Despite their growing popularity, there are very few mobile health  interventions for Aboriginal and Torres Strait Islander people that are culturally safe and evidence based. A co-design approach is considered a suitable methodology for developing health interventions with Aboriginal and Torres Strait Islander people.The aim of this study was to co-design an mHealth intervention to improve health knowledge, health behaviors, and access to health services for women caring for young Aboriginal and Torres Strait Islander children.Aboriginal researchers led engagement and recruitment with health services and participants in 3 Aboriginal and Torres Strait Islander communities in New South Wales, Australia. Focus groups and interviews were facilitated by researchers and an app developer to gather information on 3 predetermined themes: design characteristics, content modules, and features and functions. Findings from the co-design led to the development of an intervention prototype. Theories of health behavior change were used to underpin intervention components. Existing publicly available evidence-based information was used to develop content. Governance was provided by an Aboriginal advisory group.In total, 31 mothers and 11 health professionals participated in 8 co-design focus groups and 12 interviews from June 2019 to September 2019. The 6 design characteristics identified as important were credibility, Aboriginal and Torres Strait Islander designs and cultural safety, family centeredness, supportive, simple to use, and confidential. The content includes 6 modules for women’s health: Smoke-free families, Safe drinking, Feeling good, Women’s business, Eating, and Exercising. The content also includes 6 modules for children’s health: Breathing well; Sleeping; Milestones; Feeding and eating; Vaccinations and medicines; and Ears, eyes, and teeth. In addition, 6 technology features and functions were identified: content feed, social connection, reminders, rewards, communication with health professionals, and use of videos.An mHealth intervention that included app, Facebook page, and SMS text messaging modalities was developed based on the co-design findings. The intervention incorporates health behavior change theory, evidence-based information, and the preferences of Aboriginal and Torres Strait Islander women and health professionals. A pilot study is now needed to assess the acceptability and feasibility of the intervention. The health and well-being of Aboriginal and Torres Strait Islander people have been significantly affected by dispossession, interruption of culture, and intergenerational trauma since the colonization of Australia . The ongAboriginal and Torres Strait Islander people make up 3.3%  of the Australian population  and inclmHealth is the use of mobile technology to improve health. Functions include SMS text messaging, multimedia messaging service, voice, internet access, and software apps, which range in complexity. mHealth is used for a variety of purposes, including health education, health behavior change, sensors and point-of-care diagnostics, registries and vital-event tracking, and data collection . mHealthStudies focused on Aboriginal and Torres Strait Islander people using SMS text messaging to improve health show high acceptability of the modality -15. SMS Health apps continue to be popular, although the evidence suggests that apps have limited effectiveness on changing health behaviors ,20-22. SSocial media is a form of mHealth, with potential to support health. The Aboriginal and Torres Strait Islander health sector was an early adopter of social media networks to promote health ,26. SociIn response to the limited mHealth interventions available for Aboriginal and Torres Strait Islander women and children, we aimed to co-design a prototype focused on the needs and ideas of Aboriginal and Torres Strait Islander mothers. Co-design is a partnership approach where end users are actively involved from conception to dissemination . Using cIn total, 8 focus groups and 12 interviews were conducted from June 2019 to September 2019. Surveys were used to collect demographics at the start of focus groups and interviews. An Aboriginal advisory group that included Aboriginal team members who were also members of the participating communities met quarterly to oversee design, implementation, analysis, and reporting. An expert mHealth research group was consulted for opinion on research and intervention design.Human research ethics approval was received from the Aboriginal Health and Medical Research Council (1485/19) and the University of Newcastle (H-2019-00760).A co-design framework for an mHealth intervention with Māori and Pacific communities in New Zealand  based onFocus groups and interviews were held at 3 regional NSW locations: Newcastle, Coffs Harbour, and Inverell. In total, 5 Aboriginal organizations  and 3 NSW Health sites participated. Venues for focus groups and interviews were decided in consultation with participants.Women aged ≥16 years who were either mothers or primary carers of an Aboriginal or Torres Strait Islander child aged 0 to 5 years or were pregnant (≥30 weeks gestation), owned or regularly used a smartphone, and had accessed a participating service  were eligible to participate. Health professionals at participating services who worked with women or children were eligible.Convenience sampling was used to recruit participants. Aboriginal researchers  who worked within the participating communities used their personal networks. In addition, participants were asked if they would like to recommend a friend or family member to the study. Potential participants were screened for eligibility when they contacted the researcher on the telephone. The researcher explained the study and gained informed consent over the telephone initially and again in person before the start of the focus group or interview. Participants were reimbursed with a shopping voucher worth Aus $30 (US $21.6) for attending focus groups and interviews and provided with refreshments. Health professionals were recruited using a snowball methodology through the participating services. Health professionals were not reimbursed.Mothers and health professionals participated in separate focus groups and interviews. Focus groups and interviews were cofacilitated by a combination of Aboriginal researchers (NS and BH), a PhD student (SJP), and an app developer. Interviews and focus groups were 20 to 90 minutes in length. The number of participants in focus groups ranged from 2 to 6. Focus groups and interviews were recorded and transcribed, and field notes were taken.Different surveys and discussion guides were used with mothers and health professionals. Discussions and activities were used to identify (1) design characteristics, (2) content modules, and (3) features and functions.The survey comprised 16 items, including demographic, cultural, and socioeconomic items. The items were selected from a previous study , with alIn all focus groups and interviews with mothers, 3 main questions were asked. Follow-up questions were asked depending on responses. Additional questions about mobile phone use to inform features and functions were asked in focus groups cofacilitated by the app developer. The three main questions were as follows:How would an mHealth intervention designed for healthy living for Aboriginal and Torres Strait Islander people differ from other mHealth interventions?Are you more interested in mHealth for your own health or your child’s health? What topics and features interest you?What do you think stops or prevents some women from accessing health information and services for themselves and their children?Card-sorting activities were used to identify current mobile phone use . Storyboarding activity was used to elicit creative descriptions of the mHealth intervention using drawings and words on what the intervention should include. Design activity was used to gain feedback on potential designs.The survey comprised 5 items related to demographic and professional practice characteristics.In all focus groups and interviews with health professionals, 3 main questions were asked. Additional follow-up questions were asked depending on the response. The three main discussion questions were as follows:What do you think are the most important health and well-being topics to include for Aboriginal or Torres Strait Islander women, children, and family?What are the barriers for Aboriginal or Torres Strait Islander families to having good health?What types of mobile technology do you think could support Aboriginal or Torres Strait Islander women’s and children’s health?A generalized thematic analysis was completed. An Aboriginal researcher (BH) and a PhD student (SJP) independently coded themes. NVivo software  was used to complete independent coding and comparison by the 2 coders. In total, 3 predetermined codes were used based on a similar co-design study . These cThe findings from the co-design stage were subsequently used to develop a prototype intervention incorporating an app, SMS text messaging, social media, and videos. The intervention development was an iterative process, with meetings held among the team members to decide the final features and functionalities. Not all ideas could be adopted because of various reasons, such as time, funding, and technology constraints. We used a combination of building new functions (app) and using existing functions (Facebook page and SMS text messaging).cue to action component .” This highlighted why it is important that all content included in the prototype intervention be sourced from credible evidence-based health resources and broken down into palatable small chunks with links to further information.Most of the mothers said that Aboriginal designs, language, and representation were important for engagement. A mother said, “I think if it had Aboriginal designs that would be really good because if I download an app and it doesn’t have the look, like being culturally aware [I don’t use it].” Another mother said, “Don’t make it black and white, it’s got to be like colorful.” A mother spoke about the intervention needing Aboriginal representation in images and videos: “If it’s going to be an Aboriginal app, I think you have to have Aboriginal people.” Another mother discussed using an app for quitting smoking that was not representative of Aboriginal people: “It was easy to use, but I couldn’t relate to it...didn’t seem like it was aimed at Blackfellas even though we thought it was.”It was evident from the mothers’ experiences of racism that the intervention needed to be centered in culturally safety. Some mothers talked about feeling fearful and judged when seeking health care. A mother said, “Being an Aboriginal mum especially, I was just worried about DoCS [Department of Child Services]. Like whether they could see if I was handling having two children on top of my own family breakdown. Like my mum’s kids are in DoCS. So that’s what my biggest fear was.” Other mothers expressed feeling judged about certain health behaviors and topics, and a mother said, “The biggest thing is why people do hide it [smoking], because they don’t want to be judged. They don’t want to hear all that stuff.”welcome message by an Aboriginal researcher was placed on the main page; and all content was cowritten by Aboriginal researchers.To center cultural safety in the intervention, all aspects of the intervention were codeveloped by Aboriginal people: the research was governed by an Aboriginal advisory board and coled by an Aboriginal academic (KH); 4 of the 8 members of the research team are Aboriginal; an Aboriginal graphic designer designed the module icons and logo; Aboriginal researchers were administrators of the Facebook page and shared cultural links, events, activities, affirmations, and images; an Aboriginal videographer filmed all the videos; Aboriginal health professionals presented in the videos; an acknowledgment of Country and a It was decided unanimously that the intervention should include content for both mother and child. A mother said, “Is this just for children’s health? Because I feel like it should incorporate the mother’s health too.” The mothers asked for information on “things to do with our kids,” and “stuff for us women too. Pap smears and stuff like that.” Many of the mothers and health professionals suggested that the intervention needed to encompass the entire family, including the extended family. A health professional said, “Put the main focus on the child and then how their [family] health affects the baby’s health,” and a mother said, “I think a family app would be really good. Like, I know my husband, he’s never been around babies.” Some participants talked about how other family members help bring up children: “It’s nothing to see an aunt bringing up a child, or a grandparent or a sister” [health professional]. Family centeredness in the intervention was therefore conveyed through messaging that families are the most important role models for jarjums  across modules and functions. Links to websites, events, and health information for partners and other family members were included.Most of the mothers and health professionals indicated that it was important that the intervention promoted positive self-esteem and well-being of mothers. A health professional said that the intervention should give new mothers “understanding [of] how tired you are going to be, and it’s okay, ask for help, everyone feels like that but you’re not failing or not doing something wrong.” A mother suggested that we include “some sanity sayings or something like that, or some little sage advice from mums that have been there, done that before, that’d be really helpful,” and another mother said that the intervention could be “like a reassurance type thing.” Mothers and health professionals recognized that motherhood can be “totally exhausting” [health professional] and challenging at times. A mother described the initial period after coming home from hospital: “I didn't know what to do with him. What do I do with this kid? I was lost.” To create an intervention that was supportive of motherhood and of Aboriginal and Torres Strait Islander women, positive and affirming messages were posted on Facebook, sent through SMS text messages, and included in the app. Links on where to seek help for mental health concerns were included.Mothers and health professionals recommended that the intervention be intuitive, use simple language, and have few technical barriers. Some of the mothers talked about trying to use other health apps; however, they were unable to do so because of technological challenges. For example, a mother said, “It was just too hard to log in and get started so I gave up or just called someone.” Many of the mothers and health professionals emphasized that the language used in the intervention needed to be nonjargon. A mother said, “Don’t put it in a textbook. Because I’m telling you, if my family member downloaded that and it was a textbook way, they would be like—No.” Another mother said that the content should be “just little pieces of information...then links to the bigger pieces.” We aimed for simple, intuitive app design and used other mobile functions commonly used by mothers (Facebook and SMS text messaging). To ensure that the intervention was simple and easy to use, health information was presented in short key messages with links to websites for further information. All key messages were written to be at an 8th grade reading level using the Flesch-Kincaid Grade Level Test as recommended by Abroms et al .Mothers and health professionals talked about the importance of confidentiality. Health professionals focused on confidentiality in the health care setting and the complexities for some staff regarding knowing patient health details. A health professional said, “There are big things surrounding our health services confidentiality. People don’t know or want to know what other people’s business is.” Some of the mothers spoke about confidentiality; regarding being anonymous when communicating with other mothers or health professionals in a hypothetical mHealth intervention, a mother said, “Oh God, yeah. I’d ask an anonymous person on a phone. Rather than ask the doctor face to face.” Other mothers were happy to not be anonymous: “It wouldn’t bother me having my name because it would just be, this is my experience, and it is what it is. But I would understand if some women didn’t.” To ensure that women can choose to remain anonymous and keep their information confidential, the intervention design meant that no personal data were collected in any part of the intervention, other than a mobile number for the SMS text messaging component. Joining the Facebook group is an optional part of the intervention.pains after birth, breastfeeding, normal speech for toddlers, signs of autism, earaches, behavior, rashes, high temperatures, and coughs. Similar topics were grouped by the research team and combined into 6 key content modules for women’s health and 6 key content modules for children’s health. For example, birth, reproductive health, urinary leaking, and pap smears became Women’s business. All health topics captured in the interviews and focus groups were included in the intervention within a module on the app, SMS text messages, or through Facebook posts. Health modules for women included Smoke-free families, Safe drinking, Feeling good, Women’s business, Eating, and Exercising. Health modules for children were Breathing well; Sleeping; Milestones; Feeding and eating; Vaccinations and medicines; and Ears, eyes, and teeth.Most of the mothers and health professionals suggested that the intervention needed to cover a wide range of health topics for both the mother and child. Health topics identified in the data included We identified eight features and functions: (1) content feed, (2) social connection, (3) diary and storage of health information, (4) local context, (5) reminders, (6) rewards, (7) talk with health professionals, and (8) use of videos.A content feed was chosen to be a feature of the intervention based on the mothers’ current mobile phone use. During the card-sorting activity, most of the mothers reported scrolling the content feed on Facebook numerous times per day. Of the 13 women who were asked how many hours per day they used Facebook, 12 (92%) reported using it >4 hours per day. When asked what kept them going back to Facebook, a mother responded, “The content keeps changing.” Mothers frequently talked about watching photo and video stories that were uplifting, funny, or motivating on Facebook. They talked about using Instagram and Snapchat, too, although less frequently. The intervention was therefore designed to include a Facebook page with daily posts covering a variety of health content.” A mother described mothers at playgroup being “more like a family to each other.” Some of the mothers said that connecting to other mothers would be helpful because they may be going through the same situation or challenge: “Yeah [I would like to chat with mums in the intervention] because they might have experienced something that I’m starting to experience.” Some of the mothers talked about the possibility of meeting up with mothers outside of the intervention: “It’s hard to meet people...[could there be] like a mums and bubs [babies] thing [as part of the intervention],” and another mother said, “Say, if I needed to ask them a question or something that I wouldn’t want to write on Facebook [I would like to meet up with them in person].” Another mother identified that connection is important for mental health: “When they [new mothers] don’t have anybody, depression kicks in.” The Facebook page was designed to make it easy for mothers to connect and share stories and ideas. Discussion points were created to be posted on the Facebook page to facilitate discussion; for example, “Tell us how you engage your jarjums in cooking or take a pic or video of your deadly (great or excellent) li’l chef in the kitchen.”Mothers talked about the social connection and learning from other women when becoming a mother, including from their “mum,” “mother-in-law,” and “girlfriends.” The importance of positive relationships when first becoming a mother was well recognized by health professionals as well as mothers. It was acknowledged by many of the mothers that some new mothers “don’t have a big support network.A feature that enabled users to store specific information about a child’s health received mixed responses. Some of the mothers thought that having their child’s health information on hand would be of practical benefit when attending medical appointments: “Like a diary section...I found, when [my child] was sick I started recording when I gave the medication, those sorts of things. That’d be good to have an app when you go into the hospital, you go, this is his recordings.” Another mother said, “So they [health professionals] could just add in medication, add in reports...it’d be good because like [the health service] is only open during the week. Usually, like on the weekend, I’d have to go up to the hospital...So it would be good if there was information like after the visit. Because you don’t always take everything in. It goes right over your head.” Other mothers and health professionals thought there would be confidentiality concerns. Because of the confidentiality concerns raised in the co-design process, a diary feature was not included, although it may be considered as an optional feature in future iterations.Many of the mothers and health professionals spoke about the uniqueness of their community and said that the intervention needed to be relevant to each community, including language and environment , as well as health services and other resources. A mother suggested, “You could put in your postcode, location, or area or something and then it could be localized,” and a health professional said, “The contact numbers, if they can’t get into emergency, the [local] health line numbers where they can get a bit of advice would be handy on there as well.” The intervention included phone numbers of local health services for each community in the app, and Facebook posts were designed promoting local health services, events, organizations, and languages.Many of the mothers talked about the usefulness of SMS text messaging reminders from their health services for appointments, and they said that reminders for other areas of health care would be useful too. A mother said, “I would probably like all of them [milestone reminders]. I’d like the whole lot, make sure I’m not missing anything.” Another mother said, “If someone notified me on this app that I’m due for a [pap smear] or something like that, I would like being reminded of things like that.” Most of the mothers said that they would prefer reminders through SMS text messages rather than a push notification from an app because they could go back to the message and reread it. For the intervention, SMS text messages were developed covering a range of reminders, including vaccinations, developmental milestones, check-ups, smoking quit date, exercise, and eating well. Reminders about local health initiatives and events were also created for posting on the Facebook page.. The mothers who were asked about receiving rewards for a variety of health behaviors were unanimous in their opinion that rewards were enjoyable and motivating. In the intervention, weekly competitions were created for posting on the Facebook page involving mothers sharing a picture of a health activity; for example, active play or exercising with their children. Prize draws were also incorporated into the intervention for those who participated in the competitions.The mothers talked about rewards and incentives from health programs and services increasing their motivation. They talked about material rewards such as “shirts,” “caps,” and “supermarket vouchers,” as well as social rewards, including “comments” and “likes” on social media and “clapping” and “cheers” on health apps“The option to be anonymous or not known by people [health professionals] would be handy I guess for more embarrassing health concerns.” Mothers living in rural areas mentioned being anonymous more often in the discussions. Although it was suggested, facilitating a chat with health professionals directly was out of the scope of the current prototype because of cost and resources. Telephone numbers for national, state, and local health services were listed in the app to enable users to connect with health professionals, if needed, regarding the questions they might have.Some of the mothers suggested that being able to communicate with health professionals using SMS text messages or a live chat function would be beneficial. Some of the mothers said that this function would be useful to confirm whether they required face-to-face health care and for reassurance. A mother said, “Sometimes you don’t know if you should go up there [health service] or not, so you could kind of message and say, ‘Hey, this is what’s happening...is it worth coming up or is it just a viral thing going around?’” Another mother said, “I know a lot of women are just like, ‘What do I do?’ So just having that reassurance I suppose online.” Another mother suggested that it would be helpful to be able to ask health questions anonymously: Most of the mothers reported during the card-sorting activity that they frequently watched short videos on social media and YouTube. A number of mothers and health professionals advised us that videos and images may be more accessible and preferable for some mothers. A health professional said, “Videos, everyone can watch a video and understand.” Therefore, a video for each health module was developed for the intervention. Each video was stored in the app and added to the Facebook page. Additional health videos from external sources were also able to be shared on the Facebook page.The final mHealth intervention, named Growin’ Up Healthy Jarjums, aimed to improve health knowledge and health behaviors, along with providing access to health services. The intervention comprises 3 delivery modalities: app, SMS text messaging, and Facebook page.exercise, where they will find small amounts of written information, videos, links to websites, and useful contacts. The user may choose to access any topic, in any order, and consume as much information as they like.The app is a central place for users to access all content. The app is primarily for the user who wants in-depth information and has the necessary digital device, internet connection, and literacy skills to access it. It is designed to allow the user to navigate to the topic of interest; for example, My Health, (2) Jarjums Health, (3) Facebook Page, and (4) Contacts. The user may click on a button to move to the next screen or scroll down to access the embedded Facebook content feed. The embedded Facebook content feed allows the user to remain in the app and read the posts, but to comment or like a post, the user needs to access the Growin’ Up Healthy Jarjums Facebook page. An acknowledgment of Country and a spoken welcome message are also included on the home screen. The women’s health  menu page includes six buttons, one for each of the women’s health modules: (1) Smoke-free families, (2) Safe drinking, (3) Feeling good, (4) Women’s business, (5) Eating, and (6) Exercising. The Jarjum’s Health menu page has the same layout, including six buttons for the children’s health modules: (1) Breathing well; (2) Sleeping; (3) Milestones; (4) Feeding and eating; (5) Vaccinations and medicines; and (6) Ears, eyes, and teeth. Each module, for example, Breathing well, includes (1) Key messages incorporating perceived threat of illness and benefits of changing health behavior; (2) Tips to address barriers to change through reassurance and credible advice; (3) cues to action; for example, “Each time jarjum sees a nurse or GP ask them to have a quick look in bub’s ears to check if there is any infection”; and (4) links to further information, including skills and activities; for example, exercises and healthy recipes to support self-efficacy. The information is presented using small chunks of written information and videos using the same layout in each module.The app has four menu screens: (1) home screen, (2) women’s health, (3) children’s health, and (4) contacts . The homAlongside the app, the prototype included an SMS text messaging library comprising 112 SMS text messages . The SMSThe final modality included in the prototype was the Facebook page. The purpose of the Facebook page was to create community and connection, allow 2-way communication, and use a platform that is highly popular among users. Daily content was designed to be added to the Facebook page, including (1) links to reliable health websites, (2) activities for families, (3) weekly competitions, (4) key messages (written and video), (5) events in the community, and (6) supportive affirmative posts. The page was administrated by 2 Aboriginal team members (NS and BH), who shared posts relevant to their community and region. The Facebook page was embedded into the main screen of the app; it could also be accessed through Facebook. Examples of posts are presented in We codeveloped a prototype mHealth intervention focused on the knowledge of mothers of young Aboriginal and Torres Strait Islander children. The aim of the intervention was to improve health knowledge, health behaviors, and access to health services. The final prototype incorporates 3 modalities—app, SMS text messaging, and Facebook page—and includes a range of health topics. In addition, it is centered on being supportive of mothers and culturally safe.one app fits all approach is unlikely to be successful [The modality choices were based on a few factors: (1) early discussions with mothers and health services about the need for an app that is culturally relevant and safe, (2) evidence suggesting that SMS text messaging is the most effective mHealth function for health behavior change, and (3) findings from focus groups and interviews indicating that Aboriginal and Torres Strait Islander women were high users of Facebook and SMS text messaging. As suggested in a recent pilot study of a smartphone app with Aboriginal Australians, a ccessful . Using mGrowin’ Up Healthy Jarjums intervention to specific mHealth interventions for target behaviors may overcome this limitation by providing tips for more intense behavior change for those people who are ready to change. Third, because the participants were from only 3 NSW communities, the intervention may have limited generalizability in other Aboriginal and Torres Strait Islander communities. Aboriginal and Torres Strait Islander communities are made up of >250 language groups in which there is great diversity. If this intervention is to expand to other communities, systematic adaptation of the intervention would need to be carried out to ensure that the intervention is suitable to the context of each community [The first limitation of this research is that it was initiated by a research institution rather than by the community itself. True co-design should begin with completing a needs assessment with communities to see what the health priorities and potential solutions are for that community . This isommunity .A key strength of this study is that Aboriginal researchers  led engagement with participants and community organizations. Understanding the importance of trusted and strong cultural relationships, we only engaged with communities that the Aboriginal researchers had a relationship with, which likely resulted in trust as well as interest in participating in this study. Another strength of this study is the thorough reporting of the co-design processes. Inadequate reporting of intervention development was identified as a weakness in a recent systematic review on mHealth development (33). An additional strength is the involvement of primary health services and professionals. A recent review on health promotion programs in Aboriginal communities highlighted that an important consideration is to partner with primary health care services because they are well placed with frequent patient contact, health expertise, and often intricate knowledge of the community . A finalsocial connection and family centeredness, reflect Aboriginal and Torres Strait Islander perspectives of health. Connection to family, community, and culture, among other factors, are understood to be equal contributors to health [Design characteristics identified in this study, including o health . Arabenao health  suggest Deadly Choices, has 94,035 Facebook followers, 19,300 Instagram followers, and 9000 TikTok Followers [The finding that Aboriginal and Torres Strait Islander women were high users of social media, in particular Facebook, was unsurprising. Aboriginal and Torres Strait Islander health organizations have capitalized on the popularity of Facebook among Aboriginal and Torres Strait Islander people and have been early and adept users of social media for health promotion . An Aborollowers ,45.As stated earlier, the methodologies used in this study were based on a co-design study for a health app with Māori and Pacific Islander people ,40. TherCulture was also identified as important in both studies, although cultural representation may have been a more nuanced finding in the New Zealand study. In our Australian-based study, participants expressed the importance of Aboriginal and Torres Strait Islander representation in terms of designs, colors, images, people, organizations, and safety. Participants in the New Zealand study ,40 expreGrowin’ Up Healthy Jarjums intervention is shown to have adequate acceptability and feasibility, the next phase will be to measure its effectiveness in improving health knowledge and changing health behaviors. Assessing the effectiveness of this intervention will provide valuable evidence for the use of mHealth in improving the health and well-being of Aboriginal and Torres Strait Islander populations and contribute to the evidence for using co-design methodologies, both of which have been highlighted as gaps in the literature [An mHealth intervention that included app, SMS text messaging, and Facebook page modalities was developed based on co-design findings. The intervention incorporates health behavior change theory, evidence-based information, and the preferences of Aboriginal and Torres Strait Islander women and health professionals. The next step of this research is to assess the acceptability and feasibility of the intervention in a pilot study. The pilot study will be conducted with the Aboriginal Health Services and NSW Health sites that participated in this co-design study. Participating mothers will also be invited to participate in the pilot study. If the terature .


COVID-19 vaccination effectively reduces severe disease and death from COVID-19. However, both vaccine uptake and intention to vaccinate differ amongst population groups. Vaccine hesitancy is highest amongst specific ethnic minority groups. There is very limited understanding of the barriers and facilitators to COVID-19 vaccine uptake in Black and South Asian ethnicities. Therefore, we aimed to explore COVID-19 vaccination hesitancy in primary care patients from South Asian (Bangladeshi/Pakistani) and Black or Black British/African/Caribbean/Mixed ethnicities.Patients from the above ethnicities were recruited using convenience sampling in four London general practices. Telephone interviews were conducted, using an interpreter if necessary, covering questions on the degree of vaccine hesitancy, barriers and potential facilitators, and decision-making. Interviews were transcribed verbatim and thematically analysed. Data collection and analysis occurred concurrently with the iterative development of the topic guide and coding framework. Key themes were conceptualised through discussion with the wider team.Of thirty-eight interviews, 55% (21) of these were in Black or Black British/African/Caribbean/Mixed ethnicities, 32% (12) in Asian / British Asian and 13% (5) in mixed Black and White ethnicities. Key themes included concerns about the speed of vaccine roll-out and potential impacts on health, mistrust of official information, and exposure to misinformation. In addition, exposure to negative messages linked to vaccination appears to outweigh positive messages received. Facilitators included the opportunity to discuss concerns with a healthcare professional, utilising social influences via communities and highlighting incentives.COVID-19 has disproportionately impacted ethnic minority groups. Vaccination is an effective strategy for mitigating risk. We have demonstrated factors contributing to vaccine reluctance, hesitancy and refusal and highlighted levers for change. COVID-19 vaccination is an effective strategy to reduce the spread of infection and prevent severe disease, hospitalisation and death from COVID-19 . In the Vaccine hesitancy is a complex, context-dependent phenomenon . VaccineRecent quantitative surveys have explored the reasons for COVID-19 vaccine hesitancy, demonstrating concerns about vaccine side effects, long term effects on health, the speed of development of the vaccines and belief in conspiracy theories and misinformation .The disparities in COVID-19 vaccine uptake have profound implications. The pandemic has disproportionately impacted ethnic minority groups with much higher infection, hospitalisation, and death rates than White populations . WithoutThere is an urgent need to understand the factors that cause vaccine reluctance, hesitancy, and refusal and how to facilitate engagement with vaccination programmes. Primary care in the UK has had a unique role in vaccine delivery during the pandemic, mobilising to deliver millions of vaccines to the population over a short time frame, particularly to those most vulnerable. This study sought to explore barriers and facilitators to COVID-19 vaccine uptake–in key ethnic groups that have reported higher hesitancy rates–from the unique position of primary care.The research team conducted semi-structured qualitative interviews by telephone with patients who identified as belonging to ethnic groups previously identified as most hesitant ,7,19 andParticipants were identified by a systematic search of the practice electronic systems for all patients aged over 18 who identified as Black British or Black African, Black Caribbean, South Asian (Bangladeshi or Pakistani) ethnicities (or mixed ethnicity pertaining to one of the above), as coded by the practice. Further inclusion criteria included those who could consent, had declined or delayed vaccination, or had not yet received a COVID-19 vaccination. The researchers hand-searched the electronic records for patients who had accepted a COVID-19 vaccination but were significantly delayed compared to their initial invitation. Ethnicity was self-reported. The list of eligible participants was sampled with monitoring of patient demographics throughout the study to recruit a diverse sample regarding age, gender and ethnic grouping. All researchers were practising general practitioners who had decided to receive the COVID-19 vaccines. Potential participants were contacted by the team member working at the practice the patient was registered with and given a brief verbal description of the study by telephone. All individuals interested in participating were emailed, texted or posted a participant information sheet and consent form, and invited to a telephone interview at a mutually convenient time. The consent form and patient information sheet were translated into Bengali, Pakistani Punjabi, and Urdu.Ethics was granted by the Health Research Authority and Care Research Wales (REC 21/2M/0063). Participants were assured that their involvement or refusal to be involved would not affect their clinical care and received no financial reimbursement. All participants who agreed to take part provided written consent and consented to audio recording. The data were analysed anonymously.Interviews were carried out between May and August 2021. Although interpreters were offered to all participants in a language of their choice, this offer was taken up in one interview using an interpreter from a professional interpretation service.Participants were asked to provide demographic data on age, sex, occupation, comorbidities, previous non-COVID vaccine uptake, geographical location, country of birth, and education level. They were asked directly whether they would accept a COVID-19 vaccination if offered. Data collection and analysis occurred concurrently, as common in qualitative research . The autParticipants were asked about the COVID-19 vaccines and factors and information sources that had informed their decision-making, including previous experience with healthcare and vaccinations. As the study progressed, further prompts and probes were added to develop a richer understanding of the patient experience and possible themes.Interviews were audio-recorded, anonymised, transcribed verbatim by a professional transcription service, and checked for accuracy. Transcripts were analysed using NVivo software (version 12). Data analysis was inductive, informed by thematic analysis, as outlined by Braun and Clarke . After tThe research team conducted 38 interviews between May and August 2021, with a response rate of 53.5% (38/71). Interviews lasted between 15 and 45 minutes. Of those interviewed, 55% (21) identified as Black/ Black-British, 32% (12) as Asian / British Asian, and 13% (5) as mixed ethnicities. The mean age was 50.5 years, and 58% (22) were female. Around a quarter of participants (26%) had qualifications beyond A-level. Of those who declined to participate (33) in the study, the most common reason given was lack of time. The majority (66%) of those who refused were of Black British ethnicity. Of those interviewed, 37% participants expressed that they would not get the vaccine, 37% stated that they were not sure yet about getting the vaccine, and 26% said that they intended to get the vaccine or had it already, albeit with a significant delay of weeks or months after the initial invitation. There was a multiplicity of views and concerns raised by participants. Key themes for barriers included concerns about the speed of vaccine rollout, concerns about the vaccines’ known and unknown effects on health, mistrust of official information and exposure to misinformation. Key themes for facilitators included discussing concerns with healthcare professionals, social influences and highlighting incentives.There were multiple reasons given for COVID-19 vaccine hesitancy and mistrust, which reflected the diversity of the participants, and were categorised into key themes as listed below. A practical summary with recommendations to address these barriers is provided in The speed of roll-out was widely cited, with some participants stating that as a result, they saw the program as experimental. More than half of participants across ethnicities raised specific concerns about the speed of vaccine design and implementation, including the majority of Black British participants, with associated suspicion that adequate testing had not been carried out. Several participants also questioned why scientists cannot find treatments and cures for conditions that have been around longer than COVID-19.“I think the wisest thing to do is just let things play out and take it last. I think everyone in my circle’s quite like that, just see what happens.” P25, Black African, 31 years, Male“The cancer and AIDS, they’ve not been able to come up with anything substantial there for many, many years, but all of a sudden, for coronavirus, they’ve come up with some sort of vaccination that’s supposed to be 80% good.” P7 Black Caribbean, 52 years, MaleMore than one-third of participants expressed concerns and fears about the vaccination programme being experimental, with the term “guinea pigs” used specifically by four Black British participants. Several participants further expressed fears about racial experimentation and likened this to historical events.“And so it is an experiment, but it’s not acknowledging that there is an experiment. In fact, there are very few people who would say that we’re being experimented on, which in fact we are. In my opinion.” P16, Mixed/multiple ethnicities, 60 years, Male“But now with this vaccine, everybody is going to be a guinea pig because they don’t know enough information” P6, Black British Caribbean, 56 years, Female“I’m not sure because I think that they’ve been experimenting on Black people with the drugs all over the place. They would want for us to go and take this thing and if it works on us and they pass it on to everybody else.” P15, Mixed White/Caribbean, 67 years, MaleA range of concerns relating to the vaccines were raised by participants, including the risk of side effects, the impact of vaccine ingredients, and uncertainty of the possible protection and benefits provided by the vaccine.Concerns about side effects were mentioned by nearly all participants, particularly by participants with comorbidities. Concern over the harm of blood clots was the most frequently mentioned side-effect, with some participants also citing fear of the impact on fertility and pregnancy and even the risk of death. In addition, fear of unknown side effects that may present in the future was cited as a rationale to delay taking the vaccine, with the impact of the Thalidomide scandal cited several times.I don’t want to put stuff in my body that’s going to make it worse… Why would I put Pfizer that in some studies, they’ve ended up with an enlarged heart and arrhythmia?… I already have those issues. I’m not going to exacerbate them.” P29, Asian British, 56 years, Female““I worry about what I’ve heard. People are dying because they have clots” P2, Black British, 68 years, Male“…At the time they were like, yes, it’s safe, [Thalidomide], it took them five years to realise the connection…So if here we are taking this vaccine during pregnancy … but at the same time, we don’t know the long-term effects. So why are you risking it?” P38, British Asian, 31 years, FemaleOne-third of participants expressed uncertainty and concern about vaccine ingredients and the potential impact of these on health. Whilst this was in most cases not expressed as the main reason for vaccine delay, it was perceived as an additional contributor by several participants.“I just don’t trust all the chemicals that they (vaccines) put in your body.” P11, Multiple/Mixed ethnicities, 56 years, Female…The things that it has in it like element, like chimpanzees’ something… What else is it? I think it’s some kind of filling…” P12, Black Caribbean, 56 years, Female“One-third of participants expressed concerns about whether having the vaccination would even protect them or others from coronavirus, a view expressed solely by Black British participants. This led them to question if the risks and uncertainty of the vaccination’s impact on their health were worth it.“Particularly me, I don’t know if you really are going to get protected if I got vaccination?” P18, Black African, 40 years, FemaleParticipants described a range of information sources to obtain an understanding of COVID-19 and COVID-19 vaccination. Television and radio programmes, internet searches and social media posts, including videos sent via WhatsApp, were commonly cited. Whilst, not all social media messages received from friends and family were believed, many participants demonstrated a high level of exposure to misinformation via this means. All participants gave examples of exposure to negative or concerning messages about vaccination. Several participants specifically addressed the idea of misinformation and had theories as to why inaccurate information was reaching them.A lot of it [information about coronavirus] comes from WhatsApp, through the different groups that I’m part of. I do believe some of it is scaremongering, I’m not sure about the 5G….” P7, Black Caribbean, 52 years, Male“I think it was fear that was driving it (spreading misinformation) to be honest. It was such a difficult time and there were people who were really scared, there was almost like a paranoia.” P20, Asian British, 40 years, Female““I guess because there was no information coming from the government, there was an empty space, and echo chamber, and people filled the space with conspiracy theories” P10, Multiple/Mixed ethnicities, 50 years, MaleAs well as discussing exposure to a range of information sources, a number of participants described a mistrust of information from official information sources, often resulting from mistrust of the authors specifically. One-third of participants expressed mistrust of government across a mix of ethnicities. One-fifth of Black British participants expressed mistrust in pharmaceutical companies, which in some cases were considered to be in league with the government. This mistrust contributed to mistrust in the vaccination, with participants expressing the view that these organisations had ulterior motives for wanting vaccination that did not account fully for participants’ safety. A number of participants were clearly not aware of official information on current available data on vaccination safety, and the research process that the vaccination had undergone.“And with the government rules, they’re breaking the rules, you know the stories that go around …how can you trust a government that keep on breaking the rules?” P36, British Asian, 36yrs, Male “Actually, the vaccines out there are making lots of money for pharmaceutical companies. And we know, I know, that there is actually far cheaper treatments out there that are equally as effective and actually I really don’t know how effective the vaccines are.” P34, Black British Caribbean, 43 years, MaleParticipants often described information originating from different sources, and in some cases, countries, as conflicting, and as a result they expressed uncertainty about what to believe, highlighting the ‘infodemic’ nature of this pandemic.“Basically, there’s a lot of conflicting information… if you listen to French news, you get some conflicting news… If you go the other side of Europe, similar… It has been conflicting, right across board, the whole world” P26, Black British African, 70 years, Male“A lot [of information is available]. Sometimes it’s only bad, but we don’t know what can we trust? It’s good, or it’s not good. Especially me, I end up in the middle, I don’t know.” P18, Black-British, 40 years, FemaleInterestingly, not all participants felt they wanted more information about the vaccination, as they already felt overwhelmed by the current information they had received. However, several participants stated that clearer messaging to develop a better understanding of the safety of the vaccine was needed and would help them or others they know to understand the vaccine better.“So short-term probably engagement in terms of leaflets and maybe little snippets of a video, say on the BBC, about the vaccine, and about its safety and something about clinical trials. Maybe some of this stuff is already out there, but if stuff like that goes viral it counteracts some of the negative and misinformed things that are in videos that are doing the rounds.” P20, Asian, 40 years, FemaleThere were several suggested mechanisms to improve vaccine uptake.Participants were asked directly if they believed doctors were giving them correct information about COVID-19. Most participants expressed the view that they trusted information from healthcare professionals. When asked directly about their experience of healthcare and if they felt they were treated differently, all participants, except two, expressed the view that their experience of healthcare was good. Participants were then asked if there was anything GPs could do to change their minds about vaccine uptake. More than half of the participants agreed that an opportunity to receive clear and understandable information from their GP would be helpful to address vaccine hesitancy.“I feel like the doctors are in the same position as everyone else, trying to understand what’s actually going on. So, no, I don’t believe they’re giving incorrect information.” P1, Black African, 30 years, Female“I think certainly the doctors, they can do a lot. Because the worry itself can kill, you know. But if a person speaks to a doctor and the doctor answers calmly and tries to explain” P33, Black British, 61 years, MaleMost participants expressed that they did not feel seeing celebrities taking the vaccine would influence them. The justification often given was that celebrities were not seen to be any different from them, being described as “normal people” or “human beings” and did not appear to be a particularly trusted source.“Celebrities are just celebrities, they’re just ordinary people just like you and I. Them taking the vaccine doesn’t mean anything and I can’t prove they’ve actually taken the vaccine.” P5, Black Caribbean, 82 years, FemaleThere was variability amongst participants about the role of community leaders which appeared to be linked to how well-embedded the individual was in their community. More than half of participants who appeared to have strong community links or knowledge of local leaders felt they would have a role in vaccination promotion. A few participants recognised religious leaders as having a role in vaccination promotion for those with religious beliefs and for those who attended religious institutions regularly“I think it’s about [community leaders] taking it themselves. By demonstrating that they’ve had taken it and over time showing them that everything’s okay.” P12, Black Caribbean, 56 years, Female.“In the ethnic minority community, churches would be a good way. So through the pastors, that would be, or if it’s Islam, it should be the imam, that would be very good.” P10, Mixed African/Caribbean, 50 years, MaleWhen considering facilitators that would encourage them to get the vaccine, some participants mentioned external incentives as motivators; these included being able to travel and see older family members. In addition, one participant suggested how vaccination could impact everyday freedoms, such as the ability to attend sporting events safely.“Get the vaccine now, and in three months’ time I will be flying out of the country for a little while, I do that every year. And they said we have to have two. So I want this year to get the other one, that’s the reason…” P5, Black Caribbean, 82 years, Female“I think what was in the forefront of my mind is my elderly mother. So I thought that that was really important for the family time, but then also, I wanted to get on with my life.” P24, Black African, 45 years, Female“Imagine a football stadium at the turnstiles…To watch our matches you’ve got to have a vaccination. So it’s really those practical real life situations that will get people’s attention.” P22, Black African, 58 years, MaleIn this study of the barriers and facilitators of vaccine uptake in ethnic minority groups, participants highlighted a diversity of reasons for COVID-19 vaccine hesitancy which were grouped into the following key themes: concerns about the speed of vaccine rollout, concerns about the vaccines’ known and unknown effects on health, mistrust of official information and exposure to misinformation. Many participants demonstrated high exposure to misinformation from social media, family and friends. This led to uncertainty and a sense of conflicting messages surrounding vaccination. In addition, some participants were mistrustful of government and pharmaceutical companies and their motives for vaccine deployment, which led to mistrust of official information sources.Table 2.Participants identified that positive vaccine messages from trusted professionals such as GPs would help change their minds about vaccination. Some respondents stated that incentives, such as the ability to travel and see older family members, increased their likelihood to have the vaccine. Key implementation messages addressing the barriers and facilitators identified by participants have been highlighted in This is the first exploratory study, to our knowledge, in UK primary care that directly examines the views of COVID-19 vaccination from ethnic minority groups which have previously been identified as having the lowest COVID-19 vaccine uptake and highest reported vaccine hesitancy. Patients were diverse in terms of age, gender and educational backgrounds and reported a wide range of views and beliefs. The validity of the study is enhanced by using iterative data collection and analysis concurrently and in-depth interviews to gain a richer understanding. The findings have direct implications and applicability for the current COVID-19 vaccination programme. Of note, during study recruitment and analysis, the vaccine schedule was updated with more participants becoming eligible.Although all the researchers agreed on reaching data saturation, the numbers of some ethnic groups in the study are relatively small, and the groups themselves are diverse with a wide range of social, cultural and historical differences. Beyond this exploratory study, further research could seek to find out the variations between different ethnic groups and age-related differences in more detail. The research team attempted to consider how their backgrounds influenced the interpretation of the data through active reflexivity; however the team’s ethnicities did not match the ethnic backgrounds of the participants. Therefore, some participants’ responses may have been influenced by the researchers’ professional training , relatioThere is emerging qualitative and quantitative evidence on possible reasons for COVID-19 vaccine hesitancy, which aligns with our findings ,36. HoweThe majority of participants did not have qualifications beyond A-levels; this resonates with a previous study on global trends in vaccine confidence, which identified that fewer years of education was associated with decreased vaccination uptake . PreviouAttitudes surrounding vaccination from specific groups may ultimately reflect a more general underlying world view or “attitude root”, which manifests to motivate rejection of scientific evidence . This stThe findings also concur with previous recommendations on the need for targeted information, resources and support services around the COVID-19 vaccine for individuals from ethnically diverse backgrounds , and theThe endorsement from trusted healthcare professionals has been one of the most powerful correlates of vaccine acceptability among patients , this reThis study provides valuable new insights into the barriers and facilitators of vaccine uptake in ethnic minorities in the UK. Given the high mortality of COVID-19 amongst these groups, the results are immediately relevant to the current COVID-19 vaccine deployment and efforts to encourage ‘booster’ vaccination.Interventions for practice include tailored public health, in-reach campaigns to develop trusted relationships between local communities and healthcare providers delivering vaccination, working to address the concerns of these groups specifically. We know that knowledge provision alone does not lead to active behaviour change , therefoFuture research should explore the similarities and diversities between our findings and the facilitators and barriers to uptake in other vaccine-hesitant population groups such as those from lower socioeconomic backgrounds, Gypsy, Roma and Traveller populations and migrant groups amongst others, to consider generalisability . ProjectMany individuals from ethnic minorities remain unvaccinated across the UK, and in the context of high COVID-19 infection rates, future policy efforts and funding must focus on mitigating those risks through targeted campaigns and support to prevent widening health inequalities and inequities.The COVID-19 pandemic has led to disproportionately high cases, hospitalisation and mortality in ethnic minority groups, who already face major disparities in health outcomes . In addiThis is the first exploratory qualitative study about the specific barriers and facilitators in ethnic groups identified as having the lowest COVID-19 vaccine uptake and highest reported vaccine hesitancy. This primary-care based study can help tailor public health campaigns to specifically address the concerns of these groups regarding experimentation and vaccine ingredients, as well as providing reassurance on the speed of vaccine-roll out and the known side effect profile. Vaccine providers can equip themselves to support individuals from these ethnicities to make informed decisions about whether to take a COVID-19 vaccine by seeking to understand previous misinformation exposure, providing tailored information, addressing how different ethnicities were involved in vaccine studies to date and harnessing social influence and intergenerational information transfer through partnering closely with local community and faith groups.


Career choice is a complex, multifaceted process affecting all aspects of life. Motivational factors of aspiring dentists are crucial to inform institutions and aid with the admission process. The aim of this study was to explore undergraduate dental students’ perceived motivation for their career choice in the first dental institution in the State of Qatar to bridge the gap in knowledge in this area.Homogeneous purposive sampling technique was employed to collect data from all year 2 and year 3 undergraduate dental students to gain a deeper insight into their motivation of career choice. An explorative qualitative method using face-to-face focus group sessions were utilized. All focus groups were conducted in English and contained a moderator and observer. A topic guide was used to ensure data collection standardization. Participants’ views were recorded and filed notes obtained. Data was transcribed and analysis performed utilizing an inductive thematic approach.A total of 34 students (89.5%) from year 2 and 3 participated in the focus groups. Data analysis revealed six main themes emerging from this study namely; altruism and patient care, family influence factors, childhood aspirations, hands-on practical skills, professional and social status, and the opportunity to reconsider and transfer. Based on frequency, altruism, opportunities to learn hands-on practical skills and professional status appeared to be the main drivers influencing students’ choice of dentistry as a professional career.This qualitative study presents the first national study providing insightful information regarding current undergraduate dental students’ decision process in relation to their profession selection, and shows that opportunities to provide patient care seems to be the key to motivation. There was also a strong inclination towards performing hands-on practical tasks as a dentist, and developing a professional status. Interestingly, financial reward did not feature as a motivational factor in this study. The study highlights the influence of socio-cultural and economic factors on choosing dentistry as a career. This data could help dental institutions better understand future applicant’s motivations to join dentistry and assist with the academic recruitment/admission process and targeting students with a potential to excel in the profession. Career choice is a complex, multifaceted process affecting all aspects of life. Selecting a career option is one of the most important decisions an individual makes. Students entering higher education may end up choosing a particular field of study regardless of their interests and talents –3. A wroMotivation provides an individual with power and direction to progress. Educational motivation is a prerequisite to learning and is a factor that helps the learner maintain continuity and enjoy the learning experience . The perst century, the supply of dentists per capita has expanded and is projected to increase further [Over the decades, more attention has been paid to the key role of dentists in improving the quality of dental care through preventing, diagnosing and treating oral disease, and further extends to educating patients and changing behavior. Despite the expansion of services and the technological improvements, oral health inequalities continue to persist and the demand for qualified dentists remain a national target . Since t further . Many fa further , 3, 6, 7The dental profession is currently facing a time of unprecedented change, with continual advancement in techniques, materials and products , a signiOvertime, authors have explored a wide range of motivational factors underlying applicants’ career choices. Most of the published research however, has been survey-based, using different instruments, and pre-set “author” designed questions, generating findings that are not necessarily comparable . QualitaLimited data is available concerning career choice in developing countries, specifically within the Gulf Cooperation Countries. The State of Qatar has recently established the first Dental College in 2019. The dental program lasts 6 years and entrance to the program depends on the results of General Secondary Education Certificate or equivalent certificate based on the British or American curriculum. Admission criteria include a high level of academic performance, including internationally recognized tests in English and mathematics. Candidates are ranked competitively, shortlisted and then invited to a structured interview. It has been suggested that admission methods evaluating motivation could help dental schools better understand applicant’s interest in the profession, help select future successful practitioners, retain a motivational workforce and support personal professional development , 15. TheThe aim of this study was to explore undergraduate dental students’ perceived motivation for their career choice, using qualitative focus group data collection measures to shed further light and generate a deeper and richer understanding. The outcomes of this study will be used to advance knowledge regarding motivations in this region, to help inform stake-holders and facilitate the admission process.A qualitative study design using focus groups was deemed appropriate and applied to this study, as the aim was to explore, in-depth, the perceptions of dental students. Ethical approval was obtained by the institutional review board at Qatar University (IRB No. QU-IRB 1596-EA/21). Focus group sessions as data collection methods was utilized to uncover dental students’ perceptions and values for choosing dentistry as a career, and identify emerging patterns in a digital generation, encompassing those who were born into or raised in the digital era, with wide-spread access to modern-age technology. This methodological approach was selected to gain a deeper insight into an undergraduate dental program with a relatively small cohort size . HomogenAll undergraduate year 2 and 3 dental students, Qatari and non-Qatari, were invited to participate and received official emails notifying them of the aim of the study including a participant information leaflet. Participation in the study was voluntary, and a prior written consent was obtained. All participants were reassured that responses will be anonymous and dealt with confidentially. The authors carefully planned the face-to-face focus group sessions, the venue for the focus group session was accessible and convenient to all participants and booked beforehand. Spacious rooms within the dental college, with enough light and ventilation, were selected to conduct the sessions. Semicircular or circular seating was designed to allow participants to see, listen to and engage with one another during the discussions .A topic guide was developed for the focus group discussions to standardize data collection and help keep the discussion relevant to the research aim. The guide evolved based on a discussion with the research team and a literature review. It contained open-ended and neutral probing questions to avoid socially desirable responses. Guiding questions included why students selected dentistry as a career profession, what were the motivations/drivers, any internal or external factors directly or indirectly influencing their choice, and their perception regarding dentistry as a career choice? All face-to-face focus groups were conducted in English, contained a moderator and observer, and lasted approximately 60- 90 min each, to avoid participant fatigue, but ensure comprehensive data collection. Issues emerging from group discussions were probed further and participants were encouraged to elaborate on their responses further . The stuFocus groups were audio-recorded and transcribed. Data was cleaned and returned to participants for any comments. Six main stages to analyze data were followed in this study; familiarization, coding, finding themes, reviewing themes, synthesizing and defining themes, and producing a final report . The proDemographics of participants included age ranging from 19 to 22 years old, and gender distribution of: Year 3 (n = 14) had 2 groups, one with 7 females, no male participants, and the other with five females and 2 male participants. Year 2 (n = 20) included 3 groups; the first with 7 females and 2 male participants, the second with 3 females and 1 male participant, and the third with 5 females and 2 male participants. Findings from the analysis are depicted in Fig. “My father wanted me to study dentistry to be respected” .“I think what motivated me was my uncle is a dentist, so I was like I want to pursue this career too” .“My family always telling me that I have good hand skills and should apply for dentistry” .A strong family influence guiding students towards their future career direction was evident among the participants. Some students admitted that applying for dentistry was not purely their decision; they were encouraged by their families to consider Dentistry as a career. Delving into that, students felt influenced by their family because either a family member is a dentist, family thought the student had the required skills to become a dentist, or the cultural repute of dentists being highly regarded.“I didn't apply to medicine or any other healthcare profession because when watching YouTube videos on dentistry and how they do things, when carving wax for example, that really intrigued me.” .“I am good at drawing, and I think dentistry is art and that’s why I applied” .“I like doing things with my hands, so I chose dentistry” .The choice of a dental career profession related to the art and science of dentistry was evident. Out of the cohort of participating students, 35% (n = 12) showed interest in dentistry for being a hands-on practical career. Some were attracted to the “applied” aspects of dentistry:“I liked engineering and medicine, but when I saw dentistry, it combined both in terms of hands-on practice and patient care” .“When I explored dentistry, I realized it has a promising future and integrates both art and medicine and science technology to take care of an individual person. It also has the aesthetic perspective” .Interestingly, the perception of some students revealed that dentistry is a mixture of medicine and engineering, and hence, has the advantage of combining the health knowledge and patient interaction of medicine, with the art and science of engineering.“Actually, it was my childhood dream to become a dentist” .“I have always wanted to be in a healthcare profession from the beginning and dentistry was my option” .“I had a terrific experience of dentists since childhood” .The aspiration to dentistry from a young age, paving the path for this chosen discipline was evident among the participants. Students reported examples such as, acquiring a positive experience at the dentist as a child. This experience made them consider dentistry as a career.“I prefer dentistry for many little reasons, one of which is the identity” .“It's a new college in Qatar, and I thought it's a very nice opportunity.. making my country proud” .“I realized it has a promising future.. people will respect me” .“For me, being a dentist is prestigious” .Dentistry, as a profession, is ranked as a highly respected and well-paid career. Within the study participants, dentistry as a health care profession was perceived to be a prestigious career, highly respected. Interestingly, none of the participants in this study raised the financial income as a motivational reason for selecting this career.“I transferred from pharmacy as I always wanted to have more communication and contact with the patients and be able to treat them” .“I want to give people a nice smile” .“I think I’m a pure extrovert; I enjoy socializing with people, caring for them … and the dental profession is a people-oriented profession” .The privilege in providing patient care and working with people was also frequently mentioned within the cohort of students. The participants perceived dentistry as a “people oriented” profession, where they would have direct contact with the patient and feel rewarded.“I found medicine boring” .“Dentistry is more focused on one thing which is the oral cavity, but medicine covered a lot of topics” .“Engineering has a lot of physics and math, so I preferred a healthcare profession like dentistry; I wanted something to be really practical” .“Pharmacy was not as hands-on as dentistry” .At Qatar University, once students are accepted on a particular “Major” and enroll in the first year, they have the opportunity to apply for a transfer to a different college within the university if they meet the requirements at the end of the first academic year. Therefore, if a student realizes in their first year of a particular college that they have made the wrong choice, they might be able to transfer provided places are available too.An individual’s career choice is a crucial long-life made decision, most likely to have a direct impact on their future, wellbeing and the role they play in the society. The processes leading to a career choice has been described on the basis of individual differences in aptitudes and personality, in addition to sociostructural conditions, emphasizing social class and opportunity structures .Motivational factors of aspiring dentists have been investigated over the years , 22–28 aOverall, results of this study highlighted a range of opinions related to individual motivations to pursue a career in dentistry. One can observe from the gender distribution of the participating cohorts, that the majority of students were females. This is dictated by the rising number of female applicants to study dentistry in Qatar; a phenomena taking place world-wide , 29–31. Self-motivation was found to be a key motivation for a career in dentistry in Germany and Finland . In thisAcquisition of hands-on practical skills was also highlighted as a reason influencing students’ career choice. Clinically, in order to perform dental procedures, a dentist must be adept to work with precision on an extremely small scale. Additionally, superior eye-hand coordination is crucial to ensuring the safety of patients and the integrity of the profession . This stMedicine and dentistry are intimately connected, however, at an undergraduate level, medical students are expected to perform basic practical skills, such as performing electrocardiography (ECG), delivering intravenous (IV) and intramuscular injections (IM), suturing superficial wounds and Bladder catheterization . In compThe interest of the currently explored “generation Z” in hands-on practical tasks could also stem back to them being a “digital” generation. Using computers, texting on their phones with others, and playing video games are all activities that have been found helpful in improving manual dexterity . EvidencChildhood aspiration and general interest in dentistry was reported within the study cohort as a common theme behind individual’s career choice. Interestingly, previous evidence has reported that occupations are chosen at an early age, especially in the context of a scientist career in comparison to other career directions , 45.U.S. News and World Report’s annual “list of the 100 best jobs”, dentists and orthodontists are frequently named two of the best jobs. [Dentistry, as a highly respected profession, with a social status and a prestigious career was also reported within the study cohort as a reason behind an individual’s career selection. In line with previous questioner based studies, a professional job related factor was evident , 33, 34.st jobs. . Flexiblst jobs. . Previoust jobs. , 27, 33.st jobs. . Qatar nst jobs. , 50.Altruism is a term referring to the practice of selfless concern and devotion to others; in simple words, the desire to help, and act to promote someone else’s welfare . The mosThe ability to reconsider one’s initial choice and the option to transfer between colleges is an advantage. Within the participating cohort, a transfer specifically from either the medical or pharmacy colleges was recorded. Despite the scientific nature of the above-mentioned colleges, dental career path was favored and reconsidered due to the hands-on practical nature and close patient interaction within the dental profession. On the contrary, previous surveys have reported that dental college was the second favored choice, with medicine in the first rank, among the participating dental students . AlthougThe primary strength of this study is that all current undergraduate dental students participated in this qualitative research conducted via face-to-face focus group sessions. To further strengthen the methodological aspect, each session was conducted with a presence of two researchers; a moderator and observer. Additionally, no previous study of this nature has been looked into in the State of Qatar. However, this study only included views of a sole dental school and the small number of currently enrolled undergraduate students are recognized limitations, limiting the generalizability of study findings.This is the first national study in Qatar exploring dental students’ motivations for their career choice. The findings provide baseline data to inform the admission process.A range of opinions on the ideal size of focus groups has been reported in the literature ranging from 4 to 12 participants to yield diversity in information provided and allow in-depth exploration , 55, 56.The main limitation of the study is that we did not explore the influence of demographic factors, particularly gender, on choosing dentistry as a career. Future research could monitor the participants longitudinally to evaluate any correlations between motivation and academic performance.This qualitative study presents the first national study providing insightful information regarding current undergraduate dental students’ decision process in relation to their profession selection, and has concluded that students perceived their motivation to be mainly related to patient care. There was also a strong inclination towards performing hands-on practical tasks as a dentist, and developing a professional status. Interestingly, financial reward did not feature as a motivational factor in this study. This data could help dental institutions better understand future applicant’s motivations to join dentistry and assist with the academic recruitment/admission process and targeting students with a potential to excel in the profession.


Kolmogorov’s axioms of probability theory are extended to conditional probabilities among distinct (and sometimes intertwining) contexts. Formally, this amounts to row stochastic matrices whose entries characterize the conditional probability to find some observable (postselection) in one context, given an observable (preselection) in another context. As the respective probabilities need not  be of the Born rule type, this generalizes approaches to quantum probabilities by Aufféves and Grangier, which in turn are inspired by Gleason’s theorem. Still another example is the representation of an entity by isomorphic graphs.A physical system or a mathematical entity may permit not only one “view” on it but may allow “many” such views. For the sake of an illustration, imagine a metaphor mentioned by Schrödinger  cognition of ontology and might appear both trivial and sophistic at first glance. Nevertheless, it may be difficult to find means or formal models exhibiting multiple contextual views of one and the same entity. Many conceptualizations of such situations are motivated by quantum complementarity ,3,4,5.A “view” or (used synonymously) “frame”  or “cont(i)largest or maximal in the sense that any extension yields redundancies,(ii)finest resolution in the sense that the respective observables or properties are “no composite” of “more elementary” ones,yet at the same time in the (iii)mutually exclusive observables in the sense that one property or observation excludes another, different property or observation, while at the same timecontains only (iv)simultaneously measurable, compatible observables or properties.includes only In what follows, I shall develop a conceptual framework for very general probabilities on such collections of contexts. This amounts to an extension of Kolomogorov probabilities which are defined in a single context to a multi-context situation. Scrutinized separately, every single context has “legit local” classical Kolomogorov probabilities. In addition to those local structures and measures, (intertwined) multi-context configurations and their probabilities have to be “joined”, “woven”, “meshed” or “stitched” together to result in consistent and coherent “global” multi-aspect views and probabilities.In particular, one needs to cope with possible overlaps of contexts in common, intertwining, observables. Because two or more contexts need not (but may) be separated from one another, they may indeed intertwine in one or more common elements and form complex propositional structures serving a variety of counterfactual ,8 purposIn terms of probabilistic language, one might interpret contexts as conditions. Intertwining contexts might be identified with different conditionings with non-empty intersection(s).This text is organized as follows: first, Kolmogorov’s axioms or principles for probabilities are generalized to arbitrary event structures not necessarily dominated by the quantum formalism. Then these principles will be applied to quantum bistochasticity, as well as partition logics which offer an abundance of alternate configurations. Some “exotic” probabilities as well as possible generalizations by Cauchy’s functional equations are briefly discussed. Throughout this article, only finite contexts will be considered.Suppose that, as it is assumed for classical Kolmogorov probabilities, the elements Inspired by the multi-context quantum case discussed later, the following generalization to two- or, by induction, to a multi-context configuration is suggested: Suppose two arbitrary contexts l belief  or the fAssume as axiom the following criterion: the conditional probabilities of the elements of the second context with respect to an arbitrary element This presents a generalization of Kolmogorov’s axioms, as it allows cases in which both contexts do not coincide. It just reduces to the classical axioms for single contexts if, instead of a single element ted into .We shall mostly be concerned with cases for which any element of It is instructive to ponder why intuitively those conditional probabilities should be arranged in right- but not in bistochastic matrices. Suppose a  system is in a state characterized by some element On the other hand, if a particular element One way of looking at generalized global probabilities from “stitching” local classical Kolmogorov probabilities is to maintain the essence of the axioms, namely positivity, probability one (certainty) for tautologies and, in particular, additivity. Additivity requires that, for mutually exclusive compatible events argument ,14.For operators in Hilbert spaces of dimensions higher than two, and in particular for linear operators theorems ,18,19,20The general case may involve other, hitherto unknown, arguments besides scalars and entities related to vector (or Hilbert) spaces. The discussion will not be extended to potential inputs and sources for generalized probabilities as the main interest is in developing a generalizing probability theory in the multi-context setting, but clearly these questions remain pertinent.compatibility and commutativity; that is, such observables are not complementary and can be jointly measured without restrictions. “Mutual exclusivity” is defined in terms of orthogonality of the respective observables. The spectral theorem asserts mutual orthogonality of unit eigenvectors The multi-context quantum case has been studied in great detail with emphasis on motivating and deriving the Born rule ,22 from generate ,23.An essential assumption entering Gleason’s derivation  of the BAlready Gleason pointed out  that it expanding the pure prepared state into a full orthonormal basis, of which its vector must be an element.  Once the latter basis is fixed, it can be used to obtain a “view” on the former (measurement) basis, and a completely symmetric situation/configuration is attained. We might even go so far as to say that which basis is associated with the “observed object” and with the “measurement apparatus”, respectively, is purely a matter of convention and subjective perspective.It is also well known that, at least from a formal perspective, unit vectors in quantum mechanics serve a dual role. On the one hand, they represent pure states. On the other hand, by the associated one-dimensional orthogonal projection operator, they represent an observable: the proposition that the system is in such a pure state ,25. SuppTherefore, as has been pointed out earlier, an orthogonal projection operator serves a dual role. On the one handm it is a formalization of a dichotomic observable, more precisely, an elementary yes–no proposition perators .ith row jth column component corresponds to the conditional probability associated with the probability of occurrence of the jth element (observable) of the second context, given the ith element (observable) of the first context. By taking into account that cyclically interchanging factors inside a trace does not change its value, this matrix needs to be not only row (right) stochastic but doubly stochastic (bistochastic) [Consider two orthonormal bases (two contexts). Their respective conditional probabilities can be arranged into a matrix form. The chastic) ,22; thatIt is important to emphasize that bistochasticity holds for pure states but not for more general ones. In particular, for non-rank-one density matrices that are the product of two vectors, such as for mixed states, the above arguments do not apply.doubles of quantum logics, such as for spin-state measurements, and thereby their graphs also allow faithful orthogonal representations [In what follows, we shall study sets of partitions of a given set. They have models  based onntations . Yet somith, of the two valued states a nonnegative weight If some (partition) logic which is a pasting ,33,34 ofIt will be argued that in this case, and unlike for quantum conditional probabilities, the conditional probabilities, in general, do not form a bistochastic matrix.In the Babylonian spirit ( p. 172),The logic in In what follows, we shall investigate a “firefly” model that has been introduced (ii)(iii)This configuration allows two types of experiments corresponding to looking through exactly one of the two windows, respectively. Each type of experiment has three outcomes, labeled as follows:The two observers at the two windows may observe any of the four combinations This firefly configuration thus gives rise to two contexts The associated The conditional probabilities of the firefly logic, as depicted in e matrix , the row“looked upon in the first color (in this case blue), the ball drawn from the urn shows the symbols 2 or 4” will never occur; regardless of which ball type associated with the other context Take, for example, the singular distribution case such that c matrix  derived c matrix :(7)P.discontinuity of the two-valued measures which “prevents” the quasiclassical conditional probabilities to be arranged in a bistochastic matrix. A similar quantum realization could, for instance, be obtained by the three-dimensional faithful orthogonal representation [Ultimately, one may say that it is the entation  {1,2}≡1,intrinsical—that is, for any embedded observer having access to means and methods available “from within” the system—operational state preparations should be allowed. In such a scenario, it is operationally impossible for an observer with access to only one context—in the generalized urn model only one color—to single out the particular type of two-valued measure . Thereby, effectively any state preparation is reduced to the elements of the partition in the respective context (color).A different approach to partition logic would be to insist that only subsets resulting from the unions of two-valued states in Therefore, in the earlier firefly model depicted in ixtures , then there is no way to prepare or access “ontologic states”, say, selecting balls of type 1  only. The difference is subtle. In the “ontic” state case, one can resolve (and has access to) every single two-valued measure . In the “epistemic”, intrinsic, operational state case, one is limited to the operational procedures available. For example, one cannot “take off the colored glasses” in Wright’s generalized urn model. That is, the resolution of balls is limited to whatever types can be differentiated in that color.Whenever such a scenario is considered, the respective matrices representing all conditional probabilities may be very different from the previous scenarios. Indeed, one may suspect that with the assumption of preservation of equidistributed uniform mixtures across context changes, the respective matrices are bistochastic (at least for equidistributed urns) because of a certain type of “epistemic continuity”. The sum of the conditional probabilities for any particular outcome of the second context relative to all other outcomes of the first context should add up to unity.By now, it should be clear how classical conditional probabilities work on partition logics. Consider one more example: the pentagon/pentagram/(orthomodular) house  vectors ,44,45 foThe row stochastic matrices representing conditional probabilities form a polytope in ach row ( p. 49). For conditional probabilities yielding doubly stochastic matrices, such as, for instance, the quantum case, the Birkhoff theorem  yields mI have attempted to sketch a generalized probability theory for multi-context configurations of observables which may or may not be embeddable into a single classical Boolean algebra. Complementarity and distinct contexts require an extension of the Kolmogorov axioms. This has been achieved by an additional axiom ascertaining that the conditional probabilities of observables in one context, given the occurrence of observables in another context, form a stochastic matrix. Various models have been discussed. In the case of doubly stochastic matrices, linear bounds have been derived from the convex hull of permutation matrices.