The singular relationship developed over the years between northern Indigenous peoples and dogs has been profoundly changed through historical trauma, settlements and increased use of snowmobiles. Issues related to dogs have become increasingly complex and worrisome with the endemic presence of the rabies virus among Arctic fox populations, and given the fact that northern Indigenous peoples may have a higher risk of dog bites than the general population. This study aimed to investigate factors related to the risk of dog bites in Naskapi and Innu communities located in northern Quebec (Canada) by (1) describing the knowledge, attitudes and practices (KAP) regarding dogs and dog bites in these communities, and (2) analyzing experiences of inhabitants and health professionals with regard to dog bites and their management.n = 37) were then conducted with victims of dog bites, owners of dogs that have bitten a person before, and health professionals. Descriptive and inferential analysis (quantitative data) and thematic analysis  were performed.A mixed methods study design that combined an observational cross-sectional survey and individual interviews was used. The survey collected data on KAP regarding dogs and dog bites among 122 respondents. Individual interviews . The odds of being more knowledgeable on rabies were higher  among young adults. Dogs were perceived as both threats and protectors by community members. When the fear of dogs was present, it affected the quality of life of some inhabitants. There was confusion about responsibilities in the management of biting dogs, although protocols to follow after a bite were clear for health care professionals. This study revealed a lack of awareness and knowledge about dog bites and rabies risks in both communities. Results provide important knowledge for the development of interventions adapted to northern Indigenous communities. Dog bites have been studied in many contexts over the past decades due to their health impacts. Bites can cause short- or long-term physical or mental issues, such as injuries, infections, psychological traumas, and even death . IncidenIn northeastern Canada, more than 75% of the population is composed of Indigenous peoples, including First Nations, Inuit and Métis . In the In northern Indigenous communities, dog bites are frequently reported, but very few studies have investigated their occurrence and risk factors. A recent review showed that available evidence still suggests that Indigenous people living in northern communities are at higher risk of dog bites than the rest of the population . HoweverVulpes lagopus populations in many northern locations, including northern Canada, Alaska, Greenland, Svalbard, and northern Russia  among Arctic fox n Russia , 22. In n Russia . Howevern Russia . Anothern Russia . A studyn Russia . Moreoven Russia  or are sn Russia , 25. Finn Russia .To date, dog bites and their management have been studied primarily in the context of Inuit , 12, 27,This study aimed to investigate factors that impact the risk of dog bites in the context of two Indigenous nations located in northern Quebec, namely one Naskapi community and one Innu community. A mixed methods study combining quantitative (survey) and qualitative  data was completed to specifically (1) describe the knowledge, attitudes and practices (KAP) regarding dogs and dog bites in these communities, and (2) investigate the experiences of community members and health professionals with regard to dog bites and their management. This study allowed to identify the main barriers to overcome in order to improve current practices, and to implement interventions adapted to the specific context of these communities for the optimal management of dog bites and associated public health risks.Five authors are non-Indigenous veterinarians living in southern regions of Quebec and one author is an Indigenous Naskapi living in Kawawachikamach. Three of the authors have advanced degrees in epidemiology. The first author (LD) led the data collection, analysis, and manuscript writing. LD is a non-Indigenous woman, a master's degree student in epidemiology and a veterinarian. Five authors were implicated in a systematic scoping review on dog bites in northern Indigenous communities and are familiar with this subject.This study took place in two Indigenous communities and one administrative municipality located in northern Quebec, Canada: Kawawachikamach (KWW), Matimekush-Lac John (MLJ), and Schefferville (SCH). KWW is the only Naskapi community in Canada and is located 15 km from MLJ and SCH. MLJ is an Innu community surrounded by the territory of SCH . They arNaskapi from KWW are under the James Bay and Northern Québec agreement. This agreement between governments of Quebec and Canada and some Indigenous nations was signed in order to redefine the organization of the territory and its administration . Innu frBalancing Illness and Wellness at the Human-Dog Interface in Northern Canada, which aims to investigate the relationships between dogs, humans and their respective health in Canada, using the “two-eyes” model that combines Indigenous knowledge and Western science. It also aims to propose, implement and evaluate solutions to reduce the risks at the human-dog interface while promoting the positive roles of dogs on human health. The research team received the approval and support of the Naskapi community of KWW, the community of MLJ, and the town of SCH, as part of the global project.This study was part of a larger project called The study used a convenience sampling strategy targeting a sample size of 50 adults (over 18 years old) residents in KWW and 50 in MLJ and SCH. Residents were recruited in different places  until the sample size was reached. The study objectives and the consent form were explained orally and participants were given the choice to complete a questionnaire directly after, on the same day, or later. Naskapi and Innu local coordinators from KWW and MLJ participated in the recruitment of participants and translation of questions when needed.Data collection was mainly conducted in person by the first author (LD) from May 27 to June 12, 2019, in the communities. The questionnaire was based on previous studies and adapted to the current study objectives see  (12). ItRRID:SCR_016479) version 25 software. Because of the proximity between MLJ and SCH, the low number of respondents, the culture difference and the different access to government dog rabies vaccination program, data from both MLJ and SCH communities were compiled (MLJ-SCH) and compared to data from KWW, meaning that two localities were compared. Descriptive analyses were conducted globally and by the community. Statistical tests were performed to assess significant differences in proportions between communities with p < 0.05, with either Pearson's Chi squared test or Fisher exact test when the theoretical size of any cell was lower than 5. All significant results were reported in the result section. Missing data were excluded to calculate proportions for individual variables.Data were compiled and analyzed using IBM SPSS Statistics  was used to explore the underlying structure of perception variables and to identify variables to regroup for further analysis . It was analysis , 37. Newanalysis .p < 0.2 were kept for inclusion in the multivariable models. Then, multivariable models were built using a backward elimination process with p < 0.05. Gender, age, and communities were forced into all models, significant or not, in order to include the factors considered potentially confounding. Interactions were also assessed between some variables . For model C using exposure to dog bites as the dependent variable, there was no significant association with all tested variables, and so results for this model are not presented (available in Multivariable regressions were used to explore the association between selected factors and three outcome variables: (A) knowledge on rabies ; (B) dog risk perception (linear multivariable regression of the discrete perception score); and (C) exposure to dog bites during the lifetime . The dichotomized variable “Knowledge on rabies” was created by combining, “Never heard of rabies” and “Little knowledge” (low), as well as combining “Basic knowledge” and “Extensive knowledge” (high). To build the models, we used at first univariable regressions for each independent variable to assess their association with the dependent variable: age, gender, knowledge on rabies (except for model A), communities, owning dogs, been bitten (except for model C), Dog risk perception (except for model B), perceived ability to protect oneself against rabies, and Rabies risk perception. Variables associated to the outcomes with We aimed to recruit around 30 participants (15 in KWW and 15 in MLJ-SCH) in order to achieve data saturation and capture all perspectives on different questions and to identify common themes . ParticiSemi-structured interviews were conducted by a team member (LD) in French or in English and lasted between 8 and 43 min (mean: 20 min). The interview guide was developed by the research team in collaboration with the local community coordinators see . SubjectRRID:SCR_014802) version 12.6 for analysis. Thematic analysis was used to analyze the transcripts. One member of the study team (LD) read through all interview records repeatedly to become familiar with the transcripts, and CA read a sample of them. Themes and codes were generated using an inductive approach to capture the salient features of the data and to represent the main topics raised. Code development was made according to the conceptual knowledge of the research team based on a review of the literature . Two thirds were women, approximately one third were between 18 and 29 years old, another third were over 49, and most identified themselves as Indigenous , including 23 people reporting a dog bite , two who owned a dog that had bitten a person , and 12 health care professionals . Most identified themselves as Indigenous .p < 0.05; CI 1.071–7.979) in the 18–29 age group than the 50 and more group (Seventy-three percent (85/117) of survey respondents did not know that they were at risk of contracting rabies after a dog bite. Also, 50/116 (43%) of respondents described themselves as having at least basic or extensive knowledge about rabies. In the multivariate model, age was the only variable associated with Knowledge on rabies. The odds of a higher knowledge on rabies were 2.924 higher . There was also a global lack of knowledge on rabies, as one interviewee mentioned: “According to [people in the community], It [rabies] must be just a disease of dogs, but they must not even know that it is transmitted to humans. Is it transmitted to humans?” .Similar lack of awareness was also reported by most interviewees when asked if community members were well-informed about dog bite risks: “Most participants [76/115 (66%)] agreed that dogs can transmit disease and most participants [74/113 (65%)] perceived that dog bites are a serious health problem. The risk of being bitten by a dog in general was also recognized as high by participants: 66/116 (57%) agreed, whereas 30/116 (26%) were unsure. Descriptive analysis of perceptions is available in The final exploratory factor analysis (EFA) with eight variables suggested three latent factors that were named: Dog risk perception, Perceived ability to protect oneself against rabies, and Rabies risk perception. Initial and final EFA with factor loadings are presented in In the final multivariable models, Rabies risk perception was positively associated with Dog risk perception , B. CommYeah, there are too many dogs and there is no service here about controlling the dogs or the dog's population or whatever” (ID021—KWW). Worries about packs of dogs were reported, especially for children playing outside: “Because you have dogs running around and dogs forming packs, so I feel like that's more dangerous, especially for kids because we have a lot of kids that are outside even small kids and I feel like they're not being watched closely” (ID025—KWW).In the survey, a majority of respondents of both localities [100/116 (86%)] perceived that there were too many dogs in their community. This was also reflected in the interviews: “The level of fear of dogs differed among survey respondents in both localities, with 65/116 (56%) of the survey respondents who disagreed with the statement that they feared dogs in their community (no significant difference between communities).All my life, I just hear a yelp... then all my nerves are awoken […] At one point, I walked around with a Sling shot, a little sling shot. […] I never used it, it was just a security you know” . Some of the interviewees reported that they were particularly uncomfortable with free-roaming dogs. One nurse reported that “there are many patients who are afraid of dogs and they often come to the dispensary with a stick” .Interviews revealed a diversity of feelings regarding dogs in the community. Some people reported that they had developed a fear of dogs, while others mentioned being comfortable with free-roaming dogs, even if, in some cases, they have been bitten by a dog before. One interviewee has been afraid of dogs since her dog bite: “I had a dog phobia at one point. […] I was not able to go see my grandparents, me who was so close to my grandmother and my grandfather. I didn't see my grandfather for 2 or 3 weeks after [the dog bite event]” . It was also reported as a barrier to physical activity for one of the interviewees: “They are free roaming here. I can't take a walk. […] I take my pick-up to go somewhere. I would like it to walk, but I'm too afraid of dogs” . One of the parent interviewees was afraid of letting her children play outside alone.When present, the fear of dogs had important consequences on quality of life of certain participants: “I think it is very good to have dogs around here. They give you alert, if something happens, like outsiders, animals. […] If you hear dogs barking outside the community, you know there is an animal. […] Because kids are wandering everywhere” (ID035—KWW). A few interviewees mentioned that dogs can protect them when they are walking in the community or go out in the land at their camp outside the community: “Every time I go home at night, I have one with me and I feel safer because of it, if there is an animal around, I might use some help” (ID028—KWW).On the other hand, it was mentioned that free-roaming dogs were still perceived as protectors against wildlife: “p < 0.05)]. There were 6/9 (67%) of dogs from KWW and 29/30 (97%) of dogs from MLJ-SCH whose owners reported that they had been vaccinated in the last 12 months (p < 0.05).Among the survey respondents, 47/122 (39%) were owners of one or more dogs. The majority [38/47 (81%)] of those owners had only one dog, for a total of 28 dogs owned in KWW and 42 dogs in MLJ-SCH . The priPeople like dogs a lot even if it's not your dog. You know from which family he comes from, I mean… Because we all know each other here” . One interviewee perceived changes in the status and role of dogs over time: “if I go back 20 maybe 30 years ago, this is a discussion from the elders, dogs were a priority in the community. They were for hunting, fishing, you name it. But things have changed when they had dogs in every household. […] if you go back 50 years ago, when they lived up in George River, they knew what the role was. You take care of your dog because it's your life support. Today, the new generation, it's not your life support, it's just—it's a pet” (ID016—KWW).Interviewees also described dogs as members of the family and sometimes as members of the community: “p < 0.01). 30/44 (68%) of total owners reported letting their dogs free roam occasionally . However, many interviewees reported that tying dogs also had negative consequences for their health and wellbeing: “I think you should be walking your dog like habit exercise and then, maybe, if you're comfortable, bring it inside, like how you would treat a family, but at night, let tied it up so it's just safe in its dog house. I don't think they should be tied up all the time. I think it's another form of abuse” (ID031—KWW). Some people have also reported that this practice may increase dog aggression in some context: “[…] I know some people that just tie up their dogs indefinitely and they get dangerous over time because they're so secluded to their environment, they need to roam around, but maybe they should—they should put a leash on them, walk with them, play with them, love them” (ID027—KWW). It was also normal for some interviewees to see dogs roaming free: “Well, I'm actually comfortable. It has been like that for a long time. […] Like in the cities there are stray cats. Here, there are dogs” (ID028—KWW).In the survey, 14/15 (93%) of owners in KWW and 13/29 (45%) in MLJ-SCH let their dogs live outdoors . A few interviewees reported specifically that it is important for themselves to take good care of their dogs: “Yeah, because I think dogs are good loyal friends if you take care of them” (ID030—KWW).Practices toward dogs were criticized by many interviewees, Indigenous and non-Indigenous. One Innu interviewee reported that practices regarding dogs were different for Indigenous people: “Among respondents, 23/112 (21%) reported a dog bite in their lifetime . Twelve Yes, they know [generally what to do after being bitten], they go to the dispensary. […] they say, “OK, go to the dispensary, it's dangerous, you're going to get an injection there. A vaccine to not get sick.” Often people will go there” . However, six interviewees reported that they would not know what to do: “They tell us what to do when there's a fire, but they could also tell us what to do when there's a bite” . Finally, some interviewees mentioned that they did not consult any health professionals after their bites: “[After my dog bite I did] nothing. […] I didn't report it. I never report it” (ID021—KWW). Few interviewees mentioned that, being bitten as a child, they were afraid to tell their parents about their dog bites: “I didn't tell my parents, I just went home. No blood” (ID019—MLJ-SCH). Nurses from both communities also reported difficulties in follow-ups after the first visit: “But sometimes they will come because there is a wound, to see if it is infected or not. But after that, it's more at the follow-up level that we have problems” . Another nurse also reported: “So often they don't show up or they don't feel the importance of even though they're told about rabies and that it's deadly and everything” .Interviewees reported different levels of awareness regarding what they needed to do in case of a dog bite. The majority of interviewees mentioned that they seek health care after their bite: “p < 0.01). Several interviewees also mentioned children being at higher risk of bites than the rest of the population: “Most of them are children who get bitten” . Provocative behaviors were sometimes mentioned explaining this risk: “They [children] are throwing out rocks. And my dogs can be pissed and be mean back to you. They throw rocks at him” (ID035—KWW). However, other cases reported by some interviewees seem unprovoked by the child involved: “She said that the dogs were biting at her while she was trying to walk toward the community center and then she would try to push them away or try to scare them away” (ID027—KWW).In the survey, 19/50 (38%) from KWW and 10/62 (16%) from MLJ-SCH knew a child from their surroundings that has been bitten in their lifetime . Most reported having learned specifically about zoonosis through their work experience, rather than during their formal training: “I don't really have [any training in rabies and zoonoses]. We have procedures. I can show you the procedure to follow when there are dog bites. Then everything is detailed. […] It's done on the job. We are always 4 [nurses], then there is always an old one like me there. Then who says…/ But all the procedure manuals are there, clearly identified” .All nurses mentioned having a clear and specific protocol to follow in a case of dog bites: “We try to find the owner of the dog, first. And it's not an easy thing so we have cooperation from the police because there are a lot of stray dogs. […] Since we don't have an owner's name, we can't find the owner. […] So, I gave [the public health] the contact for the Naskapi police” . Second, there was confusion about roles and responsibilities with regard to biting dogs: “I know the [Local health care center] want us to pick up the dog and bring the dog to the [Local health care center], we can't do that. […] Yeah, and the thing is we didn't even have a policy on that. I could show you, we have two big binders on policies, on crime you name it, but nothing on dogs. Cause usually it is not a policing problem. Most communities I work in, we have a dog control officer that deals with it” (ID016—KWW). Finally, interviewees mentioned that there are no assigned areas to quarantine dogs after a dog bite, which creates confusion as no one feels responsible for managing the period of observation of the biting dog.Several challenges were reported with regard to the management of biting dogs. First, interviewees mentioned that it was sometimes difficult to identify and find the dog following an event: “when there is a dog bite, they have to kill the dog because he already has a taste for it, you know, the blood. Yeah, it was sad” (ID030—KWW). Some people also mentioned that biting incidents sometimes led to dog culling in the community: “And after this incident, all the dogs had to be put down except the small ones, I think. And people were really mad in the community that they went that far” (ID030—KWW).Most interviewees mentioned that biting dogs are generally killed after an incident: “[…] This mixed methods study allowed to describe and compare the knowledge, attitudes and practices (KAP) regarding dogs and dog bites in two Indigenous communities; Naskapi from KWW and Innu from MLJ.Main factors increasing the risk of dog bites and rabies that emerged from this study are synthesized in Specifically, this study revealed a lack of awareness and knowledge about dog bites and rabies risks in both communities. This is not the first time that a lack of knowledge on those risks is reported in studies addressing dog bites risks. Indeed, a survey among 5–15 year olds consulting for dog bites in United States pediatric emergency departments reported that 42% of children did not pass a test on dog bite prevention knowledge , demonstResults showed that the role of dogs is changing in the studied communities, which is coherent with observations from studies conducted in other northern Indigenous communities . In prevIf free-roaming dogs are still perceived as protectors by community members, our study also suggests that too many free-roaming dogs can create fear for some people, which in turn can impact behaviors and quality of life, for example by preventing physical activity in communities. This observation has been reported in a study conducted in 2011 among teenagers in American Samoa, an Indigenous community located in a United States territory in the South Pacific, where 14% of them mentioned that fear of dogs prevented them from getting more exercises . PsycholA topic that was frequently discussed by participants and on which there was no consensus was whether a dog should be tied up or free-roaming, demonstrating the complexity of this issue. Free-roaming dogs can be owned or ownerless. Another study conducted in an Inuit community in 2018 underlined the importance for some inhabitants of letting dogs roam free . In a stIn this study, Rabies risk perception was a factor influencing the level of risk perception toward dogs (Dog risk perception) in the communities, even though there was a reported lack of knowledge on rabies. This study also showed that age was associated with knowledge on rabies, with young adults being the group with the highest knowledge on rabies when compared to those aged 50 and over. This observation suggests that older adults should also be considered when designing education programs on dogs and rabies. In a 2021 study on interactions between children and dogs in an Inuit village (Canada), it was suggested that education programs on dog bites and care should target adults to raise their awareness and consequently, increasing child supervision in regard to dogs .The proportion of dog bites over the lifetime estimated in this study was slightly lower than what was found in previous research conducted in other Northern Indigenous communities (21% of study participants vs. 27 to 62.9% as reported in a recent systematic scoping review) . Risk faNurses from both localities reported that they were adequately prepared to manage dog bites and risks related to rabies, which is good news from a public health perspective. A major issue that came out from interviews was that a significant proportion of people do not seek medical care after a bite, which is of concern for public health. Awareness should be raised among the general population in order to emphasize the risks of not consulting, and the best practices to adopt after a dog bite.In addition, confusion about roles and responsibilities regarding the management of the biting dog may impair the capacity to prevent consequences following a bite. Killing the dog was sometimes implemented after a bite. This practice has been reported in similar contexts , 50. HowThis study was exploratory and had limitations. This study used a cross-sectional design which limits the evaluation of the temporality between risk factors and bites. Future studies should consider cohort design in order to obtain incidence measures and to estimate other associations with risk factors. Then, a convenience sampling strategy was chosen to reach a sufficient number of participants in each community. This sampling strategy could lead to a lack of representativeness of the sample. However, we did compare the distribution of age and gender between our sample and the census data and concluded that the representativeness was good . Also, iThe small sample size restrained our capacity to detect significant association between factors and outcomes investigated in this study. We chose this sample size because this study was exploratory and we wanted to avoid over-solicitation from researchers, a common problem in Indigenous communities . HoweverThis study was the first to investigate dog bites in a Naskapi community and an Innu community. It provides important knowledge on risk factors related to dog bites in northern Indigenous communities, and it delivers a first report on how dog bite management is experienced by inhabitants and health care professionals. The mixed methods design made it possible to deepen knowledge on dog bites and rabies KAP and to integrate Indigenous knowledge and perspectives. This study revealed a lack of awareness and knowledge about dog bites and rabies risks in both studied Indigenous communities. Results provide important knowledge for the development of interventions adapted to the particularities of northern Indigenous communities.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Comité d'éthique de la recherche en sciences et en santé at the Université de Montréal; certificate number #CERSES-19-048-P. The patients/participants provided their oral or written informed consent to participate in this study. The CERSES approved the use of oral consent for participants whenever it was not possible to obtain written consent. First Nations and Inuit communities primarily populate the northern regions in which this project is taking place. As described in the First Nations of Quebec and Labrador Health and Social Services Commission's Principles of Research Toolkit, members of First Nations' communities may express fears about signing forms, and it is essential to establish a relationship of openness and trust in research. In order to accommodate these cultural differences, our committee accepts the recording of oral consent from participants. This practice is consistent with the requirements of the Tri-Council Policy Statement on Ethical Conduct for Research in Canada.LD: study design, data collection, analysis, and interpretation of data and redaction. AR and CA: study design, contribution to the data analysis and interpretation, and revision of the manuscript. YR, AS, and KM: contribution to result interpretation and final revision of the manuscript. All authors contributed to the article and approved the submitted version.


C’est la Vie!, screened through biweekly film clubs in rural Senegal and included post-screening discussions and thematic workshops, meant to reinforce messages, increase knowledge, and change social norms. The objectives of this study were to assess intervention adaptation, implementation fidelity, participants’ responsiveness or engagement, and series appropriateness.Edutainment aims to spread educational messages in an entertaining way, and often reaches large audiences. While studies increasingly report the impacts of edutainment interventions, there is limited context-specific evidence on the underlying processes and barriers to effective delivery, especially in rural areas. This article presents results from a process evaluation of a community-based edutainment intervention designed to improve knowledge, attitudes, and practices on gender-based violence (GBV), sexual and reproductive health (SRH), and maternal and child health. The intervention focused on the television series, n = 3), village chiefs (n = 8), married women (n = 9), adolescent girls (n = 8), and men (n = 8); ii) focus groups with men  and women ; and iii) observations of screening sessions (n = 4) and post-screening discussions (n = 2). Data were analyzed using thematic and content analysis.The intervention was implemented from December 2019 to March 2020 in 120 villages in Kaolack and Kolda regions of Senegal, and targeted adolescent girls and young women aged 14 to 34. The process evaluation was carried out in March 2020 in 14 villages using: i) individual semi-structured interviews with implementers (The results highlight that adaptation of the intervention helped reach the target population and improved participant attendance, but might have compromised fidelity to original design, as intervention components were shortened and modified for rural delivery and some facilitators made ad hoc modifications. The screenings coverage and frequency were adequate; however, their duration was shortened due to COVID-19 restrictions in Senegal. Participant responsiveness was excellent, as was the series appropriateness for most topics, including GBV. SRH remains a sensitive topic for youth, especially when the film clubs included non-peers, such as slightly older women.This study showed that using film clubs to deliver sensitive edutainment content in rural areas is feasible and has potential for scale-up.The online version contains supplementary material available at 10.1186/s12889-022-13570-6. Gender-based violence (GBV), sexual and reproductive health (SRH), and maternal and child health (MCH)Social and behavior change communications (SBCC) initiatives are an important component of comprehensive strategies to improve GBV, SRH, and MCH outcomes. SBCC has been widely used in low- and middle-income countries to increase knowledge; change attitudes, beliefs, and norms; and ultimately improve behaviors and practices across multiple health outcomes –10. It itheory-based communication strategy for purposefully embedding educational and social issues in the creation, production, processing, and dissemination process of an entertainment program, in order to achieve desired individual, community, institutional, and societal changes among the intended media user populations.”  through these films we can see that girls are mistreated, threatened and abused in this society... These are real things that happen in life, but we didn’t know because we live in rural areas” . The series also enables them to reinforce their knowledge and learn new material. “It was in the series that I learned that early marriage was not good because it can cause health problems for a child when she gets pregnant. Just like the children that are raped and the young girls that are given away early because of money” . Finally, the series helped them to make the right choices and enabled them to advise others: “For example, for us married women, we cannot go back but we can still protect our children against certain practices such as child marriage” .Participants unanimously expressed their enthusiasm for the series and intervention. They enjoyed the series, because of the novelty and its messages, as access to this type of information is often limited in rural areas. Participants liked the show because it was interesting, important, and it “nice,” enjoys her job, and looks after and treats her patients well: “It’s because of her that I love the film.” Others included victims of mother-in-law abuse and IPV, because of their strength and courage in dealing with the abuse. The most-hated characters were an evil-natured midwife who steals patients’ money, abuses and neglects them, has a bad attitude and lacks a spirit of collaboration, and the abusive mother-in-law because she interferes in the life of couples and abuses her daughter-in-law . The violent husband was also hated.Participants cited a wide range of characters from the series as favorite or hated, thus showing their immersion and responsiveness to the series. They knew the names and plot lines of the characters, and frequently shared passages from the series to justify their choices. The protagonist midwife was most commonly identified as the favorite character, because she is ““What I like the most about the show is that we learned a lot of things there like how to run the household and a lot of other things in our daily life.” . The scene where the midwife helped a young woman give birth, was often cited as a happy moment, creating positive emotions.When asked about what themes they liked, a large majority of participants in both regions simply answered that they liked everything. Women’s health and the focus on the daily lives of women were mentioned several times: A part that I didn’t like, for example, was when the husband hit his wife until he broke her arm. You really know that what he did to his wife is not good at all. He stole her gold box to sell it. And I don’t know if he bought it or not, but whatever the problem, he shouldn’t hit her” . Scenes of violence by the mother-in-law and scenes about marital rape in the context of child marriage were also cited: “What I didn’t like the most was the death of the girl. Indeed, she died because she had an old (er) husband who forced her to sleep with him “.There were many unpleasant plot lines that touched on GBV and evoked strong emotions. Those related to IPV left their mark: ““For the men to come, it is their wives who can motivate them. It is up to them to explain the interest because alone there will be no change but if they try to convince their husbands and explain the interest they will come” . Many men also claimed that they were not informed by their wives. Other men felt their wives discouraged them from attending: “My wife never invited me to go to the film club [...]. I did go for the first screening, but when I was told that they only needed women I turned back” . Some husbands came once and never returned, considering the series “for women”, as indicated by a facilitator, “The problem we have is for men … at my first screening I had a room full of men. The men came. There were 11 or 13 of them, but at the end of the first episode they all left, and they told me the same thing: this is for the women, because we only saw secretaries.5In fact, we very rarely saw men in the film” .According to facilitators, the series was well adapted to adolescent girls in the target communities, who were often unoccupied outside of school, and to pregnant or lactating women interested in SRH or MCH. A CHV indicated that in her village, younger beneficiaries were more interested in the topic of early pregnancies, while older ones were interested in IPV. However, they reported challenges in involving men. Although men were not the main target, their participation as guests was encouraged for half of the female participants. The intervention design relied on women being responsible for inviting and motivating their husband or male family member or friend. As one facilitator explained, “I think it’s better if we watch the series alone as women and then talk about it” . A woman said that she went with her son but “kids can’t keep secrets.” An adolescent girl explained that there should be no embarrassment for young girls to watch the series with boys, but that she felt ashamed and also preferred to watch without parents: “I prefer that young people watch alone without their parents. If it’s with women it’s not a problem, but with men you will feel ashamed” . Additionally, young unmarried participants who have boyfriends would not dare invite them and risk them meeting their mothers or their mothers’ friends.Most women were in favor of being able to watch the series without men present. One main concern about the use of the series was related to the sensitivity of topics explored, especially for rural, more conservative population. According to the facilitators, sensitive issues could undermine participation in the discussions and workshops. They mentioned the following sensitive topics: (i) sexual health and behavior, (ii) use of family planning by unmarried women, and (iii) IPV.“So you see that some topics are not adapted to the realities of the region. Today, we talked about the sexuality of an independent woman, but even your boyfriend is not allowed to approach you. A woman should not have sex before marriage, you see” . Family planning was also sensitive, as it is normally intended to help married women space births, not for unmarried women to prevent pregnancy. According to a facilitator, family planning has only recently been introduced in some villages, hence interest in the topic; “They like to discuss early marriage, but also family planning. Women have not been practicing planning for a long time here, but they discuss it very often” . IPV did not generate much discussion, according to a facilitator,: “On intimate partner violence, they are not very comfortable when we talk about these subjects. Because for them domestic violence is normal. Because they say that it is between you and your husband … “ .Sex was a sensitive subject, especially when it was approached from the perspective of women’s independence and ability to control their sexuality and choice of sexual partners. This narrative shocked viewers, because it goes against social norms that forbid premarital sex, as explained by a facilitator: “The difficulties are the fact that a subject is really taboo and [...] that everyone is silent, because they say to themselves, if I say a case in relation to such a subject, people will think that it is because I am doing it, but with a little reassurance they open up. And if only one person starts to speak, everyone speaks” . In some villages, the presence of men, religious authorities, elders and mothers-in-law prevented women from expressing themselves during post-screening discussions, as explained by a woman in Kolda: “Some would feel comfortable, others would feel very embarrassed to express themselves. It is the presence of men that makes them feel uncomfortable. If women were alone, they would not feel ashamed” .Most female participants interviewed felt comfortable opening up to the facilitator and participating in post-screening discussions but mentioned that others might feel uncomfortable or be afraid to speak in public. For example, lack of confidentiality and fear of judgement in the group setting prevented some from expressing their opinions: “There are moments when almost all my targets are nieces of the aunts. During these moments, they have the opportunity to discuss very delicate and taboo subjects between parents and children, and there the mother can say what she thinks, as well as the child. It is like an intergenerational dialogue where women and mothers talk and each one could bring out their feelings, thoughts and worries” . During workshops, among the 14 to 19 years old adolescent girls, some were already married or pregnant, and therefore “not comfortable on certain topics, because they have already experienced this and they were a little embarrassed to talk about it” .Facilitators found adolescents were reserved when discussing sex in the presence of older women, but expressed themselves more freely during the adolescent-only workshops. Another facilitator, however, explained post-screening discussions to be a unique opportunity to discuss sensitive subjects in a multigenerational environment: C’est la Vie! through film clubs targeted to adolescent girls and young women in Senegal. Specifically, we address questions on the extent of adequate adaptation for the target audience, implementation fidelity, participant responsiveness, and appropriateness of the intervention. The process evaluation was imbedded in an RCT to better understand the impact pathways and improve implementation to maximize impact. Previous research on television- and filmed-based interventions exists, such as series on maternal and newborn health in rural Ethiopia  Previously, who would have thought that cinema could reach this far? Nobody! The cinema we only heard about in urban areas.” .Through a detailed analysis of the delivery and uptake of the intervention, we also assessed delivery . The conShuga had initial take-up rates during a screening session of 38% among a sample of urban Nigerian youth, with approximately 78% of those who initially attended the screening subsequently viewing at least one of the two primary series showings [C’est la Vie!, with initial attendance rates of 90% and approximately one-third of women attending all screenings can be considered relatively successful compared to other approaches.Take-up and retention, which is a common challenge of television-based edutainment, were in-line or higher in our study compared to other television-based edutainment efforts in Africa. For example, an evaluation of MTV’s showings . In addishowings . Thus, tparticipant responsiveness was high across nearly all intervention components. The television format delivered clear and strong messages that were understood by participants. Moreover, participants liked the series, were engaged, shared information and story lines with family and friends, became aware of important issues, and learned. Women could remember and identify with characters and were transported by subplots, which are important pathways for changing behavior [Female behavior , 39. Theappropriateness [Considering the iateness  of the siateness . SBCC inC’est la Vie! need time, repetition, and discussion for messages to be internalized and new social norms and behaviors to be adopted, which may limit their ability to be scaled up. When going to scale, such programs should consider innovative ways to deliver complementary educational materials, such as integrating content of pedagogical kits into existing structures to facilitative expansion .Finally, SBCC programs typically delivered in rural areas, even when effective in inducing behavior change, typically rely on one-on-one or group counseling conducted by health care workers or peer counselors . EdutainOverall, our study indicated that the community-based edutainment intervention was implemented as planned before the COVID-19 disruption, and highlighted an excellent responsiveness to the intervention and appropriateness for adolescent girls and young women. However, the pre- and post-implementation adaptations to the post-screening discussions and workshops highlight the need to focus on how to optimally integrate and find a compromise between the ‘educational’ and ‘entertaining’ components. Nevertheless, we demonstrate that using film clubs to show edutainment content in rural areas is feasible and has the potential for scale up. Future research on edutainment should document intervention adaptation, fidelity, participant engagement and series appropriateness alongside impacts for a more holistic understanding of how to improve gender norms and outcomes in rural settings.Additional file 1.


Hostility toward others is related to negative emotions, which is hypothesized to have negative health consequences. In this article, we sought to test the relationship between individuals’ attitudes toward immigrants and their self-rated health (SRH) across time in large dataset of 15 European countries.We used the 2010, 2012, 2014 and 2016 waves of the European Social Survey, which include information about attitudes toward immigrants and individuals’ SRH.Combining all countries and survey years, we found an association between negative attitudes toward immigrants and fair/poor SRH. However, when analyzing the relationship within each country, we found variations (depending on the year of the survey) in some countries, such as Hungary, Poland, Portugal, Sweden and Slovenia. Additionally, we found that there are more middle class individuals who hold unfavorable attitudes toward immigrants over time.In general, poor attitudes toward immigrants are associated with higher odds of reporting fair/poor health, although the ‘health advantage’ of those with favorable attitudes is diminishing over time. However, in some countries, this relationship is contingent on when the survey was conducted, possibly reflecting the changing composition of individuals who hold unfavorable attitudes toward immigrants. In other countries, such as Spain, Switzerland, Norway and Slovenia, far-right political parties also reached the Parliament of their respective countries during the same period. The EU region witnessed a marked increase in anti-immigrant sentiment in the wake of the Great Recession of 2007–10. Competitive threat theory suggests that anti-immigrant attitudes increase when adverse economic circumstances intensify competition with immigrants for jobs,While previous studies have focused on the detrimental effects on the groups targeted by anti-immigrant prejudice (e.g. hate crimes), less is known about the health of individuals who harbor such sentiments. In an analysis of survey data from 18 European countries included in the 2016 European Social Survey (ESS), Backhaus et al.,Attitudes toward immigrants are mainly developed during adolescence and seem to be stable across time.,,Negative attitudes toward immigrants may be thus a consequence of exclusionary othering, as it is a process often based on ethnic and/or racial biases.,In this article, we sought to test the hypothesis that individuals’ attitudes toward immigrants is detrimentally associated their self-rated health (SRH) in the general population across Europe and over time. The period selected was from 2010, as it is when far-right political parties started obtaining representation across different European countries. We focused on SRH as it is the only self-reported health measure available on the ESSs. On the other hand, the validity of the single-item assessment has been previously established based on its ability to predict subsequent hospitalization and mortality.Our hypothesis is that there is a positive association between favorable attitudes toward immigrants and higher SRH, ‘net’ of individual socioeconomic circumstances and independent of the country of individuals’ residence.www.europeansocialsurvey.org/. The ESS is a repeated cross-sectional, cross-national survey implemented in 2001, which is conducted through face-to-face interviews every 2 years. The ESS is representative of all individuals aged 15 and over living in private households in each country. A random probability sample is selected from the residential registries in each country.We used the 2010, 2012, 2014 and 2016 waves of the ESS available online at We selected the 15 European countries, which participated in all waves, i.e. Belgium, Switzerland, Germany, Spain, Finland, France, UK, Hungary, Ireland, the Netherlands, Norway, Poland, Portugal, Sweden and Slovenia. A total of 113 744 individuals participated in the four waves of the survey living in the above mentioned countries aged between 14 and 104 years.To conduct our analysis, we selected cross-sectional samples from 2010 due to the salience of immigration across Europe starting from 2009. As the dependent variable, we included individuals’ SRH and, as our independent variable, a scale to represent attitudes toward immigrants.Individuals’ general health was assessed using the ‘self-rated health’ status. Participants are asked ‘How is your health in general? Would you say it is …’ and they can choose among five categories ‘Very good’, ‘Good’, ‘Fair’, ‘Bad’ or ‘Very bad’. We dichotomized this variable so that it takes a value of 1 when the individual’s health is fair/poor, i.e. when his/her health is ‘fair’, ‘bad’ or ‘very bad’; and 0 otherwise.To measure individuals’ ‘attitudes toward immigrants’, we selected six questions from the survey that appeared in all waves of the ESS: (i) to what extent do you think (your country) should allow people of the majority race/ethnic from (another country) people to come and live here? (ii) How about people of a minority race/ethnic group from (another country) people? (iii) How about people from the poorer countries outside Europe?, (iv) Would you say it is generally bad or good for (your country’s) economy that people come to live here from other countries? (v) Would you say that (your country’s) cultural life is generally undermined or enriched by people coming to live here from other countries? (vi) Is (your country) made a worse or a better place to live by people coming to live here from other countries? Questions 1, 2 and 3 have four possible answers: ‘Allow many to come and live here’, ‘Allow some’, ‘Allow a few’ or ‘Allow none’, and Questions 4, 5 and 6 have a response range from 0 (‘worst place to live’) to 10 (‘better place to live’).We reordered the responses to the first three questions so that they took values from less openness to more openness to immigration (to be consistent with the last three items). We then summed the responses to create a six-item scale and confirmed that the resulting scale had high internal consistency reliability . The scale has a range from 0.5 (worst attitude toward immigrants) to 7.0 (most positive attitude toward immigrants).Before calculating this scale, we performed a listwise deletion of missing values. The final sample comprised 104 279 individuals.x-axis), and weights based on the distance between the ‘old point’ and the previously calculated ‘new point’ (y-axis). In this case, if the ‘old point’ is close to the ‘new point’ the assigned weight will be high and, if both points are far, the weights will be low. This latter weights allow us to reduce the impact of outliers and smooth the curve, showing the relationship between fair/poor SRH and attitudes toward immigrants.To test the relationship between fair/poor SRH and attitudes toward immigrants, we estimated a local weighted linear regression for each point of the dataset and represented it using Loess curves. In our case, each point of our independent variable (i.e. attitudes toward immigrants) uses the 80% of the dataset to fit a value. This process is made with all the points of the dataset to assign them a weight, therefore, the most weighted points would be those closest to the focal point, i.e. the point from which the process started, and the least weighted those which are further from this focal point. We have thus weights based on the distance between the points in our independent variable , indicating that as attitudes toward immigrants becomes more favorable, the prevalence of reporting fair/poor SRH is lower. Two instances of departures from linearity were: (i) in 2010, when those with favorable attitudes of immigrants had significantly lower prevalence of poor SRH compared to subsequent years, and (ii) in 2016, when those with unfavorable views of immigrants reported significantly lower prevalence of poor SRH compared to previous years. As a result, the association between negative attitudes toward immigrants and poor SRH seems to have diminished in the most recent survey year, while the ‘health dividend’ from having a positive attitude toward immigrants seems to have disappeared after 2010.In general, considering all countries and years together, the relationship between attitudes toward immigrants and fair/poor SRH was almost linear . NegativHowever, when assessing this relation by country , we findWe also analyzed the socioeconomic status (SES) of individuals splitting the sample by those hold unfavorable and favorable attitudes toward immigrants by year, as we used repeated cross-sections and different people are being captured at each round of the survey.Individuals with positive attitudes toward immigrants came from higher SES backgrounds  across all waves compared to individuals with negative attitudes toward immigrants. However, since 2010, the group expressing negative attitudes has been increasingly drawn from higher SES backgrounds .We also found that, regardless of individuals’ educational background, individuals with poorer attitudes toward immigrants reported worse SRH . HoweverIn general, as attitudes toward immigrants become more favorable, the prevalence of reporting fair/poor health is ‘lower’. However, in the most recent years, the shape of this relationship has slightly changed, which may be due to the ‘composition’ of people who have negative attitudes toward immigrants. We checked that all individuals’ SES backgrounds have improved over cross-sections, regardless of their attitudes toward immigrants. Therefore, as more individuals from advantaged backgrounds begin to harbor negative attitudes toward immigrants, the negative association that poor attitudes toward immigrants have on health might be compensated with the positive association that higher SES characteristics have on individuals’ SRH.Additionally, the correlation that attitudes toward immigrants have on health seem to vary across time and societal context, indicating that the relationship between attitudes toward immigrant and fair/poor SRH may be contingent on where and when data is collected.During the years analyzed, right-wing populism has risen in different European countries and their political discourse focused on immigration has increased the salience of the issue on the media, leading people to attach more importance to it.For instance, in Hungary, Poland and Slovenia, we found that in 2014, individuals who hold positive attitudes toward immigrants presented higher odds of reporting fair/poor SRH compared to other years analyzed. Notably, 2014 was the precise year in which far-right political parties won seats in the European parliament from these countries, and their success was very much linked to their political discourse focused on stoking racial and ethnic divisions.,,Our results also showed that there are more middle class individuals represented in the negative part of the attitude spectrum in recent years, which appears to reflect the increasing appeal of nationalist ideology to individuals from more advantaged socioeconomic backgrounds.Although this is a descriptive analysis, the results highlight the importance of analyzing attitudes toward ‘others’ on health, as they may be a marker of individuals’ negative emotions, which are related to health. Additionally, our analysis cannot test whether an individual who changes from better to worse attitudes toward immigrants would see his/her health deteriorate, as we have repeated cross-sections and not panel data.,Individuals may radically change their political affiliation due to the position that a political party has on a specific issue in a given moment,In this context, the information that individuals receive about immigration should be reliable and accurate to avoid ‘fuel the fire’ among prejudiced individuals. Besides, considering that attitudes toward immigration are developed during young ages,,Inclusionary othering, i.e. strengthening connections to others whilst acknowledging differences, has been shown to counteract the corrosive outcomes associated with exclusionary othering .Hence, investing in educational interventions that help the othering process to be inclusive rather than exclusive, i.e. helping people to see ‘differences’ as an opportunity instead of a threat, might not only improve all individuals’ health in general, but also health care provision.Analyzing how external factors that increase the prejudices and/or stereotypes toward ‘others’ impact on the relationship between attitudes toward immigrants and health, as well as the role of individuals’ SES background, will be an interesting topic for further research and better understand this relationship. To our knowledge, this is the first article, which analyzes the relationship between attitudes toward immigrants and SRH, opening a new field of study in the public health research.Conflicts of interest: None declared. Key pointsIndividuals who harbor hostile attitudes toward immigrants also report poorer self-rated health (SRH).Countries with more favorable attitudes about immigrants tend to show lower prevalence of fair/poor SRH; however, this relationship has evolved over time.The composition of people who have negative attitudes toward immigrants is changing, with more middle class individuals represented in this part of the attitude spectrum in recent years.


The construct of working alliance has been used to operationalise the patient–clinician relationship. Research evidence from the rehabilitation literature has established an association between the construct and several patient outcomes. The aim of this systematic literature review was to study working alliance in the chiropractic discipline.This review followed a mixed method systematic review methodology: EBSCO (The Allied and Complementary Medicine Database), EBSCO (MEDLINE), EBSCO PsycINFO, Web of Science Core Collection, Chiro index, and grey literature were searched for quantitative, qualitative, and mixed methods studies on 17th March 2021. Qualitative appraisal was conducted using the Mixed Methods Appraisal Tool, version 2018. The qualitative component was synthesised via thematic synthesis and explored patients’ and chiropractors’ perceptions of the nature and role of working alliance. The quantitative component was synthesised via narrative synthesis to examine how the construct has been measured in research and what its effect on clinical outcomes and patient satisfaction is. The findings were integrated in the discussion section.Thirty studies were included. The qualitative component found that both patients and chiropractors consider working alliance as a key factor in the treatment journey. The findings illustrated that the construct includes the bond between a patient and a chiropractor which is underpinned by trust and attentiveness to patients’ needs, values and preferences. Qualitative data also suggested that strong working alliance has the potential to improve patients’ adherence to treatment and that it is characterised by ongoing negotiation of expectations about the goals of care and the tasks involved in the treatment plan. The quantitative component highlighted that even though working alliance is relevant to the chiropractic discipline, very few studies have quantitatively measured the construct and its effect.The findings of this review emphasise the subjective importance of working alliance in the chiropractic clinical encounter. However, there were not enough homogenous studies measuring the effect of working alliance on clinical outcomes and patient satisfaction to conduct a meta-analysis. Future research should focus on evaluating potential direct and mediated effects on patient outcomes.The online version contains supplementary material available at 10.1186/s12998-022-00442-4. In many clinical encounters the targeted treatment regime alone is unlikely to fully explain patients’ clinical outcomes ; the relThe term WA originated from psychotherapy and there is uncertainty around its conceptualisation , 10. ThiHistorically, chiropractors have identified themselves with a treatment predominantly focused on spinal manipulation. Increasingly however, evidence suggests that the idea of spinal manipulation being the single cause of observed clinical outcomes is unfounded given the evidential impact of contextual factors, which are part of all clinical encounters , 16. PatTo our knowledge, a review of the evidence base regarding the WA between a patient and a chiropractor has not been conducted. Consequently, this mixed methods systematic review aimed to synthesise qualitative and quantitative evidence to study the nature and the role of WA within chiropractic consultations. The qualitative component of this review identified and synthesised literature concerning patients’ and chiropractors’ perspective on the construct. The quantitative component reviewed additional literature investigating how WA and its features have been measured in the chiropractic literature and the effects of WA on clinical outcomes and patient satisfaction.This review followed mixed method systematic review methodology , 20 to cThis review included quantitative, qualitative, and mixed methods studies. The qualitative component of this review considered all studies that identify and explore the perceptions and experiences of patients and their chiropractors. For studies with a broader focus, only the data relevant to WA were extracted. There is a diversity of available measures of WA in the literature, which possibly reflects the ambiguity around the conceptualisation of the term . TherefoThe search strategy used the databases which were considered by the multidisciplinary team of reviewers as relevant to the research question and aimed to locate both published and unpublished studies.EBSCO (AMED—The Allied and Complementary Medicine Database), EBSCO (MEDLINE), EBSCO PsycINFO, Web of Science Core Collection, Chiro index were searched for potentially eligible articles on 17th March 2021. The lead reviewer screened the references of the articles selected for critical appraisal. Grey literature considered for the review included, for example, conference abstracts, unpublished trial data, theses found in sources such as Google Scholar, NHS Evidence, Trip (Turning Research into Practice) database, EThOS and OpenGrey.The search strategy included terms for WA, its features, and chiropractic, combined using Boolean operators. Additional search strategy information is available in the protocol . Table 2Two reviewers screened titles and abstracts independently using Rayyan . ScreeneThe reviewer collected the following data from all papers: study aims, participants, methodology, methods of data collection, methods of analysis, key results, and details about the research context, and information about the conceptualisation of WA or its three features.The quality appraisal was conducted by two reviewers using Mixed Methods Appraisal Tool, version 2018 (MMAT), which includes a combination of individual components and mixed method approaches . MMAT foQualitative studies, and mixed methods studies that included qualitative component were subjected to a thematic synthesis: qualitative data were extracted and grouped into themes  to exploNarrative synthesis was chosen instead of meta-analysis because of the clinical and methodological diversity of the ways that WA and its features were explored , 29. TheThe convergent segregated approach to integration was selected because the qualitative and quantitative research components were expected to address different dimensions of WA . The conThe database search resulted in 3913 records, of which 1597 were duplicates. The remaining 2315 records were screened. Citations of conference summaries contained 849 additional abstracts and were screened separately. Citation searching included the screening of 1287 references. The PRISMA flow diagram illustrates the study selection process  worthwhile is if I felt comforted from it, or I had a slight glimmer of hope that there’s going to be improvement. Otherwise, I don’t see the purpose in it” (p. 11). Patients also noted that their idea of the change they desire to see is individual and subjective ” (p. 159). In such cases, the change process is indeed negotiation between the patient and the chiropractor [I trusted [the chiropractor] would understand, and he would always shift [his approach] based on whatever I was saying” (p. 159). Conversely, some patients expect that their involvement in bringing about change will be minimal, and their practitioner is the one that will improve their circumstances , the better they are… the woman who is going through the first pregnancy is very scared, hesitant, anxious and wants that kind of knowledge, and wants the practitioner to know what they’re going through and set their mind at ease.” (p. 4). Overall, patients valued practitioners’ efforts to explain and teach them how to do things correctly [instead of just printing off some exercises” (p. 225).Some patients in the qualitative component acknowledged their role in this change process : “…everyapproach : “The chopractor : “I trusmstances : “I paidlleagues  noted in Jamison  exploredducation : “I thinorrectly  “instead“What I always say is that ‘We’re going to try to get you better, it might not be me. I might need help with other people. But the end result is that I’ll do everything I can to help you out’.” (p. 101). Overall, qualitative data from chiropractors suggest that this collaboration includes communication, patient-centredness, mutual trust. The following themes will discuss in more detail these components of a collaborative working relationship.Regardless of participants’ beliefs about the level of their personal responsibility in their care process, the data revealed that patients would like to know what the plan is for bringing about change. Chiropractors considered that to be cooperative in nature, their approach should be honest and compassionate : “What IThe third theme describes the communication between a patient and a chiropractor. First, example communication techniques serving different purposes were identified and are discussed in subtheme “Effective communication”. Second, potential conflicts are described as part of the clinical encounter in subtheme “Conflicts”.“communication between chiropractors and patients depended on the knowledge level of both parties” (p. 4). Considering the importance of mutual understanding for collaboration as discussed above, one of the key communication goals should be clear explanation. A chiropractor should invest time to explain and to ensure that the patient has correctly interpreted the information [clear and timely communication is an opportunity for chiropractors to understand patient expectations and assure patients that they are in a safe environment” (p. 102). Practitioners acknowledged the importance of clear explanations in the negotiation process [We try to really map it out in layman’s terms, this is why this is affected, and this is why if we can take the time to put in the work, it’s going to help. I think that’s been the most effective approach for sure, for adherence.” (p. 225).It was noted in one study  that “coormation : “clear  process : “We try…during his explanations, the D.C. often actively demonstrates the movement or procedure he wants his patients to practice, thus identifying with the role of the patient.” (p. 97). This is useful for the patient in two ways: not only will they have a mental image of what the movement should look like, but also, they will feel more confident about doing it. Referring to Bordin’s formulation of WA [An explanation can be facilitated using non-verbal communication or analogies to illustrate a point : for inson of WA , prioritcharacterised by acceptance both of the patient as an individual and of their complaint as valid and worthy of diagnostic consideration and therapeutic intervention” (p. 96). Similarly, Mior [“the nature of the communication went beyond exploring the presenting complaint—the symptom—it focussed upon how their condition impacted upon the whole patient” (p. 153). In scenarios where the focus is the presenting complaint, communication may be entirely instrumentally oriented [During an orthopaedic examination of a patient, the doctor is intent upon identifying the problem. A long battery of range of motion and pain tolerance tests are given. Therefore, most statements made are instrumentally oriented, usually consisting of directions, requests, and some information.” (p. 97). Different communication techniques would be relevant if the purpose of communication is bonding on a more personal level. A chiropractor may use language in a person-centred manner [depersonalise a patient by referring to body parts with a definite article  but rather use a possessive pronoun ” (p. 105). Chiropractors recognised that the rapport can be further strengthened by comments of praise, encouragement, and reassurance [Jamison  showed tly, Mior  discusseoriented : “Duringd manner  when thessurance . Again, ssurance , 44. In “Uninterrupted listening provides an opportunity for patients to feel engaged and was described as a method of forming meaningful connection.” (p. 101). Chiropractors mentioned that active listening requires time [You try to direct the discussion as much as possible but give the patient the time to really explain what their experience has been, you know? I find that breaks down barriers really quickly and builds trust and confidence in a new person." (p. 5). Patients want to feel empathically understood and listened to [We have a great relationship, and we talk a lot during the treatments, so I feel like my needs are being met” (p. 5). Conversely, a condescending, disrespectful, disinterested approach, was described as a factor leading to dissatisfaction with care quality [For example, active listening is of the utmost importance : “Uninteres time : “You trtened to : “We hav quality . The rolDisagreements, tension, and passive and active antagonism tend to surface during critical points of the clinical encounter. Differences of opinion were sometimes voiced between doctor and patient. At times, this attested to the strength of their relationship when either showed s/he was not afraid to question or criticise the other's opinion.” (p. 102). Differences in opinion were viewed as a test of the WA, which could be resolved via empathy, negotiation, and active listening.In the data, the definition of conflict included differences in opinion, tension, misunderstandings, failure to manage patients’ complaints, and unwillingness to refer the patient to other specialists. Oths  describe“Dr. Miller explains that because of the power of the manual muscle test he does not need to get a detailed personal history from the patient: the body will tell him everything he needs to know. Consequently, much of the conversation is characterised by apparently unmotivated comments and questions about family, work, etc., and general medical advice.” (p. 308). Similarly, a patient described their negative experiences with chiropractors [“I don’t think that they showed the attention that they should have to the aches and pains that you were saying. They were almost focused on; well, this is what works and telling you that this is what the other doctors used to do, and it does work.” (p. 157).While using communication techniques with a specific goal in mind can be effective, this can make a chiropractor less attentive to their patient’s comments when they focus on the task at hand. Non-attentiveness may also be the result of chiropractor’s beliefs: if a practitioner expects that the cause of pain is entirely biomechanical, then he or she may be less attentive to patient’s social and psychological concerns : “Dr. Mipractors : “I don’this non-attentiveness seems to be the root of much of the tension occurring in exchanges” (p. 103). Similarly, Mior [expressed as passive tension, primarily in the form of nervousness , insecurity, overcaution, and dependency” (p. 102). In cases of conflict [expressed as open antagonism, manifested by impatience or interrupting the patient” (p. 102). Conflicts are a likely part of the working relationship: attentiveness to the expectations of both parties involved should be prioritised.Occasions where non-medical details about a patient were remembered were considered beneficial for building trust. In contrast, beliefs about chiropractor’s sincerity could be undermined by their non-attentiveness : “this nly, Mior  found thly, Mior . To avoily, Mior , which mconflict , chiroprthe quality of a chiropractor  that demonstrates a provision of care that is respectful and responsive to the patient, and which is inclusive of the person’s values, preferences, and needs” (p. 6). Often it is “expected the chiropractor to demonstrate this same quality (patient-centredness) in their interactions” (p. 6). Overall, the person-centeredness may facilitate collaboration during care and the this theme provides examples.Qualitative results from one of the studies  describe…the chiropractor should have personal knowledge of each patient as well as information about the history of their injury and his or her current medical conditions. Such personal knowledge should then be integrated into the evolving care of the individual patient” (p. 6). Such personal knowledge might enable practitioners to better understand each patient and facilitate collaboration. Indeed, patient’s perception that their chiropractor does not understand them was identified as a barrier to exercise adherence: considering patients’ values, preferences, and needs may influence patients’ active engagement in their care [Participants also noted that the chiropractors listened and “would understand” and “shift” in response to their concerns, a cornerstone to building a trusting relationship’ (p. 149). While trust is a key interpersonal process underpinning this bond, there are other positive feelings which patients associate with chiropractors whose approach is patient-centred [It’s easy to feel like you’re friends with those kinds of professionals.” (p. 5). Interestingly, the findings revealed that person-centredness comes with its challenges. For instance, a chiropractor [probably sent people for x-rays as peace of mind for the patient” (p. 224). Some practitioners felt that patients’ previous experiences and beliefs may have negative impact on the change process [they still feel like they need or they want the adjustment … we do it if we need to… but we don’t just kind of cater to expectations or wants from previous experiences…” (p. 224). A practitioner [The bio-psycho-social model is very relevant too. Because they are not all coming to me from nice family units…” (p. 5).Some patients  considereir care . Patienteir care : ‘Partic-centred : “It’s eopractor  shared t process : “…they titioner  noted: “The majority of patients felt the chiropractic care they received was patient-centred. They interpreted this as being involved, informed, and participant in approving the care they received. They reported being an active participant in the decision-making process of their care and the chiropractor seemed respectful of the patients’ needs and concerns.” (p. 157). The examples discussed in this theme reveal how patient-centred approach which treats the patient as an individual with needs, values and preferences can facilitate the formation of WA and its three components: agreement on the goals of care, agreement and collaboration on the treatment plan and the foundation of positive reciprocal feelings. The next theme examines one of the key interpersonal processes involved in this mutual bond- the trust between a chiropractor and a patient.The following quote from one of the studies  providesDr. Miller’s fundamental claim is that he is a healer. By this claim to legitimacy, he asserts that he is a qualified and practicing authority in the healing arts, and potentially helpful to people who present to him. As such he is allowed to make certain kinds of statements and do certain things, patients are correct to consult him in illness and he is entitled to the respect and rights accorded healers.” (p. 310). It was suggested that practitioners’ trustworthiness depends on the credibility of chiropractic in general, which is usually validated through scientific evidence, experience, and good reputation. If the role of the chiropractor is that of the change agent, there are standards that should be considered. For instance, the chiropractic profession in the United Kingdom (UK) is regulated by law: The Chiropractors Act 1994 provides statutory regulation, and the title 'chiropractor' is protected under this legislation [for some patients a clean office and an air of professional decorum are indicative of professional propriety and trustworthiness” (p. 310).One study exploring the therapeutic encounter revealed that trust has a specific role in the working relationship : “Dr. Miislation . Howeverislation  describeParticipants suggested that a trusting relationship would be established more quickly if they admit to mistakes and acknowledge their own limitations, which sometimes resulted in a referral.” (p. 101). As the following quote shows, referring patients to other healthcare professionals who can better address their needs may increase their trust in the chiropractor [When I refer them out to another discipline, another chiropractor or something like that, that actually they trust me more than anything else” (p. 103). Chiropractors also acknowledged that agreement on goals and tasks is key for the establishment of trust between them and their patients. As one participant [I tell them at the very beginning that I will never do things by surprise. I will always explain a thing before I do it. You are always the boss, I’m not. This visit is about you not me.” (p. 103). Considering that the process of building trust is unique for each working relationship, chiropractors also pointed out the role of non-verbal communication. First, patients’ nonverbal communication reveals their level of trust and comfort in each situation. Second, chiropractors use their own nonverbal communication to establish trust [eye contact, firm handshake, knowing when and when not to touch somebody” (p. 102).The notion of honesty was emphasised : “Particopractor : “When Iticipant  explainesh trust : “eye coIn summary, the qualitative synthesis illustrated the nature and role of WA in the chiropractic encounter. The professional relationship between a chiropractor and a patient aims to be cooperative in nature, involving collaboration and effective communication which is characterised by active listening, clear explanations, and patient education. The findings revealed the importance of trust and ongoing negotiation of expectations of the treatment plan whose main goal is to bring a mutually agreed upon change to patients’ circumstances.First, this section provides a summary of the included study designs and participants. More details about each study  are shown in Table The 23 included papers were comprised of quantitative descriptive studies, randomised controlled trials and a study conducting analysis on documents. The quantitative components of mixed method studies used questionnaires. Most chiropractic patients presented with musculoskeletal problems. Two studies focused on women with migraine and pregnant women. Studies were conducted in the United States, Canada, Australia, the United Kingdom, the Netherlands, and Sweden..Table Eight studies measured patient satisfaction by using scales consisting of items which also assessed aspects of WA. For instance, a 27-item satisfaction questionnaire adapted from the chiropractic satisfaction survey  was usedThis review included thirty studies exploring aspects of the WA between a chiropractor and their patients to study its nature and role within the clinical encounter. The qualitative component highlights the importance of WA during the treatment process and emphasise the role of effective communication. For patients, the perception that their beliefs, values, and preferences have been attended to by the practitioner strengthens the WA and might facilitate treatment adherence. For chiropractors, patients’ previous experiences, unhealthy beliefs and unrealistic expectations can challenge the establishment of a collaborative working relationship. Most of the studies included in the thematic synthesis had good methodological quality. The qualitative findings of two mixed-method studies did not contribute substantially to the synthesis , 36. ThiBabatunde and colleagues conducted a scoping review of the literature studying WA across physiotherapy and occupational therapy . They foThe qualitative synthesis suggests that chiropractic care can be considered as a prolonged change process in which collaborative working relationships between patients and chiropractors are especially important. At the start of care, a patient who seeks help to change their circumstances and a chiropractor whose role is that of the change-agent begin a treatment journey together. Strong WA can facilitate the change process ensuring its cooperative nature: our synthesis related patients’ and chiropractors’ experiences of therapeutic relationships to the role of the three features proposed by Bordin : agreemeThis notion of considering chiropractic care as a change process is in line with the dynamic model of treatment perceptions . The modThe themes generated by the thematic synthesis of this review are in line with the findings of a concept analysis which explored WA within physiotherapy literature . AuthorsThe quantitative component of our systematic review included only two studies measuring explicitly WA. Most studies explored adjacent constructs, for example, communication, patient satisfaction, and dimensions of person-centred care. For instance, questionnaires which measured patient satisfaction contain items focusing on contextual factors inherent in WA. Despite that the scales measuring these adjacent constructs include items enquiring about the chiropractor–patient bond, the collaboration on tasks and/or the agreement on goals, they have less explanatory power than a scale specifically designed to measure WA. This review provides some initial evidence for the role of WA within the chiropractic clinical encounter. Research explicitly exploring this construct should measure its direct and mediated effects on clinical outcomes and patient satisfaction. For example, Bishop and colleagues conducted a large prospective cohort study, and their findings emphasised the role of WA and its three features  as a conThe qualitative component illustrates that Bordin’s formulation of WA  has the This research project synthesised a diverse body of evidence on the topic of WA using data from quantitative, qualitative, and mixed method studies. This type of systematic review provided a nuanced understanding of such a multifaceted phenomenon and was appropriate for the explorative objective of this study. However, there were not enough homogenous studies measuring the impact of WA on patients’ satisfaction and clinical outcomes to conduct a meta-analysis. Narrative synthesis provides more limited information for healthcare decision making than meta-analysis , 29. MosWA has been studied to a limited extent within the chiropractic discipline. The nature of WA is best understood if chiropractic care is viewed as a change process in which a patient aims to improve their circumstances by seeking help from their practitioner whose role is that of the change agent. Strong WA requires ongoing negotiation of treatment goals and expectations alongside collaboration on a mutually agreed upon treatment plan. These processes of negotiation and collaboration are facilitated by, and may in turn strengthen, interpersonal bonds involving trust and mutual respect. Bordin’s formulation of WA  has the Additional file 1. Figure S1. PRISMA 2020 flow diagram.Additional file 2. Table S1. Quality Appraisal.Additional file 3. Table S2. How was the Working Alliance measured?