The importance of improving men’s and women’s knowledge of sexual and reproductive health has been emphasised in numerous global health policies. Fertility awareness literature highlights a disproportionately higher number of articles related to pregnancy-prevention compared to pregnancy-planning, which is justifiable in many contexts. However, recent concerted effort to improve fertility-awareness warrants a closer investigation of basic reproductive health terminologies. The objective of this study is to explore participants’ views of “family building” and provide a definition.We conducted 35 qualitative in-depth interviews on men, women and healthcare professionals who were sampled from a UK cross-sectional survey. We asked participants about terms such as ‘family planning’ and ‘family building’ to elicit views and explored the appropriateness of the term “family building.” Data were transcribed and analysed via Framework analysis.umbrella term for the use of contraception methods,” that “paradoxically, the term family planning almost has a negative connotation regarding having a family,” but could not state similar terminology for planning a family. Reasons cited for this perspective include the focus of school education and usage in clinical settings.When asked what ‘family planning’ meant to them, study participants stated that the term meant the avoidance of pregnancy. They viewed it as an “Family building refers to the construction or formation of a family, which can include steps or actions taken by an individual towards having children. In contrast to family planning, the intent focuses on pregnancy planning and childbearing rather than pregnancy prevention. However, it can also include actions taken to space the number of children one has.” Some balance in the global public health messages, including bridging the gap in reproductive health literature, policies, processes and practices may contribute to the effort to improve fertility knowledge. Use of appropriate terminologies help optimise reproductive health services in order to enable men and women achieve their desired fertility intentions, whatever they may be.In the absence of an explicit definition in literature, we generated a new definition for family building as follows: “Trial registration Not applicable umbrella term for the use of contraception methods”, that “paradoxically, the term family planning almost has a negative connotation regarding having a family,” but could not state similar terminology for planning a family. We introduced family building and provided a new definition. We believe that some balance in the global public health messages, including revisiting widely used terminologies can help bridge the gap in reproductive health literature, and contribute to the effort to improve fertility knowledge. Additionally, this has implications for promotion of preconception and optimising reproductive health in relevant policies, processes and practices, in order to help people achieve their desired fertility intentions, whatever they may be.Global health policies have emphasised the importance of improving individual’s knowledge of sexual and reproductive health. Fertility awareness literature highlights a disproportionately higher number of articles related to pregnancy-prevention compared to pregnancy-planning, which is justifiable in many contexts. However, the recent concerted effort to improve fertility awareness warrants a closer investigation of basic terminologies in the field. For example, although the term family planning encompasses attaining the desired number of children and spacing pregnancies, it is almost synonymous with not having children, while there is currently no widely accepted equivalent terminology for planning to have children, either in general usage or clinical settings. We conducted 35 qualitative in-depth interviews on men, women and healthcare professionals who were sampled from a UK cross-sectional survey. When asked what ‘family planning’ meant to them, study participants stated avoidance of pregnancy. They viewed it as an “ Global health policies have highlighted the importance of optimising women’s health and knowledge of contraception as part of pregnancy prevention and for pregnancy planning as part of preconception care –4. HowevFamily planning can be linked back to falling birth rates from the late nineteenth century, differentially among the social classes, the demographic transition and the role, or otherwise, of individual rational action. Pre- and early-twentieth century artificial methods of contraception were still associated with non-marital sex and immorality with historians attributing most of the declining birth rate to natural methods . By the Although the concept of family planning encompasses attaining one’s desired number of children and spacing pregnancies, it is typically attributed to the practice of limiting the number of children one has. In general usage, it is synonymous with birth control, use of contraception and prevention of unwanted pregnancy. According to Oxford dictionaries , family While the use of the term family planning for pregnancy prevention is widely established in general literature as well as scientific and clinical settings, in conducting our literature review for this study, it was evident there was no equivalent widely used terminology for describing a focus on achieving pregnancy. “Proception”  has beenThe study is a qualitative component of a wider mixed methods study. Participants were sampled from a UK wide cross-sectional survey on fertility awareness, including men, women and healthcare professionals who had agreed to a follow-up interview. Participant demographic information was collected as part of the survey questionnaire. A new study invitation email was sent to recruit for the qualitative interviews. Criteria based purposive sampling was systematically employed to cover the socio-demographic diversity of the three population groups based on gender, age, ethnicity, and education, as well as to cover the range within each group. In this study, thirty-five interviews were conducted on thirteen men, thirteen women and nine healthcare professionals as previously described in Grace et al. . Thirty-Family building refers to the construction or formation of a family, which can include steps or actions taken by an individual towards having children. In contrast to family planning, the intent focuses on pregnancy planning and childbearing rather than pregnancy prevention. However, it can also include actions taken to space the number of children one has”.“Interviews lasted one hour on average. As part of questions on their knowledge and attitudes towards fertility awareness, planned and unplanned pregnancies, participants were asked what the term “family planning” meant to them. The term “family building” was introduced to evaluate participants’ understanding. Our full definition was then introduced to study participants in order to elicit views:All interviews were digitally recorded, transcribed verbatim and coded electronically using the NVIVO Pro software, QSR International . Data anEthical approval was obtained from UCL Research Ethics committee (Reference 8421/001). All participants in this study participated voluntarily and gave informed consent. The interviews were conducted sensitively by a single trained interviewer.The sociodemographic characteristics of study participants are shown in Table “Trying not have children”. MP5—Male, Age 38, White, GCSEs, has two children, does not want more.“Family planning is just making sure you have knowledge about contraception really” MP7—Male, Age 35, Chinese, Degree qualification, has no child, would like in future.“It is an umbrella term for the use of contraception methods.” MP10—Male, Age 33, White, GCSEs, has no child, unsure about having children.“It’s obviously when you’re trying to plan so that you don’t end up having a baby that you don’t want to.” FP5—Female, Age 30, Asian, A levels, has one child, would like more.Family planning means using contraception.” HCP4- Consultant, Male, Age 45, has three children, does not want more.“When interview respondents were asked what they understood by the term family planning, by far the most common responses were that family planning meant contraception or pregnancy prevention.“For me, family planning, I would think of it as trying to talk people out of having children before they’re ready and able to support them and bring them up in a stable and secure environment. Paradoxically, family planning for me almost exclusively has a negative connotation, and I don’t mean negative as in it shouldn’t happen. I mean negative as in it should be trying to help people plan properly for a family rather than prevention therefore holding them back rather than encouraging them to have a family.” MP9—Male, Age 43, White, Degree qualification, has three children, does not want more.Interestingly, the majority of interviewees did not overthink this question. The view that the family planning terminology is used within the context of pregnancy prevention was simply an automatic response. However, some respondents were cognisant of the fact that together, the two words,’ family’ and ‘planning’, should mean planning a family which could include having children.“So, family planning I think of women’s health, I think of screening, I think of contraception information and so it can be ranging from giving out the condom to young people to testing for STDs to kind of a place to go from the whole like it’s your health issue.” FP11—Female, Age 21, Black, Degree qualification, has no child, would like in future.“I think of, like, doctors’ surgeries and that kind of thing, like, doctors asking that kind of question, like how you’re managing your fertility, in quite a medical sense rather than a more casual sense. I usually think contraception though.” FP12—Female, Age 21, White, Degree qualification, has no child, unsure about having children in future.“I think of family planning clinic. Offering contraception, sexually transmitted disease advice things like that.” HCP3, Consultant, White, no child, did not meet partner until later in life.For some respondents, the scope of the terminology goes beyond contraception and pregnancy prevention; it also covers preventing sexually transmitted infections, usage of screening services, abortion clinics and including other topics relating to sexual and reproductive health within clinical settings. Female respondents were more likely to consider the terminology in the context of women’s health generally.Following on from the responses on what family planning meant, we probed further to understand the reason why family planning was viewed almost exclusively in terms of contraception. Most respondents were unable to clarify the reason why family planning was viewed in the context of pregnancy prevention but there were some suggestions, especially amongst healthcare professionals, that it is related to the use of the term within clinical contexts. Another key theme which emerged as a reason for this connection was the focus of sexual and reproductive health school education being primarily on pregnancy prevention.“Contraception that’s the first thing that comes to mind. I have [a] medical background. I think always in terms of medicine that you know Family Planning Clinic is where people go to get their contraception or to have coils changed or to be started on the pill, after their pill maintenance, you know, having their blood pressure checked and for prescriptions.” HCP1—Doctor, Female, Age 33, has two children, does not want more.“I think of a Family planning clinic. Offering contraception, sexually transmitted disease advice things like that. Americans have Planned Parenthood, which I get the impression is the same kind of thing. It’s just the general culture of talk about family planning is that it’s about [pregnancy] prevention” HCP3—General Practitioner, Female, Age 45, has no child, would like in future.One of the key reasons provided for viewing family planning in terms of pregnancy prevention is the way it is used in clinical settings. For example, ‘family planning clinics’ are healthcare centres where patients would go to receive contraceptive services. These include clinics where patients are provided with condoms, placed on the pill, have contraceptive devices fitted or where abortion services are provided.“I remember at school it was all about not having a baby—there was nothing on planning for the future. I know you don’t want to have teenage pregnancies but when it comes to wanting to have a baby, I think it gives you a false understanding of how easy it is to have a baby because for some people it really isn’t. So, it’s really about understanding whole fertility and contraception at an earlier stage I think”. FP2—Female, Age 32, White, Degree qualification, has one child, would like more.“We didn’t learn a lot on fertility as a whole. It was based on the fear factor. We were told not to get pregnant, not to have sex. Basically, avoid pregnancy at all costs.” HCP2—Nurse, Female, Age 30, has no child, unsure about having children.“Thinking of family planning terminologies in school, there was quite a lot about contraception.” HCP3—General Practitioner, Female, Age 45, has no child, would like in future.“I don’t think that we got any good foundation on fertility, the knowledge was far more sketchy and scant.” HCP4- Consultant, Male, Age 45, has three children, does not want more.There were also ubiquitous themes regarding school education and the focus on pregnancy prevention, when family planning discussions came up as part of sexual and reproductive health education.I think it [family building] involves looking to the future. Creating a family within a relationship. MP5, male, Age 38, white, vocational qualification, has two children, does not want more.When I think of family building, I think of sitting down, having a talk with your significant other and just thinking about having a baby or furthering the relationship that way, that’s what I think. MP2, male, Age 27, Asian, Degree, no children, would like in future.When the term “family building” was introduced to respondents, they were able to view the terminology in the context of wanting to have children.“Honestly, I’m now not sure why I usually think of contraception. It [family planning] Should be about planning your whole reproduction, it’s not just about contraception. Family building makes me think of that. Yes, the whole discussion should be holistic to include having and taking a break from having children.” FP1. Female, Age 36, Asian, Degree and above, has two children, would like more.“Yeah [family building] I’d think trying to have a baby or children in future. I guess that's what family planning ought to mean if you look at it holistically.” HCP2—Nurse, Female, Age 30, has no child, unsure about having children.…Your definition makes perfect sense. I guess family building is what we’ve missed from family planning.” HCP3—General Practitioner, Female, Age 45, has no child, would like in future.“Some respondents provided further reflection on the general perception of what family planning means, welcomed the new definition and reiterated the importance of representing needs for those wanting pregnancy prevention as well as pregnancy planning.Finally, interview respondents were asked to provide their views on improvement opportunities.“So, I’d been on the pill for a long time before I decided that I wanted to have a baby, so I knew that my cycles weren’t really real. I do remember being worried about whether I’d be able to get pregnant or how long it would take. I was a bit unsure of going to the family planning clinic because I felt that they only deal with [contraception] pills… I feel they didn’t have the words or language to let women know about wanting babies.” FP5—Female, Age 30, has one child, would like more.In their responses, participants expressed the need for inclusive language to help patients better frame reproductive health needs.Yes, it should be a combination of both: talk about contraception and talk about planning for a baby. In discussions between couples, one person in the marriage or the relationship might want to start a family and then the other doesn’t. Having that discussion as to what's important to both parties and there should be a forum for that.” HCP8—General Practitioner, Female, Age 36, has no child, would like in future.“In recognition of different fertility intentions, there were views on balanced discussions on pregnancy prevention, pregnancy planning and reproductive life planning.“It’s best to give the education [so] that they [students] can make the choices they want, rather than say ‘I wish I knew that 10 years ago’.” FP11—Female, Age 21, Degree qualification, has no child, would like in future.“I think you should plant the seed when someone’s younger and then later on it should be there for them to get at the time when they want it, ‘cause everyone’s gonna want it at different times, aren’t they?” HCP5—Nurse, Female, Age 24, has no child, would like in future.Linked to the perspective that school education mainly focussed on pregnancy prevention, there were recurring themes regarding improving school education, planting ‘the seed’ young in terms of early but age-appropriate fertility education.This study aimed to explore participants’ views of the terms “family planning” and “family building” in the context of fertility awareness, review the appropriateness of the term “family building”, and in the absence of an explicit definition in literature, offers a new one. In line with literature findings, when asked what family planning meant to them, our study participants almost unanimously and automatically said prevention of pregnancy, which was a ubiquitous theme in this study. By contrast, they did not automatically offer a term for planning to have a family. One respondent highlighted that, “paradoxically, the term family planning almost has a negative connotation regarding having a family.”To the best of our knowledge, this is the first study exploring the meaning of the terms “family planning” and “family building” among men and women of reproductive age as well as healthcare professionals. We believe the use of these terms in literature as well as scientific and clinical settings is an important component for improving fertility and reproductive health awareness to enable men and women achieve their desired fertility intention as its intent focuses on pregnancy planning and childbearing rather than pregnancy prevention, which family planning represents.Due to the increased incidence of delayed family building, rates of involuntary childlessness and fewer children than desired have also increased , 26, 33.More collaborative initiatives from the different reproductive health services are needed. As highlighted by Shawe et al., “Proactive discussion of preconception care and pregnancy planning should be an integral part of all contraception and reproductive health services wherever they are provided”. In addition, new pregnancy-friendly terminologies are necessary within family planning services to encourage more balanced messages encompassing planning to have a family .It is important to note that there are considerable variations in family building intentions among different individuals . For thoIn order to address different and evolving needs, education and information packages on family building, ought to be tailored to be effective, however they are delivered. Services should be better equipped to educate both men and women about fertility awareness when they first report trouble conceiving to their HCP. This opens a potential role for general practitioners, practice nurses in primary healthcare services and sexual health practitioners, that is those working in sexual health and contraception services.Information should be targeted based on different family planning and family building intentions using a lifecourse approach such as the Reproductive Life Plan (RLP), a set of personal goals regarding whether, when, and how to have children based on individual priorities, resources, and values . This stTo encourage the engagement of men, the current female-focused awareness and education programmes on fertility and reproductive health generally should be reviewed and reoriented to be fully gender inclusive , creatinIn terms of theoretic and practical application, beyond the use of the new definition in literature, it is important to consider how the use of terminologies could be promoted to help achieve desired fertility intention. We believe that proactive discussion of family planning and family building needs should be an integral part of reproductive health services , 41. FroIn terms of study strengths and limitations, a key strength of this study is the original contribution to literature by providing a new definition for family building in the absence of an explicit definition. Another strength is the inclusion of men in the study as they are often left out of the pregnancy and childbearing discourse. In terms of study limitations, although we gathered rich data, interviewees were self-selected and results principally reflect views of those who we willing to participate. Due to the online recruitment method, there is a potential bias towards more educated respondents. Finally, family planning clinics in different countries across the world may serve different purposes, which has implications for the generalisability. While in principle, the study findings are applicable in similar contexts, the representativeness of the UK population would need to be considered.Our study provides as new definition for family building as follows: “Family building refers to the construction or formation of a family, which can include steps or actions taken by an individual towards having children. In contrast to family planning, the intent focuses on pregnancy planning and childbearing rather than pregnancy prevention. However, it can also include actions taken to space the number of children one has.” Historical global emphasis on pregnancy prevention means that, by comparison relatively little attention is being drawn to issues associated with postponement of childbirth and infertility. Although there is still an important need for continuous advocacy of contraceptive methods for family planning within fertility awareness campaigns, some balance in the global public health message may help alleviate problems experienced with involuntary infertility, including use of terminologies. Effective discussion of family planning and family building needs is integral to reproductive health services. This new definition creates an opportunity for those who are actively seeking to create or build a family to better express their needs and desires and engage constructively with healthcare professionals. It also has implications for inclusive language in the promotion of preconception and for optimising reproductive health in relevant policies, processes and practices, in order to enable men and women achieve their desired fertility intentions, whatever they may be.


Undergraduate nursing students were inevitably recruited to provide care in response to overloaded hospitals with COVID-19 patients. The placement was potentially a stressful event and we aimed to understand the students' perception of direct nursing care during the pandemic.https://ethics.research.ac.ir).This qualitative content analysis study carried out in 2020 (May-June) in Tehran, I.R. Iran. Using explanatory questions, we interviewed 15 undergraduate nursing students who provided direct care for at least 2 months to patients hospitalized with COVID-19 in the beginning of the pandemic to obtain their deep experiences. We applied the MAXQDA 10 to extract codes, used the qualitative content analysis method for investigation, and then applied the Lincoln and Guba criteria for rigor and trustworthiness. The study was approved by the National Committee for Ethics in Biomedical Research (IR.BMSU.REC.1399.070. available at: Four hundred and 54 codes were identified, which were then sorted into 12 categories underlying four main themes of “hard and unpredictable,” “posttraumatic growth,” “on the path to self-determination,” and “commitment.”Even though the undergraduate nursing students experienced some stress in the beginning, with close support, their caregiving skills improved and they were able to meet the national healthcare needs. More studies are needed to confirm our findings regarding the experiences of the nursing students in combating COVID-19. The novel coronavirus COVID-19) pandemic exacerbated a global nursing shortage concern that healthcare provision is being compromised due to a lack of qualified nurses 9 pandemi–4. Iran To meet the needs, Iran's Ministry of Health and Medical Education (MoHME) inevitably drafted under-graduate nursing students to care for patients with COVID-19 in response to hospitals receiving COVID-19 cases . BaqiyatBeyond the pandemic, undergraduate nursing students are vulnerable, and the clinical setting usually has a stressful influence on nursing students, as has been well-documented in previous studies. Al Rasheed et al.  study shThe qualitative content analysis study carried out on May-June in 2020 in Tehran, Iran, to illuminate the experience of the students of care provided to COVID-19 patients.Eighty-four students participated in a preliminary short course outlining “how to provide care to the patients” prior to embarking. After 2 months using purposive sampling, 15 participants  including 10 nursing students, 3 anesthesiologists, and 2 operation room technologists were interviewed. Sampling continued until data saturation was obtained. Sample of follow up questions were: “Tell us about your feelings when you were introduced into the hospital wards,” “How did you spend your time during the pandemic?”, “What was it like to care for a patient with COVID-19” and “What did you think when you decided to go back to the hospital?”. For enhancing the maximum variation, students from different disciplines and semesters including both male and female were interviewed. Those who had at least 2 months of direct caring from COVID-19 patients' experience, were invited to participate in the study.Semi-structured interviews lasting 25–45 min were carried out. After several warmup open-ended questions, the interviews were continued with probing and explanatory questions. Students were asked to narrate their experience in as much detail as possible. Interviews were conducted in the faculty of nursing office in favor of the students. All 15 interviews were done in the Persian language by a single interviewer. Only the quotations that are presented in the findings section were translated into English.The Graneheim and Lundman approach for qualitative content analysis was used . After eWe received the ethical approval number of IR.BMSU.REC.1399.070 from the National Committee on Biomedical Research. The research objectives were explained to the participants and written informed consent was received. The participants' permission was also obtained for recording their interviews. The time and place of the interviews were determined by participants, and they were free to stop if they felt exhausted or distressed. Having no tendency to continue, disagreements to record their voice, and or take their notes were used as exclusion criteria. One of the female students didn't agree to voice recording, so the interview was done using simultaneous note taking.Data analysis revealed 454 codes that were sorted into 12 categories outlining four main themes including “hard and unpredictable,” “on the path to self-determination,” “posttraumatic growth,” and “commitment” .This theme comprised of categories of “stress and anxiety,” “hard situation,” “lack of knowledge and skill,” “lack of personal protective equipment” (PPE), and “lack of coordination.”Students experienced stress for two reasons: The main cause of stress was related to the nature of the disease. In addition to worrying about becoming infected, they were concerned about contagion to the family, colleagues, students, and immunocompromised patients. The second source of stress was their knowledge and skill deficiency and a fear of harming patients.I was not worried about myself at all. Patients' immunity was poor. I was afraid of passing contagion to them.”A female nursing student said “The hard situation had different sources, including lack of PPEs, nursing shortage and their fatigue, crowding, families request for coming back home, and being away from family and friends. Also, they were under pressure due to patients' lack of response to treatment, being critical, and in some cases death.Having a critical patient was very hard for me, especially the night that the patient died. He was fine at 9 o'clock at night. Within 10 min he became critical. I was very much stressed.”A female nursing student said “Students reported their knowledge, skills, and readiness for clinical practice in different aspects including documentation, using PPE, therapeutic intervention, and drug interactions.The first day that the patient was handed over to me, I was confused. I think I wasn't ready enough to care independently.”A male student stated “In the first days, PPE was not adequate. With the passage of time, the supply chain improved and PPE was adequately available. Also in regard to the supply chain, different wards were not allocated based on their needs.In the first days of the pandemic, the number of protective equipment was inadequate. We had to use a single mask for a 12-h shift. If it was damaged, no replacement would be made.”A male student stated “One of the main problems was the lack of coordination between nursing faculty and the hospital. Students' duties, allocation to the hospital wards, the instructor's role, unclear expectation from students, and inadequate attendance of the instructors were the main problems.At first, the coordination between nursing faculty and the hospital was not good. The head nurse had some expectations that were discordant with our instructor.”A male student said “Despite the hard situation of working in infected wards, students gained worthwhile experiences and skills. Their independence was improved. They were working as educated nurses. Of course, this independence was not complete, and they needed education, support, and supervision.Students were not ready for working overtime and they had to work independently. Consequently, they gained new experiences and skills. They learned to be responsible. Their judgment about the patient's condition improved. Documentation, decision making, using their previous knowledge, teamwork, relationship with patients and colleagues, self-esteem, working in an infected ward, and readiness for catastrophic situations were some of their newly acquired skills and capabilities. They saw themselves as better and more patient than before. Clinical skills were significantly improved, and stress repetition decreased.Day by day my skills improved. By spending time, I felt that I can afford myself. I can prioritize the problems and then one by one solve them”A female student said “This was the first time that students had to work independently. They had a path of being independent. During the students' regular shifts, they had no accountability, and the main responsibility was for their instructors and patients' nurses, so they referred to their instructors as soon as they faced the slightest challenge. In the new situation, they had to support the patient independently. This experience was before their graduation and helped them to be ready for graduation. They were able to use their experience in the future and manage their patients easily. Also, they were able to manage their patients during the night shifts independently and felt useful because of this independence.Over time, I was able to prove [to] myself that I can work as a completely independent nurse. I could easily manage my patients in the night shifts. I felt myself to be more useful.”A male student said “Students had to do some work being dependent due to inadequate knowledge and skill. They were gradually trained and supervised so that they could work as independent nurses. Additionally, the supportive environment and some strategies used by students helped them.Head nurse referred me to the nurse educator. He told me: Observe anything and report to me your notes. In [the] following days, he taught me [the] required procedure during implementation.”Wherever an individual has to work independently, they must first be trained and then monitored. First, the student nurses were oriented for several days, and then they worked with a nurse educator or an experienced nurse. They observed the behavior and the work was explained to them, and then feedback was received. In the early days, students worked functionally and with their supervising nurses. Afterward, they provided care for the patients independently, but under the supervision of the head nurse or an experienced nurse. Procedures were monitored continuously and reviewed. A male student said “Students had strategies for learning such as observation and experience, asking the head nurse, studying, learning from others, and using the supervision of skilled nurses. They were checking the errors and ambiguous points with head nurses. Most of the students had a checklist for their daily duties too.I was writing everything in the ward. I checked them at the end of shifts with [the] head nurse or other experienced nurses. I had a checklist in my box. Every hour I was checking for missed work.”A female nurse stated “The students considered the supportive environment to be the most important thing in dealing with this critical situation and its difficulties. The nurses had a good relationship with the students and were replying to their questions. Nurses supported students when they did not have enough information or had critically ill patients. Experienced nurses provided emotional and psychological support. Also, in the case of attendance of instructors, they were supported.Head nurse was quite supportive. This support resulted in higher self-esteem. Also, other colleagues were supportive. One night when my patient turned critical, my colleague accepted the responsibility of the patient.”A female student said: “After achieving independence, the students were present in their shifts as staff. They cared for the patients as nurses, and they felt good to be seen. They acknowledged that they were respected and not abused.After several orientation shifts, I was independent. I was respected like a nurse, and they expected me to do the duties completely.”A male student said: “The students attended voluntarily and somehow considered it as their duty to attend. This theme has two categories of “call of duty” and “responsibility.”Students said that COVID-19 patients are just like any other patients and have the right to receive medical care. They felt it was their duty to help during the shortage of nurses, and while the nurses were fatigued. They felt good providing psychological support to the patients and felt that they had to be strong so that the patients would be encouraged to see them. It was like a battlefield for them, and they took it as a duty to be present on this battlefield.We prayed for the assistance. This was our mission because our people needed help. So, I felt a duty to attend in this field.”A male student said: “Students were sensitive to doing things right. They were trying to be highly accurate in caring for patients. They were monitoring continuously, because taking responsibility for patients' health was difficult and stressful for them. They followed all health protocols while working.I was working with cancer patients. Their immunity was compromised. I was washing my hands before and after every procedure. In case of a patient having leukopenia, I even washed the devices such as blood pressure cuff using an alcohol pad.”A female student said: “To date, limited data are available about experiences of undergraduate nursing students providing care for patients with COVID-19. However, similar results were recently reported by Rahmani et al.  about excommitment,” Lovic et al.  reported the undergraduate student nurses experienced fear of possible contagion to their cohabitant, stress, insomnia, nightmares, and anxiety. They concluded the students had emotional tension during clinical education that was eased by support of co-workers and their families recommending psychological support in probable upcoming situations (Considering the theme of “om Spain 21 reportHaggard's study from Arkansas (2022) on undergraduate nursing students' health behaviors showed the students experienced more panic attacks, headache, and more consumption of alcohol prior to the pandemic (quarantine period) . It was on the path to self-determination” and “commitment” in our study showed the students have considered the pandemic as an inevitable but unique condition in their career.On medical education during the pandemic however, Khamis et al.  expressehard and unpredictable,” Fan et al. . The patients/participants provided their written informed consent to participate in this study.The studies involving human participants were reviewed and approved by National Committee for Ethics in Biomedical Research (IR.BMSU.REC.1399.070. available at: FF and SM worked together equally during the project and drafted the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In the published article, there was an error in Literature review and hypotheses, Relationship between workplace ostracism and KSBs, Hypothesis 1. This sentence previously stated, “There is a positive relationship between workplace ostracism and KSBs”. The corrected sentence appears below:Hypothesis 1. There is a negative relationship between workplace ostracism and KSBs.The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.


Perceived severity and susceptibility of disease are predictors of individual behaviour during health crises. Little is known about how individual beliefs influence intentions to adhere to public health guidelines during periods of health crises, and how access to and consumption of information influence these intentions. This study investigated behavioural beliefs, normative beliefs, and control beliefs, and their influence on behavioural intentions to adhere to public health guidelines during the COVID-19 pandemic.Participants were recruited from a related COVID-19 study conducted by our team, and through snowball sampling in subsequent. Using a maximum variation sampling technique, we recruited a diverse group of participants representing six major regions in Canada. Participants took part in one-on-one semi-structured interviews from February 2021 to May 2021. Data were analyzed independently in duplicate by thematic analysis. The Theory of Planned Behaviour (TPB) was the conceptual framework used to organize dominant themes.We conducted a total of 60 individual interviews  and identified six themes organized according to the three constructs of behavioural, normative and control beliefs as described in the TPB: (1) Behavioural: My “New Normal,” Individual Rights and Perceived Pandemic Severity, Fatigue with COVID-19, (2) Normative: COVID-19 Collective, (3) Control: Practicality of Public Health Guidelines, and (6) Conflicting Public Health Messages. Most  participants perceived individuals in their geographic community to be following public health guidelines adequately. Several participants  commented on the unequal impact of restrictions based on socioeconomic factors .Individual perceptions of risk, loss of control, access to resources , and societal expectations, shaped intentions to engage in disease preventative behaviours  during the COVID-19 pandemic.The online version contains supplementary material available at 10.1186/s12889-023-15344-0. Infectious disease outbreaks pose severe risks to public health , 2. Targpersonal attitudes toward behaviour), normative beliefs (subjective expectations of others), and control beliefs   parties and the most ridiculous things happening.” 81-year-old female from OntarioMost participants commented on perceived pandemic severity, and relatedly, individuals’ selfishness. Older adults (particularly in Ontario and British Columbia) were more specific in who they perceived were selfish, pointing to younger adults as the “cause” of spread.“I think in the beginning everybody was … following it [public health guidelines] as much as they possibly could because they realized that this was a serious thing .... But I think the more time that went on ... people are getting frustrated, really frustrated, and really upset. Anybody that I talk to is just annoyed with everything” 28-year-old female from OntarioMany participants acknowledged the challenge of adhering to public health guidelines as the pandemic wore on, with physical distancing recommendations a particular point of contention.“I think people are just getting a little fed up that isolation, this isn’t the way to live. I mean, you can’t just stay holed up in your home forever and not see anybody because there’s a risk of something happening.” 63-year-old male from ManitobaParticipants attributed COVID-19 fatigue to extended isolations, describing the toll that loneliness takes on people, psychologically.“I mean, at this point I think people are just getting tired. So, we’re seeing lots more of our ... People who aren’t in our inner circle of friends, that are starting to push the boundaries, and you’re like, “Come on guys, the end’s in sight. We just got to hold the line a little longer. Why are you starting to do things like that? Why are you going to social things?“ Things like that.” – 40-year-old male from British ColumbiaWhile the majority of participants openly described fatigue in relation to others failure to comply with guidelines, few discussed fatigue in regard to their own behavior. Notably, when discussing COVID-19 fatigue, some participants clearly distinguished between “us,” and “them”.In this study, normative beliefs reflected the subjective norms held by participants, or their perceptions of what they think that others should or should not do, regarding a specific pandemic behaviour. This was most evident when participants discussed the importance of collective action and the influence this had on intentions to behave in accordance with public health guidelines.“I think anytime something happens, the community comes together and they’re not necessarily focused on themselves. It’s more so for the community… Even just recently when we had back to back days [of high case numbers] the community came together and did their part [to get cases under control].” 27-year-old male from Nova ScotiaThe majority of participants noted a sense of community action, describing that prioritizing community safety over their individual selves was the “right” thing to do. When providing examples of collective action in their own lives it was clear that participants were proud to be part of the collective placing the health of others over personal desires.“To tell you the truth, in the beginning especially, I didn’t do any of it [follow public health guidelines] because it all wasn’t mandatory but then I went along and I wore the mask and I did all that stuff just to be courteous, to be respectful of other people who would be paranoid otherwise. As far as how I felt for myself, concerned? No, I wasn’t.” 65-year-old male from AlbertaSome participants recalled their skepticism surrounding collective action at the start of the pandemic. For these participants it was evident that the perceived behavioural expectations, set by the community, influenced their behavior as well as their intentions to behave.While participants were largely supportive of public health guidelines, their control beliefs were reflected in their concerns about people’s ability to comply with rules due to a lack of access to certain resources. Participants reflected on the practicality of public health guidelines, as well as conflicting messaging, commenting on their ability and intentions to adhere to these guidelines.“[people] are just unable to...for structural reasons…are unable to follow the recommendations out of necessity, because of the way they live… for example single women who go to work and then there is no one who can look after the children… they will not have the choice.” 39-year-old female from QuebecMany described that their intentions to engage in preventative behaviour was linked to the perceived practicality of public health guidelines. Most participants described restrictions as reasonable within the context of their own lives. Some participants voiced concern for vulnerable groups  acknowledging the added challenge to adhere to guidelines.“I feel like with using the media, we’ve painted this brush of, “No other problems are going to exist other than the pandemic until the pandemic is over, so let’s just deal with the pandemic, and then we can get back to normal. Then, we’ll deal with your mental health problems, or then we’ll deal with your cystic acne or your bad digestion… We’ve cut back on all of these services, because right now the pandemic is the thing.“ I think that what’s been communicated to us, the overall message has kind of been diluted, I guess, or spun to make it like, “This is a problem of the individual person,“ and then a lot of people I know just carry around this intense and immense guilt for not doing well enough with the regulations.” 23-year-old female from Nova ScotiaFinally, participants argued that preventative measures often fail to accurately represent the complexity of individual lives, and regularly discussed the challenges of trying to balance preventive measures with other health issues and needs.“As you know, in New Brunswick, we have colors [to delineate phases]. One color, nobody knew, wait now, wait now, wait now. What do we do here? … they’d say, “Well, yellow isn’t quite the same as yellow was last.“ That’s where we didn’t know. We didn’t know whether we were allowed to go to the hospital to visit people. We didn’t know anything. Couldn’t figure it out.” 82-year-old female from New BrunswickParticipants unanimously agreed that individuals’ intentions and ability to follow public health guidelines depends fundamentally on their understanding of set guidelines. As healthcare in Canada is managed provincially, government responses to COVID-19 outbreaks varied. Participants described that this led to increasing confusion, coupled with the everchanging nature of public health guidelines and information.“I think, like I say, they’re [public health officials] inconsistent. One day they say this, and the next day they say that ... I think people are just tuning out, quite frankly, because they’re frustrated, and because they’re not consistent.” 47-year-old female from PEIParticipants deepened their discussion on confusion by describing how their intentions and willingness to engage in appropriate behaviour was influenced by lack of understanding appropriate behavior at any given time. While many participants acknowledged the challenge for health authorities and governments to stay on top of the science, the influence of contradictory messaging on people’s ability and intention to engage fully in preventative behaviour was recognized.We conducted a qualitative description study using the TPB as the underpinning conceptual framework to investigate behavioural beliefs, normative beliefs, and control beliefs, and their influence on intentions to adhere to public health guidelines during the COVID-19 pandemic. Our findings from semi-structured interviews suggest that for behavioral beliefs, acceptance, perceived risks, and loss of control, shape participant’s intentions to behave. For normative beliefs, we found that adhering to protective behaviours is linked to collective action and perceptions of societal expectations. Finally, for control beliefs we determined that confusing pandemic health guidelines and contradictory messaging from regulatory bodies and news outlets influenced individuals’ ability to follow public health guidelines. Understanding the role that information plays in shaping these beliefs is critical, particularly as we grapple with a wealth of misinformation. For some, the information they received encouraged compliance by building confidence in the efficacy of health regulations. For others, this information sowed fear and increased confusion as contradictory messages appeared everywhere.Our findings on intentions to behave in accordance with public health guidelines reflect earlier research regarding individuals’ fear, trust, and compliance generally within the context of global health crises. One study conducted in both Italy and France during the first wave of the COVID-19 pandemic found a positive correlation between the likelihood to sacrifice constitutional rights  in the The “collective” and the importance of engaging in pandemic preventive behaviours to protect their wider community was a common theme in our study. Within the context of the COVID-19 pandemic, research has highlighted how dominant language in the media generally supports the moralization of certain pandemic behaviour. For example, words like “covidiots” reinforces the idea that failure to comply with guidelines is attributed to lack of intelligence, common sense, or morality . RelatedThere are limitations to consider when interpreting our findings. First, we were unable to contact potential participants from Newfoundland or the Territories as they were not surveyed in the previous study associated with this work. The absence of their perspectives and experiences in this work reflects a potential gap in our knowledge. Second, due to the recruitment methods, selection bias is possible as the consenting participants were individuals who had participated in a previous study, indicating an interest in COVID-19 research well before the interview took place. It is possible these individuals are more likely to follow health guidelines and continue to engage in pandemic preventive behaviour. Third, while our sample was diverse based on age, gender, and region, the qualitative nature of this study meant that findings could not be generalized statistically and applied to the broader population. Fourth, it is important to note that while several ethnic groups were present in our sample, the majority of participants were white-identifying. Future work should include an ethnically diverse sample in sufficient numbers to understand how culture and ethnicity might shape pandemic-related behaviour. Fifth, as the data collection took place online, perspectives from individuals who did not have access to, or sufficient understanding of the internet are potentially missing from this work. Sixth, the TPB has been used in quantitative studies as a framework for predictive modelling of behaviour . While qThis difficult period presents the unique opportunity to deepen our understanding of how to advance prevention-focused, population-level, public health guidelines. While the COVID-19 pandemic represents a unique threat, it is imperative that we recognize the late effects that are yet to come—human behaviour disorders, fear complexes, and dominant narratives about morality, that often emerge after health crises. Improving individuals’ knowledge, beliefs and behaviours toward preventative public health guidelines will improve overall public health during current and future public health crises. The lived experiences of participants in this work emphasize the importance of consistent, transparent, and accessible information so that individuals can successfully implement preventative behavior in their daily lives to mitigate the impact of the COVID-19 pandemic. Research must continue to examine adherence to public health guidelines to further understand how beliefs and intentions may shift over time.Below is the link to the electronic supplementary material.Supplementary Material 1


Teatro La Plaza conducted three online sessions with a group of adolescents and another with a group of young adults from Lima, Peru. The artistic outputs, which included images, similes, monologues, and narrations, were used to describe the experiences of depression and anxiety symptoms following a content analysis using posteriori categories. Results: Seventeen participants joined the sessions. The artistic outputs showed: physical, behavioral, cognitive, and emotional manifestations of depression and anxiety; a perception that both disorders have a cyclical nature; and an awareness that it is often difficult to notice symptom triggers. The mandatory social isolation due to the COVID-19 pandemic was highlighted as an important symptom trigger, mostly linked to anxiety. Conclusions: The findings are consistent with the literature, especially with regard to the manifestations, representations, and potential causes that trigger depression and anxiety. Using arts-based methods allowed adolescents and young adults to expand the articulation of their representations of mental disorders.Background: Arts-based methodologies can be beneficial to identify different representations of stigmatized topics such as mental health conditions. This study used a theater-based workshop to describe manifestations, representations, and potential causes of depression and anxiety as perceived by adolescents and young adults. Methods: The theater company  Globally, it is estimated that 1.2 billion people are aged 15–24 years old, representing 16% of the population ,4,5. ThiVarious studies have highlighted the high treatment gap for mental health care among young people ,10. For It has been hypothesized that understanding how this population perceives mental health disorders could help develop specific strategies to increase treatment-seeking and adherence . QualitaIn contrast, arts-based research methodologies can be beneficial in providing perspectives not typically addressed in research. Arts-based research is a new transdisciplinary paradigm building on the similarities between arts and science  using arWithin health research, arts-based research methodologies have been used to explore health topics that, due to their stigmatized nature, might be difficult to discuss among young people such as body image, reproductive health, depression, and suicide ,23, someTo identify and describe the physical, behavioral, cognitive, and emotional manifestations of depression and anxiety as perceived by adolescents and young adults.To describe the potential causes of depression and anxiety symptoms identified by adolescents and young adults.The present study used arts-based methodologies to gather the representations of depression and anxiety among adolescents and young adults living in low-income urban communities in Lima, Peru. This study, conducted as part of the project “Building resilience and resources to reduce depression and anxiety in young people from urban neighborhoods in Latin America (OLA)” , had twoTeatro La Plaza and the research center People’s Palace Projects. They were designed to motivate participants to express themselves about their experiences of depression and anxiety through different creative exercises.We conducted a qualitative study using a phenomenological-hermeneutical approach in order to understand the experiences of the subjects of the study . This deArena y Esteras, an arts organization that has collaborated with Teatro La Plaza on previous projects. Arena y Esteras runs art programs involving theater and circus in low-income urban settings in Lima, Peru’s capital city.Participants were former and active students of art programs delivered by Arena y Esteras’ creative programs to guarantee that they are familiar with art activities, (d) having consent provided by a parent/guardian (for participants under 18 years of age), and (e) having the capacity to provide assent (for participants under 18 years of age) or consent (for participants above 18 years of age). Potential participants were excluded if they (a) had a diagnosis of severe mental illness , (b) had a diagnosis of cognitive impairment, or (c) were unable to provide informed consent or assent.The inclusion criteria comprised (a) being between 15 and 24 years, (b) being willing to take part in arts-based activities, (c) participating or having previously participated in at least one of Teatro La Plaza designed a dramaturgy-based workshop to be delivered online to abide by the social distancing restrictions due to the COVID-19 pandemic. Participants were allocated to two groups according to their age, based on the premise that young people feel more comfortable sharing their experiences with people of a similar age and currently doing similar activities . The first group included adolescents between 15 and 17 years old, and the second group included young adults between 18 and 25 years old. The cut-off age also marks the usual end of school years, so the research team assumed that participants in each group will have different daily experiences. Both groups involved male and female participants.Teatro La Plaza. Each session focused on a specific topic. Session 1 explored the manifestations and representations of depression and anxiety, session 2 explored the potential causes that could trigger these disorders, and session 3 explored the strategies that helped them cope with emotional distress. The final session’s content was analyzed in another publication ” .The second type, in which the speaker’s voice is merged with the author’s voice, was used by some participants to show their mood, thoughts, emotions, or perceptions about events happening to them.“Today, as usual, I arrived at school and, as usual, she started speaking, not as she did before, but with a kind tone and hurtful words… what is leading me to this, that doesn’t cause me pain, but some sort of satisfaction? I don’t know if it is true, but it feels like it is. I don’t have any value” .The 18 images presented by the participants included illustrations downloaded from the Internet and the participants’ drawings see a,b. MostParticipants worked on 17 lifelines using threads, markers, and pens see . All of Finally, the participants wrote eight narrations (four by adolescents and four by young adults) about the events identified in the lifelines, detailing actions, people, spaces/contexts, and times of the onset of symptoms in the plot of the narration. These elements made it possible to identify the triggers of the symptoms of anxiety and depression and the underlying and consequent factors to these, in addition to the different types of associated symptoms.“And suddenly, [we were] locked up (…) When the quarantine began, it didn’t shock me much. Sometimes we cooked, we played cards. Later, yes… I started to get bored because my family no longer wanted to do activities with me. I wanted to go out, and they wouldn’t let me even go near the door. As I got used to it, not I feel lazy to go out.I take my classes in bed, watch TV in my bed, talk to friends in my bed, have Zoom parties in my bed, listen to music in my bed… The only thing I don’t do [in my bed] is to eat and go to the toilet.” .We defined four main categories to analyze the artistic outputs presented above: (a) Manifestations of depression and anxiety; (b) Conceptualization of depression and anxiety; (c) Depression and anxiety symptom triggers; and (d) Factors influencing the continuity or severity of symptoms. Each of these categories will be described in detail below.Two subcategories identified as part of the analysis explain how adolescents and young adults understand and represent depression and anxiety. First, the manifestations of both disorders aimed to explain how depression and anxiety were perceived by young people when experiencing them. Second, using an artistic expression, the participants provided their interpretation of what depression and anxiety were and how it was to live with them.The manifestations of depression and anxiety reported by adolescents and young adults have been categorized into physical, behavioral, cognitive, and emotional. However, it should be noted that the participants sometimes expressed different manifestations in the same output. Most of the manifestations were shown in the similes, images, and monologues, but some could also be extracted from the lifelines and narrations.Cognitive and emotional manifestations of depression and anxiety were the most commonly reported. For example, loneliness, rumination, a feeling of not belonging, and lack of motivation were common manifestations of both disorders among the two age groups. Emptiness and sadness were also commonly reported as depressive symptoms, and a constant state of alert and distress as anxiety symptoms.Other cognitive and emotional manifestations of depressive and anxiety symptoms that were identified, although less frequently, were confusion, sense of abandonment, anger, emotional pain, and frustration. In addition, feeling worthless or as defeated fighters were also reported by a few youths as a depressive symptom.“When I am anxious, I feel like an abandoned soldier”“When I am anxious, I feel like a defeated boxer” .Concerning the physical manifestations, participants commonly reported physical exhaustion as a depression and anxiety symptom as well as crying and headaches, although less frequently. In addition, they mentioned insomnia, sweating, trembling, and tension as common manifestations of anxiety, while difficulty breathing and, sometimes, chest pain, were manifestations of depression.“When I am anxious my hands get sweaty, and I can’t help it. I can’t sleep at night and that means the next morning I have dark and deep eye bags” .Finally, regarding the behavioral manifestations of depression and anxiety, variations in food intake were the most reported, although they were more commonly associated with anxiety. Interestingly, anxiety was mainly linked to increased food intake, whereas depression was related to increased and decreased food intake.“My mother complained many times at school [about] the jokes targeting me, but for me, those were not jokes. It was not only the way they talked, but it was also that I am a foreigner. (…) Since that first time, I made a decision, I would mimic a way of talking I didn’t even know, nor was mine. I started practicing at home that way of talking, and I was anxious about learning it, I was eating a lot. Every time I went to school, I didn’t want to speak to anyone, I sweated a lot and my hands were shaking” .Other frequently reported manifestations were self-harm for anxiety in adolescents and depression in one young adult see  as well To conceptualize depression and anxiety, similes and monologues were used. Within these artistic outputs, one of the most recurrent topics was the length and course of these disorders. For example, some of the participants’ outputs revealed that they did not realize the presence of depressive or anxiety symptoms until after experiencing them for some time, or that there was no way to anticipate when an episode would arise. The outputs also highlighted it was impossible to anticipate how long the symptoms would last, and that these tended to have a cyclical nature.“(…) I am here to make you company. As much time as you allow me to.” .“Well, it was a pleasure talking to you… I will come back when you least expect it…” .Another finding is that depression and anxiety were sometimes described as “friends” that accompanied the young person when coping with difficult situations and it was not until some time had passed that they realized how difficult it could be to get rid of them. The participants’ outputs also expressed a feeling of symptoms merging with their personalities, and that in the long-term, symptoms would become a part of them.“I can help you whenever you need it, I can be your friend and partner forever.” .“And if I stopped worrying? No, I can’t. The anxiety is a part of me.” .The two subcategories identified as potential causes were split into (a) triggers that could induce symptoms of depression and anxiety, and (b) factors influencing the continuity and/or severity of symptoms. These subcategories were obtained from the images, lifelines, and narrations.The triggers identified during the analysis were at the individual, family, social, and educational levels.At the individual level, the most common triggers for both depression and anxiety include having suffered an accident or illness that put someone’s own life at risk or going through medical intervention or surgery, both reported by adolescents and young adults, and not achieving an important personal goal, only mentioned by young adults. Although less frequent in both groups, other triggers were romantic relationship issues or a negative body image.“I fractured my finger, this finger, and the surgery was expensive for us at that time (…) we were paying for a motorcycle I used for work and I couldn’t work for almost a month (…) I was feeling depressed, well, anxious. First of all, because of the surgery I was going to go through, I did not really know it was a surgery, how it was, what was going on, or what they put on you. And at that moment I felt… I felt scared about what they were going to do to my finger and all that. But I also [felt] scared when I was there, in bed. I could still move, but I couldn’t work because the wound would open, [which] would be worse (…)” .“In 2018, we had a tour in Germany. In the second show, I had to use a unicycle (…) At the moment I had to do the pendulum, the chain in the unicycle loosened up a bit and during the fall, I fell with all my weight onto my right wrist (…). Once the show finished, they took me to the doctor, they put on a splint, and I could not move it for three months. I was crying a lot, I felt angry and sad at the same time, like a whirl of emotions, washing away all the emotions because of what happened to my wrist (…)” .Other situations identified as potential triggers for anxiety included the feeling of not being able to make their own decisions about going out with friends or performing certain daily activities due to illness, or fear of performing in public in the young adult group.At the family and social level, in both groups, it was found that one of the most significant triggers for depression and, to a lesser extent, anxiety symptoms, was the death of a family member or a significant person, closely followed by a relative going through a life-threatening accident or illness see .Other events identified as anxiety and depression symptom triggers included migration or changing houses and being physically distant from relatives. Situations related to difficulties in the relationship with parents such as constant arguments or distant relationships were also linked to depressive symptoms for both age groups see .Furthermore, family violence, involvement in youth gangs, disagreements or arguments with friends, and losing their trust in a significant figure were also identified as triggers of depression symptoms in the participants’ outputs.At the educational level, the adolescents highlighted that changing schools, having exams, failing a course or having difficulty giving presentations at school could trigger anxiety symptoms. Similarly, young adults reported that starting or changing universities, being rejected at admission to the university or suffering bullying were possible depressive symptom triggers, while difficulty choosing a career was a source of anxiety.“(…) the day I received the notes, I found that I was missing a single point to be able to enter. I was stunned, afflicted, I did not know what to do.” .Finally, within the COVID-19 pandemic, participants from both age groups, especially adolescents, highlighted mandatory social isolation as an important symptom trigger, mostly linked to anxiety symptoms.Only a few adolescents mentioned issues that could affect the severity or continuity of depression and anxiety including changes in the family structure after a loss, the prolonged absence of family members, experiencing bullying and xenophobia.“It was just any morning, I was in fifth grade (…) I arrived home and found my aunt, [who] started saying stuff like “your father was a good man”, “your father will go to one place and won’t come back”, “he went to a good place”. (…) When I found out, I was devastated and, on the next day, I went to my father’s house for his wake and to see him for the last time. Without him, I felt that I was really lonely and sad, I needed my family, but everything worsened when I felt they were distancing me. My brother moved out with his father, and my mother worked too much and didn’t pay attention to me (…). And I felt lonely, I started being a little aggressive towards my family and it was because they were not there for me when I felt bad; I cried a lot when I was alone and I didn’t speak to anyone (…).” .Young adults, especially males, mentioned that constantly self-evaluating their work, study, or family decisions could increase their symptoms of depression or anxiety.“(…) You feel anguish… thinking that you have to choose between limited options and (…) then not being clear about what you want to do or thinking about (…) not achieving what you wanted and thinking that you did not put effort into it (…) I also realized that sometimes there was no support (…) so much so that I felt anguished, I felt anguished because I didn’t know what to do.” .Other factors identified included overprotection from parents; other people’s negative perceptions about their capacities or abilities; transitioning from school to graduate studies; difficulties adapting to new settings; and pursuing ideal models based on social media characters  that encourage comparisons between the life models shown and the one they experienced.“By that time, I had become a little sedentary, I stopped practicing dancing because I felt tired. I thought “well, we are in quarantine, I will rest, I’ve been dancing all the summer”. Whenever I had free time, I would start watching videos of other dancers, I used more social media and, little by little, I was comparing myself to them. I was telling myself: “wow, they dance so good, I’d love to dance like that. I want that way of dancing”. So I started feeling frustrated, being in a bad humor, to grump, even feeling desperation because I wasn’t doing the dance moves as I wanted.” .Finally, in both age groups, economic deprivation was a constant stressor that sometimes hindered addressing their problems.“Anguish is when I, well, my family decided to move to Lima. (…) but when I got here I realized that we had no money, no money, no place to stay, I felt stressed, I really wanted to go back, to go back to where we lived before.” .Our study used arts-based methods to understand the representations of depression and anxiety in Peruvian adolescents and young adults. The results were based on the analysis of five different types of artistic outputs and organized into four categories: (a) Manifestations of depression and anxiety; (b) Conceptualization of common mental disorders; (c) Depression and anxiety symptom triggers; and (d) Factors influencing the continuity or severity of symptoms.Some of our main findings are consistent with those reported in previous research. Undoubtedly, cognitive and emotional manifestations were perceived as core elements of depression among our participants, as has also been found by adolescents and young adults in countries such as Brazil and the United States ,42. SomeRegarding the physical and behavioral manifestations of depression and anxiety, difficulty breathing, sweating and shaking have also been found in previous research among youth ,47. In aConcerning the conceptualization of the disorders, the participants highlighted their cyclical nature, which is consistent with the literature about relapses ,48, but Two other representations of the disorders included seeing depression as a “friend” that accompanies the young person and as a characteristic that becomes part of their personality, which coincides with a stage of developing identity. Although we did not find any literature related to the first, two articles supported the latter, stating that the symptoms become part of the youth’s sense of self , and theIn our study, most of the attributed causes and aggravating factors of depression and anxiety included daily life worries such as relationships with family and friends, making life decisions, work or study-related concerns, and economic constraints as well as isolated events such as illnesses, deaths, and changing houses. Even though several studies have also found these causes ,43,49,50Particularly within the COVID-19 pandemic, in which Peru was one of the most affected countries worldwide , adolescFurthermore, we emphasize the importance of using arts-based methods as a tool to collect sensitive data from adolescents and young adults. As described in previous studies ,55, collOne participant said his depression: “Is like a water jar with a leak…It just empties little by little. It fades, but not at once. But then it is also like someone grabs it and turns it over because they can’t stand this slow leak […] So it’s just empty and they can start over, buy a new one.”  [y 1, 15) .The artistic language adds nuance to the sensations and emotions produced by the experiences of disorders such as depression and anxiety. Using metaphors to describe them added color and transmitted feelings that may not be described in full detail by conventional words. For example, when one of the female adolescent participants referred to anxiety as a needle picking her skin, she expressed how anxiety represented a corporal experience of pain, but also that she faced a state of alert. The artistic language merges with the narratives of daily activities experienced by adolescents and young adults, which enables us to understand how the local context shapes the experiences of depression and anxiety. Using characters to embody depression and anxiety enabled us to understand how the symptoms of these disorders accompany the young people living with them.Using arts-based research, specifically performance approaches, is also innovative because it challenges the idea that data are always objective. As Chamberlain et al.  describeThe workshop was initially designed for in-person delivery. However, due to the social distancing restrictions as a result of the pandemic, the research team and arts organization decided to shift toward an online delivery. Since the sessions took place shortly after the pandemic began, facilitators and participants were still adapting to remote activities, which might have produced discomfort among participants who were not used to virtual platforms. Another study limitation is that the participants were already engaged in art activities prior to the study, which could be an indicator of accessing resources not all adolescents and young adults have access to; thus, it is impossible to generalize the results for all people within this age group. A final limitation was that the workshop design did not include follow-up questions to the artistic outputs, which sometimes made their interpretation difficult.This study allowed us to explore how a group of low-income adolescents and young adults represented depression and anxiety using arts-based methods. A dramaturgy-based workshop enabled the participants to share their views on the manifestations and causes of depression and anxiety. Although some of the findings were similar to those produced in previous research, this method expanded on the knowledge of how young people perceived the process of depression and anxiety and how difficult it was for them to notice when these conditions started and settled. The artistic tools offered an insightful view and we encourage the incorporation of arts-based methods to allow young people to creatively express their views about mental health.