representing six different MENA countries and Pakistan were included. Each FGI consisted of three to six participants, at locations near the participants’ homes or workplaces. The mean interview length was 83 minutes .Six out of seven participants with a child eligible for HPVV had agreed to vaccinate their children. Three out of fifteen participants had been eligible for HPVV themselves and all of these had initiated HPVV. Twelve had been eligible for CCS, of these eight had participated in minimum one CCS, four had not.The atmosphere of the FGI´s were dynamic, positive and respectful. The participants came across as curious, focused and active. During the FGI´s they were able to present own perceptions and barriers openly, while discussing, absorbing and respecting each other’s various perceptions and barriers.These characteristics gave rise to many rich and nuanced discussions. For example, one participant told about her prior negative experiences with breast cancer screening, while two other participants contributed by sharing their own positive experiences and addressing issues such as false positive and negative screening results.One participant´s perceptions were fundamentally different from the others, as she presented high level of knowledge, no barriers or mistrust. While one participant remained passive and contributed substantially less than the other sixteen. However, in most cases, participants across all nationalities and age groups shared similar views, resulting in relatively few yet strong perceptions.The perceptions and barriers initially presented were; insufficient knowledge regarding CC, lack of nuanced understating of HPVV/CCS, and low perceived risk and relevance of cancer prevention especially CCS. Besides socio-cultural barriers related to issue of the female genitals. However, towards the end of the interviews, as their knowledge and perceived relevance of HPVV and CCS improved, most participants expressed a more positive attitude towards cancer prevention especially HPVV. Furthermore, advocating a need for more targeted information and CC preventive efforts in their communities. Some even suggested implementing compulsory attendance to secure better compliance.Following themes emerged from the STC analysis of the data: (1) ’Perceptions of health and disease; (2) ’Perceptions of CC prevention’ (subdivided into two sub-themes (2.A) ’Perception of HPVV’ and (2.B) ’Perceptions of CCS) and (3) ’Perceptions of the Danish healthcare system’, the latter having a more subsidiary character–as it was not a direct aim of the study—than the preceding two themes. An overview of themes, sub-themes and findings are illustrated in Insufficient knowledge regarding HPV-induced CC consisted of a lack of awareness concerning aetiology, transmission pathways of HPV, and thus perceived risk factors. Many were convinced that CC was an inherited disease; some believed that cancer aetiology was unknown and that it developed without previous signs/symptoms.If you have someone in the family [with cervical cancer], you have a higher tendency to have it.-Cancer never shows a sign. It just comes suddenly… just suddenly someone can die.When presented to the causal link between HPV infection and cervical cancer, participants focused strongly on the contribution of men in transmitting HPV.So (HPV) virus, I get it from my husband, or?-The thing about cell changes—if I was with my husband—and I am 100% sure he’s been a virgin. So, haven’t I got that cell change?If he’s been a virgin.-After all, they (the men) have it (HPV)… [laughs] … why should we have it (the vaccine)?Consequently, most of them felt that they were not susceptible, if they had no family history of CC and were in monogamous and faithful relationships. This low perceived risk resulted in a low relevance of CC prevention.There are some people who will think "I have only one partner ", so I don’t get it (HPV infection).Furthermore, most friends and relatives they knew with cancer had died from it, making them question the prospects of preventing cancer.Those who come from where we come from, most of them, they go (to the doctor) when it’s already too late.-Because everyone who gets the disease. They are DEAD.Some questioned the very relevance of disease prevention when not sick.If you are not sick, why should you check it out?Irrelevance of prevention)-It (cancer) is not something that has really sparked my interest. Now, we had an aunt who passed away two years away from cancer, so we started to get a bit more information on it.Even at the end of the FGI´s when the participants’ awareness of CC prevention was improved, one woman stated not wishing to attend CC prevention, as the negative  consequences of knowing were considered to weigh higher than the positive consequences of early cancer detection.If I, personally, had cancer then I would not want to know. Because you go down a lot more mentally when you know it. So better to live the days you have.turning the blind eye to cancer (prevention)).All we know are the usual vaccinations, the rest we don’t know.Others had associated HPVV with the massive negative media attention regarding the safety of HPV vaccines; which had caused a national crisis in HPVV attendance in Denmark few years earlier and resulted in them being afraid or in doubt whether to (continue to) vaccinate their children against HPV.What happened in the media made me, at least afraid to send my daughter off (to HPVV)For these mothers it seemed that the decision to disrupt or continue HPVV was influenced by whether or not they had received a clear recommendation from their GP. Those who had received a clear and reassuring recommendation from their GP were able to cope with the insecurity of the media storm, and did not disrupt HPVV for their daughters. However, those who didn’t receive adequate recommendations from their GP disrupted HPVV–not only for their daughters who were eligible at the time–but also for their younger children.Another concern was that vaccinating young girls against a sexually transmitted infection could endorse promiscuous behaviour and provoke a backlash among key individuals in the society . One particular young mother expressed that she prior to the interview would not have vaccinated her daughter but that she would reconsider doing so now, after becoming aware of the vaccine benefits, while admitting that she probably would continue concealing the purpose of the vaccine in order to hinder premarital sex and multiple partners.I could never ever have dreamt of getting my daughter vaccinated for this (HPV) before I came here today… I don’t want her to be with anyone until she gets married. So I didn’t see it as an opportunity for her to be vaccinated at [the age of] 12. (…) But now I actually think it will be good (….) But I will not tell her why she is getting it.Simultaneously, most participants were surprised over the fact that several of their fellow countrymen had declined HPVV for their daughters, comparing HPVV to other childhood vaccinations .It is strange that one doesn’t get the vaccine, because it is just a vaccine in the end. You get lots of vaccines.Finally, at the end of the FGI´s, many expressed a need for more tailored efforts to improve knowledge and HPVV attendance among their countrymen, advocating for community or school-based HPVV and/or education of children and parents. Furthermore, even advocating for mandatory HPVV.Can’t you make it (the vaccination) compulsory?You can say it’s just like the other vaccines you get as a child.In line with this, when considering the pros and cons of HPVV and CCS, many stated that they would choose HPVV over CCS, if they were given a choice.So, if I were faced with the two choices, without really knowing what it meant, then I would take a vaccine.At the start of the interviews, most of the participants stated that they didn’t understand the logic behind CCS, thinking that due to this fact many were “lazy” or had other more important things to take care of than CCS.I think that because they are lazy… many people are actually too busy to go for such tests, and especially when it is that they actually do not REALLY know what it is aboutAs a result of this lack of understanding, most stated that they at one point in life had thrown away at least one CCS invitation.When I was 23 the first time (I received) the invitation (CCS). But I threw it in the trash. All the time… [giggles].-Some participants born abroad stated this lack of understanding was because prevention was not available in their home country, where most people used to seek medical attention only when feeling ill.And you are not used to it… going for such tests … for example, screening. So, in our home country… if you are not really SICK. So, it’s not like you’re getting a service.Some actually found it a bit amusing that some people would seek medical attention if they did not feel ill.Many perceived CCS to be painful and embarrassing, and felt that this was the main reason for their non-attendance.That I should have the doctor take such a test (CCS), for me it is just … embarrassing. Even if it is about my health. And I also think that’s why I haven’t taken it very seriously.While other participants expressed, despite the fear of pain, that CCS had turned out to be a “quick” and painless examination.Across nationalities and age groups, issues linked to female sexuality and genitals were commonly considered to be very private matters or even taboo subjects for discussion.To be completely honest, I think some of these issues are a little taboo in our culture. So I don’t think you really talk about it openly, to others.-If there was a Pakistani woman who had it , then one will not talk so openly about it, in front of others.… I just think it’s because it’s a WOMEN’S AREA.Therefore, issues regarding CCS seemed to challenge the participants on a deeper level than those regarding HPVV. As one woman stated “HPVV is just a jab”. Another example illustrating the potential deeply challenging result of attending CCS, two women discussed that having been screened and found to have precursor lesions and thus a sexual transmitted disease (HPV), could lead to serious consequences in marital relationships, as one could be accused of infidelity. Some had heard of marriages being broken as a result of such infidelity accusations,So, if I find out I have it (HPV) then my husband has a problem… (laughs). Don’t get me wrong… it’s because I haven’t had (other partners).Response:But he (your husband) may also think that you have had something or other (partners), so conflict can quickly arise. Exactly. So, there is a lot of culture in it.There are sometimes stories about, that is, a woman who got this disease. Then you hear that she is leaving her husband. And often, it is sometimes the case that it’s in this way that it gets discovered that someone has been unfaithful.Despite the fact that many of the women expressed that men in their societies were often more sexually liberated, they were certain that the woman would automatically be labelled as the “sinner” in these cases. Putting women at risk of being outcasted.Furthermore, the fact that CCS requires a pelvic examination seemed to be an obstacle in itself, not only because it was perceived as exposing and embarrassing, but also, because it was perceived as jeopardizing virginity and thus not acceptable prior to marriage.Such things , you don’t do it until you are (married)(….) So before I got married … yeah, at that time I was afraid of losing my virginity.For some of the participants, an examination by a male practitioner was considered to be particularly awkward, while for others the gender of the practitioner was irrelevant.Exclusively among the Somali participants, pelvic examination was considered challenging, due to mental and physical sequels after female genital mutilations (FGM).I come from Somalia; you were circumcised. I mean, I know it is good to go to the doctor and get some tests. But the thoughts you have about down there,… I mean, to be touched down there, I don’t want to.At the end of the FGI´s participants did gradually become more positive towards CCS and some unscreened participants even considered attending CCS in the future. Furthermore, when reflecting on their own development during the interviews, many participants were astonished over their own misperceptions prior to the interview. While others continued to have difficulties distinguishing between cancer prevention and cancer treatment.Consequently, many women expressed a need for more targeted CCS information  and CCS “nudging” . However, while many stated that, through these educational and nudging efforts, more women would probably attend CCS, they all agreed that CCS would remain challenging for many women like themselves, and that it would not be possible to overcome all presented barriers to CCS. Making broad improvement of CCS attendance among ethnic minority women a complex and difficult task.Mistrust in the Danish healthcare system revealed itself through the participants’ interpretations of healthcare professionals’ (HP) intentions, prioritization and medical skills, as well as frustrations with HP´s manners of communication.First of all, most of the participants perceived themselves as low frequent users of health care services, and they were therefore especially frustrated when addressing their GP and feeling rejected by the system. This frustration was based on experiences of GPs refusing to treat them in accordance with their expectations, or denying them a referral to a more specialized service.People they say we are never referred anywhere. And we get no treatment… Then there are many who do not want to go to the doctor.While some participants perceived this rejection as systemic issue , others perceived that it was because they were immigrants, living in deprived areas or because they had many children. In other word an issue of discrimination.Some stated that they felt Danish doctors avoided or rejected taking responsibility as they involved the patient in too difficult medical dissensions, making the participants feel insecure.The doctor says “It is such and such, but it is YOU who has to make the decision!" It was BIG. Because I don’t know anything about it (HPVV)… it’s a burden to get it back (the responsibility), sometimes people think "No, now I don’t want to take on that big responsibility"Another factor that made them insecure was when Danish doctors expressed lack of immediate knowledge of the topic of the consultation or sought information on the computer during the consultations. Such behaviour was interpreted by the participants as medical insecurity.Yes, I actually called my doctor to ask her. Because my daughter had just had one (HPVV), and then all that came in the media. So, I contacted my doctor and asked her… “What happens now?” Now I’m very worried. And funnily enough, the doctor was herself unaware of whether it was true or not (the possibility of HPVV resulting in adverse side effects) …And of course it made me even MORE uncertain.Many of the participants also agreed that doctors in Denmark frequently gave “non-medical” recommendations, such as ’drink water’, ’do some sport’, ‘just rest’ or ´wait and see’. These recommendations, seemed inadequate in relation to their expectations and experiences from doctors in their home countries. Therefore, many felt that going to the doctor in Denmark with non-acute issues was a waste of time.I only go to the doctor if I am really sick. Maybe also because I have experienced going to the doctor, I am told that I need to relax and take Panodil (over the counter painkiller—Paracetamol). Do you understand?So, I feel like maybe I’m wasting my time.Some had negative experiences from relatives being admitted to Danish hospitals, where they had felt under-prioritized or even abandoned by the hospital staff. As they didn’t feel their relatives were given sufficient attention, treatment and care.Also, the time when she (my aunt) passed away … we (the family) stood there ourselves with her and she passed away in front of us… and it was one and a half or two hours later that a doctor or nurse came to the room …. My uncle he simply had to go around the various corridors to find a nurse. So, for us, it seemed like it (my aunt´ situation) was unimportant. And they had given up on her.These experiences influenced their trust in the healthcare system to such an extent that they felt reluctant to approach their doctor unless it was absolutely necessary, and resulted in many of the participants seeking second opinion abroad (e.g. either in their home countries and other western countries like Germany and USA).She (my doctor in DK) says that I should not take the tablets prescribed in Turkey. But I go to a professor in Turkey who was trained in the US who is really good. But I shouldn’t take those tablets, she says… But she doesn’t treat me (my doctor in DK).We aimed to explore individual perceptions of and potential barriers to HPVV and CCS among a group of women from MENA countries and Pakistan in Denmark. Initially, we found an overall insufficient knowledge of HPV-induced cervical cancer, and unfamiliarity with CC prevention. When discussing the two preventive measures against cervical cancer, we found that the barriers to HPVV and CCS, respectively, were distinctly different—those related to CCS more often related to socio-cultural barriers. Finally, we observed a general mistrust of the Danish healthcare system that could contribute to hesitancy in attending public health services, such as HPVV and CCS. However, at the end of the interview participants developed a more positive attitude towards CC prevention—especially towards HPVV. Resulting in participants stating that by introducing tailored efforts they believe that many of the presented barriers could be altered. Nonetheless, also stating that not all barriers are adaptable—especially if related to socio-cultural perceptions of female genitals and sexuality.A qualitative approach making use of FGI constituted a rich, rigorous empirical material, where the generated data proved sufficient to achieve the required information power . FurtherAs we were particularly interested in gaining insight into as many perceptions and barriers as possible, we chose FGI in which we strove to endorse and promote group discussions, in order to elicit as many perspectives as possible and study interactions , 22. To We ended up mostly recruiting women who had lived in Denmark for many years, and thus had become accustomed to Danish health care system and traditions, while also possessing knowledge of their cultural background. Therefore, our findings may not cover the presumably greater challenges faced by less acclimatized women . We recruited participants through “snowball” sampling , using tOur semi structural interview guide included two time-outs. The argument for including these was to frame the FGI´s and to build a common fundament of knowledge, regarding CC and its prevention, for further discussions. These presentations did expectedly alter the participant’s attitude toward HPVV and CCS. However, they did not modulate all barriers especially not those related to CCS, which indicated that improved knowledge and awareness may have less influence on their CCS behaviour compared to socio-cultural barriers. We were further mindful, in our verbal and non-verbal communication, of the fact that these presentations could introduce a power asymmetry  between We were furthermore attentive of our own reflexivity  as cliniAll interviews were conducted, transcribed, and analysed in Danish. Participating in a Danish spoken interview could have made the presentation of complex perceptions and emotional topics difficult for some participants. As a result, the empirical data may lack some nuances, as these could be difficult to express in one’s second language . Furthermore, transcribing audio data from bilingual participants may have caused some misinterpretations potentially affecting the analysis. However, including a translator would have introduced other potential challenges which we avoided in the present study. Our findings represent perceptions of women originating from six MENA countries and Pakistan living in Denmark, who have been exposed to the opportunities and traditions of the Danish society, and the results may not reflect immigrants from other regions of the world living in other settings different from the Danish.The participants sample was contained relatively high proportion of Somali participants, while lacking contribution from some other MENA backgrounds . This could have amplified the challenges faced by Somali women and challenges faced by Iranian, Kurdish, Syrian women could be missing. However, as only the issue of FGM related solely to participants of Somali origin, we do not believe that this had any important implication for the study results.Many of the presented findings in our study (e.g. insufficient knowledge of CC beside unfamiliarity with and lack of understanding of CC prevention), has also been observed in several other studies conducted among immigrants in different western countries  , 26–29. In our study we further observed HPVV-specific barriers such as; fear of possible adverse vaccine side-effects and fear of promiscuity among daughters after HPVV. Fear of HPVV side-effects was also previously observed among native and immigrant women from different regions of origin , 30, 31.Furthermore, we found that the CCS-specific barriers were more often related to cultural, traditional or religious norms, than HPVV. It was a general perception among our participants, that women’s sexuality, genital organs, and issues related to these were taboo subjects in their communities. A finding also presented in a qualitative study among native Lebanese women , a studyOur findings further suggest that MENA and Pakistani women may perceive attending CCS and having precursor lesions as a challenge, because it could cause shame or accusations of infidelity. Shame in relation to having precursor lesions was also observed in a UK study among both immigrant and UK women . InfidelLastly similar to our study, a US study among Somali immigrants, found negative emotions and physical discomfort related to traditional FGM. An issue faced by the majority of Somali women . All of However, some of the barriers found in this study may have a more universal character, also affecting western women (both native and immigrants); for example, the observed insufficient knowledge regarding HPV-induced cervical cancer. This has also been reported in studies among native Danish and UK women , 42. AnoWhat might be the reason for the significant lower HPVV and CCS attendance among women with MENA background compared to other women?If many of the findings among our participants are also seen among native women and immigrant women from western and other non-western, then a question arises: We find it likely that, besides the aforementioned factors, a combination of cultural-specific health and illness perceptions among MENA and Pakistani women , unfamilBased on the above, we believe that we have presented findings of a high level of internal validity. Furthermore, we evaluate that our findings are transferable to MENA and Pakistani women in other parts of Denmark, as well as in other countries that have similar sub-populations, and healthcare system/traditions as Denmark. While some of our findings may in addition be transferable to native and immigrant women from other countries, such as insufficient knowledge, pelvic examinations being humiliating and painful.educational or nudging strategies such as school-based HPVV, to help individuals overcome their barriers. Most participants agreed that they would choose HPVV over CCS if they were given a choice, and believed that others would do the same. However only a few studies have investigated the interplay between HPVV and CCS perceptions and barriers among non-Western immigrants [At the end of the interviews most participants expressed a need for new strategies to improve CC prevention in their community, and suggested implementing various migrants , 17, 19,An international systematic review among different populations, comparing environmental, information and behavioural interventions to increase HPVV, found that educational interventions improved HPVV uptake during the active period, but were not sustainable when used alone . They fuThis was highlighted by a recent Danish study examining the effect of reminder letter in the national vaccination program , where tIn light of our findings and previous findings, we suggest that implementing tailored strategies to improve HPVV in addition to existing CCS, represents a potent strategy. Besides HPVV seemingly being more acceptable among ethnic minority women/mothers, the currently available nine-valent HPV vaccines protect against 90% of all cervical cancers, as well as HPVV being offered in new gender-neutral programs. All of which could contribute to more equity, larger herd effect and better overall public protection against HPV-induced diseases.We found elements of insufficient knowledge and understanding of HPV, and unfamiliarity with CC prevention among a group of long-time resident MENA and Pakistani women in Denmark. Furthermore, we found that socio-cultural barriers, particularly towards CCS, presented a strong hindering for attendance. Additionally, negative experiences and unmet expectations lessen participants trust in the Danish healthcare system. All of which negatively affected their attendance and underlines the need for new tailored CC preventive strategies for this group. Based on our finding we suggest that future studies develop and evaluate complex interventions aiming to improve HPVV and CCS, including strong user-involvement.S1 Fig(PDF)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(PDF)Click here for additional data file.S4 File(PDF)Click here for additional data file.