Older adults’ out-of-home behaviors (OOHBs) are critical for maintaining health and quality of life. Taking Singapore’s Yuhua East as a case, this study applied a qualitative approach to explore what neighborhood environmental factors influence older adults’ OOHBs. Twelve older adults were recruited for walk-along interviews through the use of purposeful convenience sampling. A content analysis was conducted using NVivo 11 via an inductive approach. Research results revealed 12 categories of environmental factors that affected older adults’ OOHBs: access to facilities , pedestrian infrastructure , aesthetics , traffic safety (behavior of other road users and road width), safety from crime, wayfinding, familiarity (long-term residency and routine activities), weather, social contact, high-rise, high-density , affordability , and maintenance and upgrading. This analysis concluded that access to facilities and pedestrian infrastructure are important for older adults’ OOHBs. Considering Singapore’s weather, sheltered walkways, the proximity of facilities and connectivity should be given serious emphasis. In addition to physical factors, social contacts and the affordability of shops and services are also important. Out-of-home behaviors (OOHBs) have been demonstrated to be important for older adults’ health and quality of life. OOHBs refer to engagement in activities out-of-home as well as the full range of behaviors of moving from one location to another ,2. ThougA neighborhood environment is both physical and social . There hMeanwhile, there have been a small number of studies using qualitative approaches to explore the impacts of the environment on older adults’ OOHBs, especially using spatial qualitative methods. One review article looked into qualitative studies investigating physical environment and physical activities, and it identified 10 articles, three studies using photovoice, three using walk-along interviews ,9,10, anThe Yuhua East neighborhood is located in the town of Jurong East, in the west region of Singapore . It is aThe major advantage of conducting walk-along interviews is that it allows researchers to observe participants’ spatial behaviors, access and interpret their perceptions and experiences about the surrounding environment when the researchers walk together with the participants, ask questions, and listen along the way ,19. In sTo gather more information and empower the participants as much as possible, this study took a more unstructured approach. The participants were recruited at amenities and open spaces within the boundary of Yuhua East. After explaining the research purposes and procedures to the participants, the researcher walked together with the participant and asked questions along the way from a neighborhood destination to the common corridor of the participant’s home, or the other way around. The walk would stop or begin, normally at void decks (vacant spaces on the ground floor of HDB flats) if the participant felt uncomfortable. In this case, information about the missing parts of the route would be collected without walking-along. This study allowed the participants to talk as freely as they liked even though the conversation went beyond the study purpose. This also allowed the participants to conduct various activities along the route or stop for a chat. As a result, the duration of the interview ranged from 9 min to more than 2 h.® (TOEFL®) test score of 106. Though older adults are generally defined as those above 65 years and over, this study included those aged 55–64 because that Singapore is ageing rapidly and their opinions are valuable for future developments. The percentage of participants aged 55–64 was expected to be less than 20%. Selected samples were also expected to cover similar numbers of male and female, including Chinese, Malay, Indian, and other. To be recruited, participants needed to be able to speak either English or Mandarin Chinese, living in Yuhua East, or living in the nearby neighborhood but walking to the facilities in Yuhua East on a daily or weekly basis. Interviews were recorded and transcribed for analysis if the participant agreed. Otherwise, the researcher jotted down key phrases and facts on the spot and expanded them into full sets of field notes as soon as possible after the interview. During the walk, the researcher also took photographs of the things mentioned. The routes were hand drawn on printed maps, compiled, and digitalized later. The starting/ending points on the digital map were adjusted to the surroundings to protect the participants’ information. The study protocol was approved by the IRB of the university (S-18-155E). Walk-along interviews were carried out from August to September 2018 by one researcher using purposeful convenience sampling. The researcher’s mother language is Mandarin Chinese, with Test of English as a Foreign Languagen = 4) and Mandarin (n = 8). Field notes and transcribed interviews were in their original language, and the translation was done by the same researcher who conducted the interviews. The translation took place during the analysis to ensure the authenticity of the findings [Data from the transcribed interviews, field notes and photographs were added to the NVivo software. The walk-along interviews were conducted by the researcher in English , between 55 and 80 years old, including 10 Chinese, one Indian and one other . The resA qualitative data analysis revealed 12 categories of environmental factors that affected the older adults’ OOHBs : access n = 12) mentioned that shops and services along the way encourage them to go out, including a hawker center , a market, coffee shops, supermarkets, exercise corners, parks, kindergartens, playgrounds, schools, a community club and a social service center. They also mentioned shops and services not seen along the way that entice them to go out, such as hawker centers in other neighborhoods and Jurong West (another town next to Jurong East), a Chinese Garden, polyclinics, National Trades Union Congress (NTUC) LearningHub (for skills development), Jurong Regional Library and shopping malls located in the town center. All the participants  mentioned access to public transit. For those who are still working or occupied by various interests, living near to the Mass Rapid Transport (MRT) stations and bus stops are important for their OOHBs. When asked about her feelings about her neighborhood, a participant stated: “This area is very good actually. You can go everywhere, it is easy. If you want to go to Jurong East MRT, very convenient, you can walk or take buses. I have stayed here for 18 years.” Another participant specifically pointed at the MRT station and said: “We are so close to the MRT. You see that there is an MRT station over there… Chinese Garden MRT. It is blocked by these trees and it is only an eight minute walk. Do you see the roof? That is Chinese Garden Station (Many participants ( Station .”n = 3) mentioned a variety of pedestrian routes and multiple connections that permit flexible paths. A participant in her 70s mentioned that the increased connectivity gives her the opportunity to choose a path suitable for her physical capacity and the weather conditions:“I want to take a short cut from here. Actually, you do not have to cut through here. You can walk on the main road and take the stairs down, then you go straight. But I want to avoid the stairs, so I go by this way. If it is raining, I do not walk here. I walk over there. It is a covered walkway all the way back. If you do not carry an umbrella, it is still okay.” A few participants ; it is good. It is covered from the rain. If not, you must walk over there. You see? .” n = 10) were generally satisfied with the sidewalks because they are smooth, very easy to walk on, clean, and maintained regularly. Nobody complained about the continuity of sidewalks. One female participant said that the upgrading carried out by HDB did a good job in changing the sidewalk material from cement to tiles. She complained that one particular material turned dirty very easily. There were also participants who mentioned that the sidewalks tended to be slippery after rain and maintenance work (the flushing of the floor). The floor should be replaced by coarse materials. Many participants (n = 8) mentioned sheltered walkways and considered them to be one of the most important features that make walking pleasant. When asked about the general feelings about a route segment, one participant said: “This route? Very good. People will not get wet if it rains.” Another participant was very satisfied with the extent of the coverage of the sheltered walkways and said: “We have covered walkways all the way to my place. Whether it rains or shines, I will be protected.” Some participants (n = 8) discussed universal design during the interviews. Though some mentioned that stairs with only one step are dangerous and inconvenient, ambulant participants usually do not mind a few steps. Even for the participants with reduced mobility and using walking aids, rails can enhance their out-of-home mobilities. For longer stairs, the participants prefer ramps or elevators if possible. Though the neighborhood is wheelchair accessible, the provision of accessible routes does not take weather conditions and ease of travel into full consideration. A male participant, who has volunteering experiences of pushing wheelchairs, mentioned that the width of some ramps is too narrow, so they are very dangerous, especially at the turning point. The wheel may get stuck at the edge, and then both the wheelchair and the older adult on it may even roll over. A conversation during an interview with a participant and her friend also revealed the inconvenience of some accessible routes. The majority of the participants , you do half stairs, half ramp, then people can push the wheelchairs. Although they say there is a slope, that is not covered .”For overhead bridges, the participants’ opinions were influenced by physical capacities. Older adults with good physical capacities stated that they do not mind the absence of ramps. However, for participants with foot pain or ankle problems, ramps are necessary. For example, a participant said: “If there is the overhead bridge, I walk on the long ramp. I do not want to climb the stairs. My foot starts to hurt .” As then = 11) mentioned crossings. They felt that it is safe to cross the street if there are traffic lights. The presence of zebra crossings at school zones is considered very safe. As for waiting time, some participants do not think it is too long because they are not busy or in a hurry, while one participant complained about the waiting time and that sometimes people have to wait under the strong sun. For the green man time, the participants generally feel that it is enough. However, a participant in his 60s said that 35 s is necessary for an eight-lane road. He is satisfied with the green man time in Yuhua East, but feels that one crossing in Clementi (another town) has an inadequate green man time:“You see that traffic light (in Yuhua East) has extra seconds now. I visit the temple in Clementi every week. For that traffic light, they did not extend the time. You count how many lanes here, one, …, eight lanes. For pedestrians to cross, you need to have 35 seconds. There, I have seen a few times, older adults do not have enough time to cross. For us, it is okay. But for older adults, 30 seconds is not enough time to cross the eight-lane road.” The majority of the participants (n = 4) mentioned benches. A male participant who walks 10,000 steps every day stated that he did not perceive the need for providing seats along the way: “I seldom sit. I take a rest after I finish, not halfway.” A seating area not only serves as a resting spot but also as a place for social gatherings. A participant mentioned a seating area in the void deck and said that some blocks have only a few benches:A few participants (“They (HDB) do this. It is their small meeting garden. You can sit down and chit-chat. If you are tired, you can also rest. They (other residents) said several blocks do not have enough benches for them to sit. For example, when you wait for a taxi or other transports, there are not enough places to sit, so they have to stand .”n = 1) mentioned public toilets as a factor influencing OOHBs. They knew that public toilets can be found in shopping malls and coffee shops.Very few participants (n = 6) expressed that they enjoy greeneries during their walks. For example, one participant stopped at a park  mentioned buildings. One participant mentioned that the clean buildings and roads make her walking experiences pleasant, and another mentioned that it is a pity that a lot of old buildings had been torn down. Some participants (n = 3) talked about noise. One participant mentioned the noise from the construction sites, and another complained that the hawker center is sometimes very noisy. The participants expressed that they enjoy the quietness of the common corridors, which are shared by fewer flat units.A few participants (n = 4) expressed that the clean environment makes their out-of-home activities pleasant. The cleanliness is the result of regular maintenance. One female participant said: “The road is usually clean, sometimes there are litters before the washers do their work. A little bit of waste there but usually very clean. Everything I can feel, the buildings (and) roads are clean, so I feel comfortable.” Some participants (n = 4) expressed their concerns regarding traffic safety on the sidewalks and roads. As older adults may need extra green man time to cross the road, the participants mentioned that some drivers do take notice and slow down while others pay no attention. Regarding sidewalks, the participants expressed safety concerns related to the behavior of other road users, cyclists and those on personal mobility devices. A participant said: “Be careful. Sometimes, there are people who ride on scooters or bicycles. Need to be careful (and) walk on one side (Some participants (one side .” One man = 2) talked about road width. Local roads between blocks are perceived as safe. For wider roads, the participants wait at the traffic light to be safe. A few participants (n = 2) mentioned safety concerns related to crime. The neighborhood was perceived as very safe. For example, a participant who used to be a security guard shared: “It is very safe to walk in Singapore. I told everyone there is no need to be afraid at night. I myself walk back and forth every week in the night. Unless you are very unlucky (to) meet those drunk men, very rare. Coming back at midnight, it is still safe.” A few people (n = 5) shared with the researcher how they find their ways to get to a facility mentioned during the interview and how they get back. Road junctions and specially built environment features usually help, such as overhead bridges, bus stops, schools, hawker centers and shopping malls. The participants also mentioned that a place with a large population is usually the place they want to go. Some participants  were also stated to improve familiarity and encourage OOHBs. For majority of the participants, routine activities generally involved eating, shopping, and exercising, while some participants also work, attend courses, and attend group activities. A participant who walks back and forth to IMM at the town center perceived no obstacles along the way: “I get used to walking. I walk every day. Climbing up the stairs and climbing down are the same. It does not matter.” For the participant on a wheelchair accompanied by a foreign domestic worker, her out-of-home routine activities are carried out as follows: being pushed to the exercise corner across the street in the morning and doing exercises by herself, then being pushed to the market and walking into the store, buying goods and food by herself, being pushed back to the void deck and meeting friends, and then finally being pushed back home. Her familiarity with the neighborhood helps her find accessible routes, locate shops necessary for daily living, gain a certain level of independence, and maintain friendships. Routine activities conducted by the participants (n = 9) mentioned that hot weather or rain influences OOHBs, especially for recreational activities. The participants expressed that they avoid going out in the early afternoon and prefer to do just a little exercise if the weather is nice. For the participants who have jobs, join fixed-time activities, or need to buy necessities, they go out regardless of the weather conditions. In this case, sheltered walkways play an important role in encouraging older adults to go out. Sheltered walkways with slopes are necessary for wheelchair users’ OOHBs because the caregivers may not have free hands to hold the umbrellas for them . The weather was so hot and my skin sticky, very strong sun. That night, I took a shower and did a little bit of exercise. Then I felt my body was very hot, my eyes were foggy. I took my blood pressure and it was more than 180. It has never been this high before.”Singapore has a typical tropical climate with high and uniform temperatures and with high humidity all year round. Many participants (for them . Addition = 7) talked about their friends along the way, their friends drinking coffee in the hawker center, chit-chatting in the void deck, doing group exercises, and even their friends taking courses together. Maintaining social contacts is considered necessary for mental health, preventing depression and dementia. A participant shared a story about her son’s English teacher:“After retirement, she did not contact anyone, very self-centered. Within half a year, she had depression, feeling that there was nothing to do. She might have thought that she was useless. I think she probably thought like this. If she had come out and learnt something, she would not end up like this. The important thing is to contact people, then you will not get dementia so fast.”Social contacts are an important factor encouraging OOHBs in older adults. Four participants met their friends or neighbors during the interviews and said “Hi” or waved their hands to their friends. Some participants  2 and 3 (are) okay, so there is no problem.” Residents living in blocks undergoing upgrading may experience some inconveniences because only one lift may be operating to serve all the residents in that block, and the waiting time may be quite long. The participants stated that they do not perceive that there are too many people in the neighborhood, except in the hawker center, the market, and the public transit. One participant said: “On Saturday and Sunday, the hawker center is full. There is no place to sit. We need to wait until 9:00 a.m. or 10:00 a.m. to find a seat.” For older adults with good mobility, the high population in hawker center does not influence their visiting. However, it is a little inconvenient for older adults on wheelchairs to navigate. The foreign domestic worker of a participant said: “From Wednesday to Sunday, there (hawker center) are too many people. We are afraid to go in. Because she is on the wheelchair, it is not convenient. We go to the coffee shops nearby.” Another participant using a walking aid stated that she prefers to walk instead of taking the bus even though the walking distance is a little far. She explained: “Taking bus is not convenient. With this (a grocery trolley), you need to pull it onto the bus. Sometimes when there are too many people, I move very slowly.”n = 4) expressed satisfaction with their spacious flats. Only one participant mentioned that he wanted to go out to take a break from the walls at home. Some participants (n = 3) said that they prefer quiet common corridors shared by fewer units. The participants who mentioned common corridors  after we have finished eating our food. They  need to make money. If they (customers) go back to the office, you can sit for two-to-three hours, it does not matter then. It is free. In the hawker centers, you can find a meal for $2, three dishes, all vegetables. Meat is a little bit expensive .” The affordability of shops and services is considered a very important factor for older adults’ OOHBs. Public spaces that do not impose any charge for entry provide the older adults with a place to spend their time. For example, a participant said: “The library is where anyone can enter, you can read the newspapers or do other things.” Hawker centers and coffee shops with affordable food and drinks are ideal places for meeting up with friends or reading newspapers. People can stay for a whole afternoon or longer if the business is not too busy. A participant talked about his time spent in the hawker center and the need to save money:“… If our salary is below $2000 (per month), we can take courses and only pay 5% of the course fee. Like the computer course, which costs $500, we only pay about $20. Then, if you take two courses, they (the government) will give you $200. If you take four courses, they will give $400. I make money by taking courses.” The participants also mentioned the affordability of social services and courses. For example, a female participant who attends courses like qigong, yoga and Malay language said: “The price is affordable. We pay only $5 or $10 for 10 lessons. Qigong is free. Everyday exercise is free.” A 65-year-old participant shared her experiences in taking courses:n = 1) mentioned the affordability of public transport. One participant suggested that older adults, aged 65 years old and over, should enjoy free bus rides or pay only 50 cents per ride.Very few participants (n = 9) talked about maintenance and upgrading, probably because Yuhua East is currently under the Home Improvement Program and Neighborhood Upgrading Program. Upgrading programs have positively contributed to the older adults’ OOHBs by improving sidewalk quality, having lifts that stop at every floor, adding pedestrian crossings and sheltered walkways, and updating exercise facilities. Meanwhile, the regular maintenance of blocks and common areas carried out by the town council guarantees the cleanliness of the neighborhood environment and the smooth operation of lifts. The participants generally gave positive feedback on what has been done: “This is very easy to walk, after they finish that (upgrading);” “This route looks very good. Last time, we do not have this, but now they have already upgraded everything.” Meanwhile, their requirements for the neighborhood environment are restricted by government programs and public expenditures. Their general comments were: “It is already like this, how to change it. I think it is impossible. There is no room to change. There are too many things. It takes a lot of money (and) it is not easy.”The majority of the participants  is already good enough, I do not need anything more.” Some passive attitudes may be the reason that some older adults feel reluctant to go out, as shared by one participant who volunteers to befriend older adults:“While walking, you can see some people do exercises, qigong, or whatever. Most of them are ladies. I do not see many ladies on wheelchairs. It is mostly men on wheelchairs. This kind of observation gives you some information that it has to do with the type of activities.” One male participant mentioned gender differences in OOHBs and the necessity to arrange activities that attract males:“Hawker center is great! Because no matter what meat you eat, what skin color you have, white or black, what religion you belong to, once you enter (hawker center), you can sit all together, there is no disagreement. I do not eat pork, but there is no need to separate us. You eat your food, sitting next to each other, he eats his.” As a multi-ethnic country, the provision of facilities in Singapore takes the different demands of the different groups into account. One participant from Myanmar expressed her appreciation for the different shopping choices in her neighborhood: “Here is an Indian shop. Usually Indians’ and Myanmars’ favorite foods are very similar. If I like to buy our food, I go and buy from the Indian shop.” Another participant expressed his pride about the tolerance of the hawker center for different ethnicities:While walking, the participants discussed government policies about housing, transportation and health. Though there were complaints about high healthcare cost, the participants appreciated the efforts of the government to promote OOHBs among older adults. For example, one female participant in her 60s said: “The government has provided many programs for the older adults to encourage them to go out of their homes.” Another male participant shared: “I cannot remember what it is called, national health… but it encourages people to walk 10,000 steps using certain measurement (pointing to the waist), like the steps tracker. The government is doing a lot of things, making the places friendly for older adults.” The participants’ health conditions influence their OOHBs. They generally perceived their health as good, but the majority of them have some health issues, including hearing problems, foot pain, knee pain, spinal pain, hypertension and high cholesterol. Those with foot and knee pains have difficulty climbing stairs. For example, one participant said: “For me, I do not mind going up the stairs, but going down is quite a problem.” Another participant expressed his safety concern because of his ear problems: “I cannot hear, (so I) do not even know who is coming from behind.” Confronted with these issues, the participants have adapted themselves to remain active by walking slowly and shorter distances and by replacing strenuous exercises with mild exercises. For example, one participant who had gone through cancer treatment said: “I do exercise every day, mostly walking exercise. It is very good for our age. Running or any other activities, no. When I was young, I played volleyball, badminton, ….” Meanwhile, the participants also mentioned that OOHBs are necessary for health.Access to facilities: Our findings suggest that good access to facilities encourages older adults’ OOHBs. This result is supported by previous studies [ studies ,23,24,25 studies ,24. Addi studies ,26. Stud studies . Pedestrian infrastructure: As proven in other studies [ studies ,11,25, p studies , three s studies ,29, in rAesthetics: The presence of natural elements and a quiet, clean and well-maintained neighborhood can encourage older adults to go out [o go out ,8,24,30.Traffic safety: Road width was uncovered as a predicator for traffic volume and traffic speed. For another subcategory behavior of other road users, personal mobility devices have emerged as a safety concern for older adults [r adults ,32, due Safety from crime: Though it has been demonstrated in other studies as an important factor [t factor ,30,33, ft factor . Wayfinding: It was found that people use mental maps to help them navigate their ways in cities, and these maps are made up of five elements: path, edge, district, node and landmark [landmark . In thisFamiliarity: Familiarity can be explained by two sub-categories: long-term residency and routine activities. According to Rowles [o Rowles , older ao Rowles . Continuo Rowles . In thiso Rowles ,39. Weather: Weather is another important factor influencing OOHBs, a fact which has been well documented in other studies [ studies ,40. In S studies . In thisSocial contacts: Social contact encourages older adults to go out, a fact which is supported by previous qualitative studies [ studies ,42,43 an studies . High-rise, high-density: Studies have argued that high-rise, high-density developments promote efficient and intensive land use and provide amenities and services in proximity, all of which not only lead to more walkable cities and convenient lives but also stimulate social interactions, social capital and a sense of community [ommunity ,46,47. Hommunity ,48,49. Iommunity ,47. On tAffordability: Considering that there is no universal pension system in Singapore, the affordability of shops, services, and transportation have great influence on older adults’ OOHBs, including total time spent out-of-home, number of places visited, range of activities engaged in, training, and employability. Affordability has been found to play a key role in attracting older adults to urban spaces and promoting social interactions, because commercial spaces with high-end design features tend to discourage older adults from taking a seat and having casual conversations there [ns there . The cosns there . A studyns there .Maintenance and upgrading: Maintenance is one of the important concerns for high-rise living since it guarantees lift operation and the cleanliness of common areas [on areas . UpgradiTo answer the question of what factors encourage older adults to go out, this study emphasizes the necessity to consider neighborhood environmental factors, regional factors , and personal factors  as a whole. For example, a decision to visit a park is the combined result of one’s physical capacity, preference for an active lifestyle, the presence of parks in proximity, good pedestrian infrastructure, aesthetics, the affordability of travelling to the park and enjoying services in the park, traffic safety, good weather, the availability of companions, and health promotion policy by the government. For facilities necessary for daily living, long travel distance may prompt older adults to walk longer but may also inhibit walking if the older adults choose to use public transportation instead. As for the walk-along interview method, this study has shown that an unstructured walk-along interview approach can be quite beneficial because it not only discloses the implicit and unconscious aspects of the neighborhood environment but also allows the participants to share their interests, concerns, and personal histories along the way, all of which provide ample explanations for their OOHBs ,18. ThisMeanwhile, the walk-along approach has several limitations. First, as shared by other qualitative research methods, the extent of active participation is influenced by the participant’s age, personality and socio-economic status. This becomes more obvious in a walk-along interview because it hopes to empower the participants to gain control over the walk. In this study, those with higher socio-economic status tended to be more critical or more positive and speak continuously to take control of the whole process. Instead of wheelchair users or older adults with walking aids complaining about universal design features and long-distance to reach the amenities, those who are relatively younger or have experiences of pushing wheelchairs had stronger opinions about the built environment. This may also be due to the fact that people tend to become more tolerant and less demanding when they get older ,53. SecoExcept for the walk-along approach itself, this study had three limitations that should be taken into account. First, considering that Singapore is a multi-lingual, multi-racial society, the language limitations of the author may have excluded a small portion of older adults who cannot speak Mandarin or English. The language barrier may also have led to the failure of recruiting Malay participants. Second, the study was conducted in public housing estates in Yuhua East. Other neighborhoods in Singapore that follow different planning models with different sidewalk systems and service provisions may produce different results. The samples do not cover older adults living in condominiums and landed properties. Third, the sample size was very small. Though this study covered older adults with different ethnicities and different mobility capacities, the small sample size makes the results reported in this article hard to be generalized to other population. Some limitations will be addressed in the researchers’ future walk-along studies in other neighborhoods in Singapore.This study concludes that access to facilities, services, and pedestrian infrastructure are important for older adults’ OOHBs. The elderly can gain a sense of familiarity via long-term residency and routine activities, which give them the confidence to go out even with reduced physical capacities. Considering Singapore’s climate, sheltered walkways, the proximity of facilities and services, and connectivity  should be considered holistically. Considering the increasing number of older adults, universal design should go beyond the idea of accessibility and take a holistic view of planning accessible routes with shelters at convenient locations. Besides physical factors, social contacts and the affordability of shops and services are also important. Meanwhile, reflecting on the data collection process and research results, older adults’ feedback was constrained by what has been offered when living in public housing estates. Their suggestions and complaints were the results of what they saw provided by HDB in other estates. A top-down strategy and budget control make older adults passively accept the current situations. Elderly persons need to be further empowered to decide on their ideal neighborhoods for ageing-in-place. In summary, the findings from this qualitative study highlight the importance of multidimensional and contextual viewpoints to explore neighborhood environmental effects on older adults’ OOHBs.


More than half a century of research has documented that people's capacity to predict the actions, attitudes, and abilities of themselves and others is quite limited (e.g., Milgram, how-explanations, as opposed to “ultimate” why-explanations, of various lay beliefs.In a recent paper, Boyer and Petersen  attempt Firstly, we are not fully convinced with the way Boyer and Petersen  address Taking that into consideration, we also disagree with the thesis that biases typically constitute only proximate explanations of laypeople's beliefs. In our view, a bias account can very well offer ultimate explanations of various lay beliefs. Consider the following examples. Researchers rate their own manuscripts as better than those authored by their peers; in fact, they even believe that their rejected manuscripts are at least as good as others' accepted manuscripts (Van Lange, Rather than treating biases as idiosyncratic deviations, it may be more meaningful to perceive them as beliefs or behaviors that evolved because they were “good enough” responses providing us with fast answers to specific situations (Goldstein and Gigerenzer, TO lead-authored the article, with input from PM. Both authors approved the final version of the article prior to submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Relapse to smoking postpartum is a common and important public health problem. Difficulty in adjusting to a non-smoking identity is a key factor prompting relapse. However, postpartum relapse prevention interventions rarely focus upon offering support for identity change. We conducted an exploratory inductive analysis of a dataset from the Prevention of Return to Smoking Postpartum (PReS) study to understand identity constructs and experiences of pre- and postpartum women (smokers and ex-smokers), partners and health professionals. Data were obtained from 77 unique participants via focus groups, interviews, email or online questionnaires, and were analyzed by two researchers independently, using NVivo 12. Four main themes emerged reflecting identity transition from the pre- to the postpartum period: (i) Pregnancy and the categorization of smoking status; (ii) the disruption of motherhood and loss of self; (iii) adapting to a maternal non-smoking identity; and (iv) factors influencing sustained abstinence versus relapse to smoking. Postpartum relapse prevention interventions need to consider support for women, and the whole family unit, in adjusting to a new identity as a non-smoking mother. Smoking status should be revisited throughout pregnancy and into the postpartum period to aid the long-term integration of smoke-free behavior.  Relapse to tobacco smoking among women who quit smoking for or during pregnancy is common. Up to 76% of spontaneous quitters return to smoking postpartum . RelapseIdentity, as a smoker or non-smoker, mothering identity, social identity and relationships are strongly connected to postpartum smoking relapse ,7,8,9,10There is a strong policy drive to reduce smoking cessation in pregnancy , and ideWe report a qualitative analysis of data from the Prevention of Return to Smoking Postpartum (PReS) study, an early phase study to develop an intervention to maintain smoking abstinence postpartum. We sought the views of pregnant and post-partum women (smokers and ex-smokers), partners and health professionals. We used semi-structured interviews to explore participants’ perceptions of smoking relapse, barriers and facilitators for behavior maintenance, and views on any potential components of a smoking relapse prevention intervention . In thisThis study was approved by West Midlands-Edgbaston National Health Service (NHS) Research Ethics Committee on 21st July 2017 (ref: 17/WM/0285). Participants gave written consent prior to the interview. Recruitment and data collection took place between September 2017 and September 2018 in the East of England . Participants were recruited via health visitors, midwives, NHS Smokefree Norfolk, and children’s centers using posters, flyers and electronic advertisements. In addition to referral from services, researchers identified participants in person, from antenatal clinic waiting areas and children’s centers. Participants were also recruited through general media, community and social centers, and word of mouth.Eligibility criteria for all participants included being aged 18 years or over and able to communicate in English, due to the in-depth nature of the interviews. Specific inclusion criteria for women were: Having quit smoking during, or in the 12 months before pregnancy; currently pregnant or having given birth in the last five years; and self-reported ex-smokers or smokers (relapsed to smoking). The inclusion criterion for partners was to be a partner to a woman meeting the eligibility criteria. Eligibility for health professionals were: To be working as part of the health visitor services; midwifery services; NHS Smokefree Norfolk or children’s centers. To reach a diverse sample, interviews were conducted as focus groups or one-to-one interviews, via telephone or in person, at a time and location convenient to the participants. Participants were also invited to comment electronically  if unable or unwilling to attend an interview. We aimed to recruit approximately 74 mixed stakeholders purposively selected by subgroup  and continuing to recruit until we believed we had achieved a sufficient range of views. We aimed to over-sample women and ex-smokers in particular, in order to test a prototype intervention with women for the PReS study . Semi-structured interview schedules were developed with patient and public advisors (PPI). Interviews lasted 90 minutes, and participants were compensated with a £20 shopping voucher. Interviews were conducted by Tracey J. Brown and Caitlin Notley , and digitally audio-recorded. Data were transcribed verbatim, and analysis was facilitated using NVivo version 12 . Tracey J. Brown and Caitlin Notley independently coded three transcripts, met to review codes, and agreed a general coding framework, which was then applied across all transcripts by Tracey J. Brown. All coding relating to identity was extracted for subsequent analysis. This further analysis used constructivist grounded theory to code all data extracts relevant to identity, informed by a theoretical consideration of identity as a narrative in life course development . All datData were obtained from 77 unique participants who took part in the PReS study  Table 1Table 1. A strong theme unique to this population was anxiety around classification as a current ‘smoker’ or ‘non-smoker’ at the first maternity booking appointment. Women’s response to the question of their smoking status by a midwife was perceived as a crucial moment of assigned identity, which would influence them through their current pregnancy, to motherhood. Primary reasons given for desiring a pregnant ‘non-smoker’ status were concerns of judgement and stigma, and of pressure by health professionals or others, to change their behavior. Women expressed a desire to move from a stigmatized smoking ‘out-group’ to an accepted non-smoking ‘in-group’. Many participants held powerful, often moral, beliefs against smoking whilst pregnant: ‘I certainly don’t want to judge anyone but I personally found there’s something that really makes you think okay, there’s a baby inside me. You know what I am putting into my body directly affects that’ (025 postpartum ex-smoker)There was mention of pride, conviction and resolve in remaining smoke-free. Some women indicated they felt impervious to relapse and were unwilling to admit any vulnerability to their new non-smoking identity:‘for someone like me right now, I feel very proud that I’m in the non-smoker box. I don’t want to be put back in the smoker box because I want to kind of resist being there’ (001 pregnant ex-smoker)Health professionals recognized that relapsing to smoking during pregnancy might be perceived as ‘taboo’, ‘a stigma’, and might be ‘embarrassing’ for women to admit. Maintaining a good patient relationship was perceived as paramount, and professionals realized patients’ concerns of judgment. However, they acknowledged this discord likely acted as a barrier to establishing the smoking status of women and their partners, and providing support:‘Like you say, people feel so judged and so dreadful but actually there’s hundreds of other mums and dads and partners that feel exactly the same way’ (009 smoke-free advisor)For most women the key motivator for quitting smoking was ‘for the baby’ and not to change their own smoking identity or health status. Women spoke of struggles in remaining smoke-free and meeting expectations of a non-smoker identity. Difficulties in adjusting to a pregnancy identity were evident, particularly in the cases of first pregnancies, unplanned pregnancy, or in the first trimester where the pregnancy was (in some opinions) less ‘real’. For others the final trimester was a particular challenge, with some anticipating relapse after birth, or giving themselves permission to return to smoking:‘So I stopped but for example, in my sleep, like I dreamt every single night that I’m taking—I’m smoking, so for me it was, waiting to give birth and have my first cigarette’ (027 postpartum relapser)This participant reflected on what smoking meant to her and her thoughts about ‘losing that part’ of her, which led to her relapse. For women with smoking partners, abstinence could be particularly challenging, in light of their partner’s views of their smoking identity:‘I’m doing the damage to myself but I’m not doing the damage to the baby’ This sense of ‘distancing’ in some cases reflected partners’ perceptions of playing a relatively insignificant role during the pregnancy. Both women and partners spoke of barriers for partners in attending antenatal appointments, often due to employment. Some partners felt alienated, ‘a spare part’, even when attending appointments. Most participants felt the key focus was on the baby, and whilst this was appreciated, the parents could feel disconnected as a unit. Women could feel positioned as the go-between, relaying information from health professionals to their partner: ‘I kept trying to say to him…smoking around me is still going to have an impact but because it was me saying it, not a professional or somebody who knows what they’re on about, he wasn’t really interested’ (023 postpartum ex-smoker)Pregnant women generally had few relapse prevention strategies, relying upon willpower and physiological changes reducing their smoking cravings. Hormones, mood swings and the ‘crazy journey’ of pregnancy could detrimentally affect coping. For women relapsing during pregnancy, feelings of guilt and remorse as a mother-to-be were described:‘I done it! So I took her choice away and that to me reads as wrong and it’s not supposed to be that you take the choice away from your own kid. She’s trying to grow and be healthy inside there and she’s got no other choice what she breathes’ Shortly after birth, women felt particularly vulnerable to relapse, or indeed did relapse. Vulnerability was due to perceived factors including a reduction in intensive health service support, leaving ‘the midwife bubble’ and entering the ‘scary zone’, and partners or family members smoking. Of greatest significance, risk of relapse increased due to feelings of dissociation and detachment from the baby on leaving a pregnancy identity:‘I was like oh, I’ve given birth now, ooh, I could smoke if I want to’ (039 postpartum relapser)Feelings of loss and disruption were strong and recurring themes. Whilst many women expressed the joy of having a baby, they simultaneously felt a loss of themselves and their pre-birth identity:‘it’s such a massive lifestyle change and what I felt, although I’m absolutely over the moon and I’m so happy being a mummy, you get really lonely…you feel like you’re struggling and it’s never ending’ (004 postpartum ex-smoker)The abrupt change to parenthood was perceived by many to be disruptive, an acute interruption to their former lives. Women spoke intensely of feelings of loneliness and low mood, particularly on the return of partners to work and a reduction of family visits after the initial excitement of the new baby. Participants were affected by feelings of stress at having a baby to care for, and in some cases, perceptions of a new mundane regime. Smoking was frequently perceived as a coping response for these stressors. Women could be sentimental when reflecting on their pre-pregnancy smoker identity:‘when I was younger, like even couple of years ago, I’d just go down the pub, you know, have a drink, have a smoke in the sun, it was lovely. It was lovely’ (044 postpartum ex-smoker)Some women expressed resentment at losing their former identity, particularly in light of partners or family members: ‘we’ve got to be the ones about health and serenity and all this—where the dads can just carry on normal life’ (034 postpartum ex-smoker)Women felt conflicted and under pressure to be ‘perfect’. They perceived an expectation to stay smoke-free, having achieved this during pregnancy. However, women could struggle to conceptualize themselves as non-smokers, ‘once you’re a smoker, you’re always a smoker’. Smoking for many women and also partners, was an integral part of their identity prior to parenting, thus relapse could be positioned as part of regaining the previous ‘lost’ identity:‘It was very easy to go backwards to what I knew…I have such a limited social life and you need something just to take away from the nappies and the bottles and everything. You do it every day so you need something else’ (028 postpartum relapser)‘her mum…said she’ll have her the night. It’s often we’ve turned around and said well what did we do before we had a kid? And I’ve gone and said bloody this! And we’re sitting outside and having a fag or sitting in the kitchen having a fag’ Further into the postpartum period, it became easier for women to adapt to a maternal non-smoking identity, wanting to do the ‘right thing’ for their child. There was an acknowledgement of responsibility, particularly for the baby, and in some cases for the wider family. Some women spoke of their longevity, hopes for seeing their child into adulthood, and perhaps have children of their own. These feelings of accountability and the extension of their perceived identity to include their baby, drove both adjustment to a maternal identity, and a focus upon maintaining positive health behavior change:‘It makes you feel like a mum as well because you’re protecting your baby by something that you can do… there’s other things that you couldn’t prevent, but if this is something that I can prevent, I’m going to do it’ (064 postpartum ex-smoker)This strong maternal nurturing instinct, and status as a ‘mum’, acted as a key motivator to remain smoke free. Concern of the link between smoking and an increased risk of sudden infant death syndrome  was central. Some women also referenced the increased likelihood of their child becoming a smoker if they witnessed their smoking. These concerns, and the passing of time further into the postpartum period, aided a shift in smoking attitude, and in turn, assisted the transition of identity from smoker to non-smoker:‘I hate it now, I absolutely hate it now. I’m shocked that I used to be a smoker’ (064 postpartum ex-smoker)Most women used willpower and an imagining of future outcomes for their baby, to help them stay smoke-free postpartum. Many were also driven by a desire to be in control of their new lives and live without ‘guilt’. Women who were successful in remaining smoke-free appeared to have developed more strategies to maintain smoking abstinence, and more coping skills for general parenthood. Knowledge of coping skills was largely gained through self-help techniques. These techniques were varied, ranging from practical approaches, such as a jar to save money from not smoking, to psychological techniques, including boosting mood, reducing stress, and reflecting on their reasons for their previous smoking. Some women capitalized on their change in lifestyle to break these smoking habits. It was important to acknowledge that days could be ‘tough’, and there was a deliberate avoidance of putting themselves under the pressure of conforming to societal expectations. There were some references to the importance of maintaining a sense of self:‘to the woman who hasn’t been herself for a while—stay hopeful, that spark will reignite soon. This weight will have itself lifted off your tired shoulders soon…you’ll be back’ (059 postpartum ex-smoker)This mother was referring to an online poem which struck a chord with her. Maternal status and focus on the baby, in some instances provided pivotal moments for supporting smoking abstinence:‘it was something that I could kind of cling onto, almost like a bit of a life raft at times where it was remembering that I can deal with stressful situations without having to go and have a cigarette. And I remember thinking at the time; stress isn’t something that just suddenly happened to me at 16 when I had my first cigarette…at his age, there will be situations that are a bit stressful, he doesn’t need to have a cigarette to cope with them, does he? So why do I?’ (058 postpartum ex-smoker)This participant makes reference to clinging on to her strategy like a ‘life raft’, acknowledging how challenging it was for her to stay abstinent.A range of factors influenced the likelihood of integrating smoke-free behavior and maintaining long-term abstinence. Partner influences were frequently raised. Staying smoke-free was easier if living with a supportive partner, particularly where partners were non-smokers or ex-smokers. In addition to encouraging women’s continued smoking abstinence, providing general support for women’s welfare and support as a father in caring for the baby were perceived as significant:‘(my partner) will put him to bed so it just gives me an extra like twenty minutes to chill out…it helps loads doesn’t it’ (062 postpartum ex-smoker)Enabling women to have more time to themselves helped them to retain their pre-pregnancy identity and to integrate the new identity of a maternal non-smoker. Similarly, the role of family, friends and wider society were influential, both directly, and more indirectly, by promoting a shift in perceived smoking norms. ‘I know I can’t smoke in my car and I wouldn’t, I don’t think I would smoke now at work because it’s now a non-smoking site’ (065 postpartum ex-smoker)Whilst some women were able to integrate their smoke-free behavior, for others, adapting to a non-smoking identity was unmanageable. This was particularly the case where women relied heavily upon willpower as a relapse strategy. Particular risky times for relapse postpartum were social situations, stopping breastfeeding, or returning to work. These times presented openings for women to revisit their pre-pregnancy smoking identity. Having smoking family members, friends, or more crucially a smoking partner, had detrimental effects:‘the whole time through all my pregnancies, he never gave up and we were walking somewhere and he had a cigarette and I said oh just let me try a bit…as soon as I had a toke, then that was it, I was smoking again’ (056 postpartum ex-smoker)This ex-smoker was describing a previous postpartum relapse. There was a sense of being readily hooked back into nicotine dependence. Our sample generally perceived tobacco smoking as an ‘addiction’ that was difficult to control and had formed part of their previous identity. For some, this contributed to a disconnection from their identity as a maternal non-smoker, increasing the likelihood of a smoking relapse:‘I’m like oh back in the day I used to be such a little lush and smoke fags. So in my head I’m like well this is what I do’ (059 postpartum ex-smoker)With hindsight, many women reflected that it might have been beneficial if their smoking status at the first midwife booking appointment was re-visited. For many it seemed to be difficult for them to raise this subject themselves, and they looked to health professionals to prompt this conversation in a non-judgmental way:‘there was never a conversation about smoking in any of my appointments apart from that very first one. So if they knew that I was a smoker in the past, it should be highlighted and then they could maybe go—this has been quite tough, you know, have you felt the urge to start smoking again? Have you started smoking again? Is there anything we can do to help you stay smoke-free and keeping the smoking in the forefront of the conversation because at the moment it’s a one tick box and never mentioned again’ (034 postpartum ex-smoker)Identity is co-constructed in relationship with others, health professionals, family and partners. From the defining moment at the first midwife booking appointment, all stakeholder groups perceived opportunities to further engage a woman’s partner or wider support: ‘if you visit a family and there’s a dad there and you ask them a question about how they are, they almost like nearly want to fall off their chair because someone’s actually given them some speaking time’ ‘So encouraging them to quit and kind of, yeah letting them know at that point, you know to get their partners thinking about e-cigarettes as well, would be a good time’ Our study explored the identity constructs and experiences of adjusting to a new maternal, non-smoking identity. Four inductive themes were generated based on identity as a central theme. We theorized identity to be fluid and shifting, and our findings clearly demonstrate that changes in the perception of identity as a mother and a non-smoker, reflected the transition from the pre- to the postpartum periods. For both new mothers, and those who had previously had children, pregnancy acted as a powerful motivator to quit smoking. By quitting smoking in pregnancy, women experienced a positive identity change and the sense of movement from a stigmatized ‘out-group’ to an accepted ‘in-group’. Women were eager to classify themselves as a ‘non-smoker’ at their first midwife booking appointment. For some women, this classification generated a potentially misplaced feeling of being impervious to relapse after the birth of the baby, whereas other women were anticipating a return to smoking. Uncoupling from the baby at birth, and the disruption of entering motherhood, increased this vulnerability to relapse. Our analysis revealed loss and disruption as strong themes of identity change on entering the postpartum period. Smoking for many was a fundamental part of their pre-parental identity, and consequently relapse could be viewed as part of regaining this ‘lost’ identity.Whilst some women failed to adapt to motherhood and relapsed, others adapted, re-configuring identity and remaining abstinent. Integration of smoke-free behavior was heavily influenced by coping strategies, the support of partners, and wider social support. Many women wanted health professionals to discuss their smoking status in later pregnancy and postpartum, and to offer assistance to them and/or their partners to maintain long-term smoking abstinence. A potential weakness of this study was the low proportion of partners who we were able to recruit to participate. We also included a high proportion of ex-smokers relative to smokers. We aimed to oversample ex-smoking women to test a prototype intervention to prevent relapse as part of our wider PReS study , and havStrengths of this study include independent coding of data by two experienced qualitative researchers and the validation of findings with all authors and PPI groups. We included a wide variety of stakeholders to triangulate data sources: Pregnant and postpartum women, partners and various health professionals. We offered interviews both in-person and over the telephone, and offered reply electronically and/or anonymously to broaden reach. Our results reinforce and advance findings from the literature, showing that difficulties in adjustment to identity as a mother and a non-smoker are key influences in return to smoking postpartum ,7,8,9,10Women were perhaps particularly susceptible to relapse after the birth of their baby due to a longing to regain their former pre-pregnancy identity, low confidence in remaining quit, and stresses of caring for a new infant ,9,10,20.Identification of self as a role model and valued self-identity are recognized behavior change techniques, which might be used to support smoking cessation during and after pregnancy in future interventions and clinical practice . CurrentHealth professionals  as part of society, might aid the construction of a new non-smoking identity. However, professionals are often concerned about raising/repeatedly raising the subject of smoking, due to the potential negative impact on the therapeutic relationship . ConversOur analysis suggests that interventions to support postpartum relapse prevention must critically include support for women in adjusting to a new identity as a non-smoking mother as women transition from the pre- to the postpartum periods. Interventions that do not acknowledge the struggle of managing disruption to the narrative flow of identity may be less effective. Identity is co-constructed with others, and the role of social support, particularly from partners, must be considered as part of identity adjustment. Health practitioners should make opportunities to include the wider family unit, and to revisit smoking status at every opportunity.


The migration of physicians from low-resource to high-resource settings is a prevalent global phenomenon that is insufficiently understood. Most low-income countries are severely understaffed with physicians, and the emigration of the already limited number of physicians to other countries can significantly reduce access to healthcare in the source country. Despite a growing interest in global capacity building in these countries by academic and non-governmental organizations in high-income countries, efforts to stem physician migration have been mostly unsuccessful. The authors reviewed the current literature for the motivational factors leading to physician migration in the context of Maslow’s hierarchy of human needs. Our study found that financial safety needs were major drivers of physician emigration. However, factors related to self-actualization such as the desire for professional development through training opportunities and research, were also major contributors. These findings highlight the multifactorial nature of physician motivations to emigrate from low-resource countries. Maslow’s Theory of Motivation may provide a useful framework for future studies evaluating the concerns of physicians in low-income countries and as a guide to incentivize retention. The benefits of physician migration to academic centers in high resource countries are something the authors have personally experienced and appreciated. However, in our volunteer efforts to train and build the physician workforce in low-resource countries, we have also seen the resulting damage to healthcare delivery when medical personnel migrate out of their country. We sought to improve the understanding of physician migration from lower-resource countries by finding a common language on motivating factors for more consistent data collection. We mainly wanted to investigate whether financial need is the primary driver of physician migration or if other motivating factors also play important roles. It is essential to carefully examine the literature using a widely accepted framework because a comprehensive assessment of current knowledge on physician motivations is necessary for developing initiatives to counteract migration. However, existing literature on motivations of physician emigration is descriptive and is missing a theoretical framework that could be used to build a database that is consistent across different political and social environments.We hypothesized that Maslow’s hierarchy of human needs would be a useful framework for collecting data on physician motivations to migrate. Abraham Maslow was an American psychologist who proposed a hierarchy of human needs that he believed determined how people are motivated. He believed that human needs fall into five categories, that the needs in the lower categories are stronger drivers of motivation than higher ones, and that they must be at least partly satisfied before a person will be motivated to work towards the higher categories. The five categories were the following: physiological needs, safety needs, social needs, esteem needs, and self-actualization ,2 Figur. Maslow’The worldwide shortage and maldistribution of healthcare workers are at a critical stage and is threatening the sustainability of health systems . The Wor“Brain drain” is particularly a problem in Africa, which has 25% of the global disease burden but only 3% of the global health workforce . Some AfDespite limited information on the factors influencing physician migration, there have been some efforts to counteract the outflow of doctors from LMICs to HICs ,20,28,29We surveyed PubMed, Web of Science, EBSCO MEDLINE, and the Google Scholar scientific database. We used the terms “physician emigration,” “physician migration,” and “physician brain drain” as keywords. We curated the database manually to remove citations about the migration of physicians within HICs. We focused our review on physicians due to the considerable loss of return on investment for LMICs described in previous literature . We limiNineteen articles satisfied the search criteria and gave specific answers to questionnaires asking for motives to emigrate from the country of training to higher-income countries. In these articles, basic food and shelter needs were mentioned twice, physical and financial security needs 12 times, a need for social belonging twice, a desire to improve educational or professional opportunities (self-esteem) 13 times, and self-actualization or “being all you can be” 15 times  27,31,3,56,57,58The first level of Maslow’s hierarchy, the need for food and shelter, is mentioned only twice as a motivator of emigration in any of the studies reviewed ,56. ThisThe second level of Maslow’s hierarchy also includes the need for financial security. In half the studies in which medical personnel’s opinion on emigrating was elicited, a desire for improved financial earnings was explicitly mentioned as a driver for emigration  31,40,4,53,56,59Maslow’s third level, the need for social acceptance, was found primarily to serve as a deterrent for migration. Having strong personal and family roots in a native country are good predictors of retention, and this was one of the primary reasons voiced by students from Malawi and Nigeria for wanting to practice locally ,66. FamiMaslow’s fourth level, the need for self-esteem or desire for educational and professional development opportunities, was mentioned 13 times in the questionnaires studied  31,41,4,53,54,56Maslow’s fifth level, self-actualization or “being all you can be,” was the most commonly mentioned reason for emigrating in the questionnaires included in this review. Physicians mentioned the need to improve “research opportunities” and “career opportunities” and to “excel professionally”  31,40,4,54,56,57Physician migration from LMICs to higher-resource countries is a poorly understood phenomenon that has significant consequences on health care in all countries. Our review of the literature has found that motivating factors vary somewhat from country to country, but many are shared and can be categorized into Maslow’s hierarchy of human needs ,33. The The effect of financial security on emigration has been more often studied, perhaps because an increase in income potential has traditionally been assumed to be the primary driver of brain drain ,41,48. OThe need for social belonging was infrequently mentioned as a motivator for emigration and only in situations where relatives or other social supports were present in the destination country ,44. PhysOur review found that non-monetary factors are important drivers of migration. Once their basic safety and financial security needs are met, physicians seek to satisfy their need for self-esteem and self-actualization through improved professional development, advancements, and opportunity to pursue research ,49,59,66Maslow’s theory of motivation provided a useful framework to highlight the multifactorial nature of physician migration from LMICs. Current studies indicate that the development of comprehensive incentive programs and better academic infrastructure could be useful avenues to promote physician retention. This review also highlights the need for future studies evaluating physician migration and mechanisms of retention.


Considering the association between the neighborhood food environment and individual eating behaviors, this study aimed to assess the association between parents’ reported use of food facilities by their children, and parental perceived travel time to food facilities, with their children’s dietary patterns. Parents reported the use of supermarkets, full-service and fast-food restaurants, and perceived travel time to these food retailers. To assess school children’s food consumption, a previous day dietary recall was applied. Factor analysis was conducted to identify dietary patterns. To test the association between reported use and perceived travel time to food retailers and school children’s dietary patterns, we performed multilevel linear regression analyses. Parents’ reported use of supermarkets was associated with children’s higher score in the “Morning/Evening Meal” pattern. The use of full-service and fast-food restaurants was associated with children’s higher score in the “Fast Food” pattern. Higher parental perceived travel time to full-service and fast-food restaurants was associated with children’s lower score in the “Fast Food” pattern. Although the use of full-service and fast-food restaurants was associated with a less healthy dietary pattern, the perception of living further away from these food retailers may pose a barrier for the use of these facilities. There is a growing amount of evidence for an association between the neighborhood food environment and individual eating behaviors ,2. ConsiExposure to the food environment comprises access to many different types of food retailers. The literature shows that supermarkets are an important source of food for many families  and liviFurthermore, a higher proximity from a school or residence to fast-food restaurants is associated with unhealthier diets among students, including lower consumption of fruits and vegetables , higher Exposure to food retailers can be assessed using different measures, tools, and methodological procedures, including metrics based on geographic information systems , which cThe aim of this study was to test the associations between parental reports of their children’s use of food retailers and parental perceived travel time to food retailers with school children’s dietary patterns. We also aimed to examine effect modification by income levels.This cross-sectional study is part of a wider research project funded by the Brazilian National Council for Scientific and Technological Development (CNPq). The project aimed to analyze the tendency and prevalence of obesity and its associated factors among primary and secondary school children from seven to 14 years old from Florianópolis, southern Brazil.Details on the sampling and design of the project were reported by previous studies ,24. In sData were collected from September 2012 to June 2013 by trained researchers. Anthropometric measurements of school children (weight and height) were collected according to a protocol defined by the World Health Organization (WHO) , which uThe research protocol was approved by the Ethics Committee of the Federal University of Santa Catarina (UFSC) , in accordance with the standards established by the Resolution No. 466/2012 of the Brazilian National Health Council. The study was conducted in accordance with the Declaration of Helsinki, and only school children whose parents or guardians signed the informed consent term participated in the study.We asked parents how often , in the past six months, their children used restaurants and fast-food restaurants. Fast-food restaurants may refer to both commonly known fast-food chains that sell burger-based meals and also to small local-owned food retailers that sell traditional baked and deep-fried snacks. Parents were also asked whether or not they buy foods to cook at home in the supermarket. Parents answered how far  restaurants, fast-food restaurants, and supermarkets were located from their home. Response options in minutes were “one to five”; “six to 10”; “11 to 15”; “16 to 20”, or “more than 20 min”.Based on the data distribution, we categorized the reported frequency of use of restaurants and fast-food restaurants in the past six months into two categories (“did not use” or “used”). The use of supermarkets was originally asked in two categories (“did not use” or “used”). Parents’ perceived travel time was also categorized into three categories: less than 10 min, 10 to 20 min, and more than 20 min of walking distance from their home.Food consumption information was collected using a qualitative food frequency questionnaire named QUADA (Portuguese acronym for “previous day food questionnaire”), an instrument developed and validated by Assis et al. , designeWe derived dietary patterns performing factor analysis via the principal component method. The sum of all foods consumed by the children in the previous day were entered into the factor analysis which was performed using a polychoric correlation matrix—the most suitable for our food consumption data . The obtSociodemographic characteristics were obtained from a questionnaire answered by the parents including information on children’s sex , age (continuous), type of school (public or private), mother’s self-reported weight and height ), mother’s education, and household income. Response options for mother’s education were no formal education, incomplete secondary education, complete secondary education , incomplete high school, complete high school , incomplete higher education, and complete higher education (university degree or higher). The variable maternal education was categorized into “complete secondary education”, “complete high school”, and “complete higher education”. Household income was continuously assessed via a questionnaire referring to the sum of the monthly net income of all household residents with a paid job. We split the continuous variable of income into tertiles to test effect modification by income levels. School children’s nutritional status was determined in terms of anthropometric measures; weight and height of school children were objectively measured and used to calculate the BMI. The school children’s BMI was then classified into “normal weight” and “overweight” following the WHO age and sex-standardized cut-offs . The perAll the school children with complete food consumption data were kept in the analysis, resulting in an analytical sample of 2484 participants. Assuming that incomplete values were missing at random, we applied multiple imputation to all variables, except the outcome, using the predictive mean-matching method . The per® 3.2 . Descriptive and multilevel linear regression analyses, as well as multiple imputations, were performed using Stata® 13.0 .To test the association between parental perceived travel time to supermarkets, restaurants, and fast-food restaurants, we built six different models to test the associations between the three “perceived travel time” variables and reported usage of supermarkets, restaurants, and fast-food restaurants with dietary patterns. We tested for clustering at the school and at the grade levels across all models. Firstly, a random intercept for school was added, followed by a random intercept for grade. Using two-log likelihood tests, we found these two levels to be significant and, therefore, performed linear mixed-models analysis with participants (first level) clustered within grade (second level) and school (third level). We created product terms for the variables of use and income levels, as well as for the variable of perceived walking distance and income levels. To test effect modification, we added these product terms to the respective models. All models were a priori adjusted for age, children’s nutritional status, mother’s BMI and educational attainment, household income, and type of school. Questionnaire data were entered by two independent researchers and processed by Software EpiData2. A large majority of parents reported the use of supermarkets in the past six months (95.7%); restaurants and fast-food restaurants were reported to be used by 65.6% and 64.1% of parents, respectively. Most participants reported to live 10 min or less from a supermarket (40.6%) and from a fast-food restaurant (42.1%), whereas 40.2% reported to live more than 20 min away from a restaurant.Participants characteristics are described in The factor loadings for each food item in the corresponding dietary pattern are presented in We explored the associations between parents’ reported use of food retailers by school children and parents’ perceived travel time to food retailers with school children’s dietary patterns. We found an association between the use of supermarkets and a higher score in the “Morning/Evening Meal” pattern. The use of full-service restaurants and fast-food restaurants was associated with a higher score in the “Fast Food” pattern. Higher perceived travel time to full-service restaurants and fast-food restaurants was associated with a lower score in the “Fast Food” pattern. We found no association between the use of food retailers and the “Traditional Brazilian” or the “Healthy/Fresh” foods pattern. No association was found either for perceived travel time to food retailers and the “Morning/Evening Meal”, the “Traditional Brazilian”, the “Healthy/Fresh Foods”, or the “Bread and Chocolate Milk” patterns. No effect modification was found by income levels.The fact that no association was found for the use of and perceived distance to food retailers and the “Traditional Brazilian” and the “Healthy/Fresh Foods” patterns is surprising, as we expected, for instance, that the use of and greater perceived distance to fast-food restaurants would be inversely associated with both “Traditional Brazilian” and the “Healthy/Fresh Foods” patterns. The hypothesis would be that traditional meals and fresh foods would more likely be consumed at home, meaning fewer visits to fast food restaurants. As shown by previous Brazilian studies, eating out of home is associated with the consumption of unhealthy foods  ,35, whilThe use of full-service restaurants and fast-food restaurants, which is linked to the consumption of foods away from home, was associated with the dietary pattern composed of less healthy foods. Powel and Nguyen investigated the association of eating in full-service restaurants and fast-food restaurants and increased energy intake . They foThe association between use of fast-food restaurants and the first dietary pattern was expected, as fast-food consumption is largely related to unhealthy dietary patterns. Fast-food consumption is associated with a lower overall diet quality in American children aged 2–18 years old; children characterized as high consumers of fast food presented a higher intake of sugar-sweetened beverages and French fries, and a lower consumption of fruits and vegetables when compared with children characterized as low consumers . A positDespite the positive association of the use of full-service restaurants and fast-food restaurants and a higher score in the “Fast Food” pattern, the perception of living further away from these outlets seems to have a protective effect on children’s diet; higher perceived travel time to full-service restaurants and fast-food restaurants was negatively associated with the “Fast Food” pattern. Although the effect sizes found in our study are rather small, considering all individual and environmental factors that influence school children’s dietary behavior, we consider those to be relevant effect sizes. Similar to our findings, Cutumisu et al.  found a Some studies explored the perceived availability of fast-food restaurants and found a positive association with a higher consumption of unhealthy foods among children and adolescents ,43. The Our results are subject to some limitations, such as the fact that QUADA assesses the frequency of intake rather than quantity. Regarding the use of food retailers, when asking parents how often their children use restaurants and fast-food restaurants, we did not ask if the children were accompanied by the parents or not. This could lead to a mistaken report, especially from parents of older children. However, we assume that parents would know when their children visited restaurants, even when the parents were not present. The social desirability bias could be considered, especially among the older children, which could feel discouraged to report the consumption of less healthy foods in the presence of their peers and researchers. A common limitation with the use of food questionnaires is memory bias. Nonetheless, QUADA was developed to minimize difficulties related to children’s assessment of portion size and to avoid lack of memory, since it accesses foods consumed in the previous day. In addition, during the administration of the questionnaire, researchers ensured that the students were situated in time and space while presenting the foods in the QUADA chart in a chronologic order. Although dietary intake from one day only may not be representative of the habitual individual intake, it is an advantage of our study that it included the coverage of different weekdays, including weekdays and Sundays . We wereOur results indicate that, although the use of restaurants and fast-food restaurants may be associated with the “Fast Food” pattern, the perception of living further away from these food retailers might have a positive influence on school children’s diet. These findings highlight the importance of evaluating the perceived food environment and the use of food retailers, which can provide a complementary understanding of the relationship between the food environment and diet.