Interviews were audio-recorded, transcribed verbatim, and analyzed. The data were obtained from 26 physicians and nurses caring for patients with COVID-19. The mean age of the participants was 29.41 years (SD = 2.72). Six main themes and 17 subthemes were identified: (i) emotional reactions; (ii) preparation; (iii) source of support; (iv) extreme workload; (v) occupational challenges, and (vi) work-related concerns. The results showed that nurses and physicians caring for COVID-19 patients in Jordan were experiencing mental and emotional distress and were practicing under inadequate work conditions. This distress could be multifactorial with personal, organizational, or cultural origins. Our findings may guide policymakers to consider the potential factors that significantly affect working environment in healthcare settings, the physical and mental wellbeing of HCWs, and the required professional training that can help in enhancing resilience and coping strategies amidst crises.Various changes have affected health services delivery in response to the repercussions of the COVID-19 pandemic, and this may exhibit unprecedented effects on healthcare workers (HCWs). This study aimed to explore the lived experience of physicians and nurses caring for patients with COVID-19 in Jordan. An interpretative phenomenology approach was used, and sampling was purposively performed. Data were collected through semi-structured interviews using an online meeting platform (Zoom Coronavirus disease 2019 (COVID-19) is rapidly spreading internationally. As of August 2021, about 202 million cases were confirmed worldwide, with more than 4.2 million deaths ,4,5. AddTraumatic events can cause a wide range of psychosocial and physical impacts on individuals . HCWs whIn addition to the stressful conditions, HCWs are exposed to serious risks and even death while administering care for patients with COVID-19. This led to an increased mental and emotional distress. In Iran, a qualitative study showed that nurses working in the wards and care centers designated for patients with COVID-19 are experiencing mental and emotional distress . SimilarJordan, a country located in the Eastern Mediterranean Region (EMR), effectively succeeded in preventing the spread of COVID-19 during the first six months after confirming the first case in early March 2020 ,19. HoweAn exploratory qualitative study was conducted among physicians and nurses caring for patients with COVID-19 in Jordan. In specific, an interpretative phenomenological analysis (IPA) design was utilized to explore the lived experiences of the participants. IPA is useful when there is a paucity of information available regarding the phenomenon under study and when the researchers want to generate a rich description of this phenomenon ,30.Participants were recruited through purposive sampling. Participants who were (i) Jordanians; (ii) registered nurses or/physicians; and (iii) in direct contact with COVID-19 patients for the last three months, were included in the current study. The study setting was two hospitals that were the main designated treatment and care centers for patients with COVID-19 in the country, and where most COVID-19 confirmed cases that need admission as well as tertiary care are referred to. The first facility  is one of the public-based tertiary care centers that was established in Amman, the capital city of Jordan, with occupancy of 441 beds , while the second facility  is one of the tertiary care centers that was established in Irbid city in the north of Jordan, and It has 542 beds . According to the latest available data from the World Health Organization’s Global Health Workforce Statistics and the World Bank, Jordan had 2.82 nurses and midwives per 1000 people in 2018, while around 2.32 physicians per 1000 people in 2017 ,32 Sampl®, because of the strict isolation procedures, which prohibited the entry of miscellaneous people to the COVID-19 units and to protect the interviewers from any risk associated with meeting high-risk individuals.The researchers conducted 26 interviews with 26 Participants. A copy of the ethical approval was sent to the department heads of the targeted hospitals to interview nurses and physicians. Flyers were posted on the units’ notice boards. The flyers included the purpose of the study, inclusion criteria, and the researchers’ contact details. Participants who were interested in the study were able to communicate with the researchers either by phone or email, any further concerns were answered, and the interested participants were invited to take part in the study. Participants who agreed to take part in the study were invited to attend an online interview at an agreed time. The interviews were conducted online using a Voice over Internet Protocol (VoIP) application called ZoomA semi-structured individual interview was used to collect data. In-depth interviews were conducted with participants and recorded. Each interview lasted between 45–60 min. At the beginning of each interview, the researchers collected verbal consent from all participants before recording and asking guided open-ended questions to establish a rapport. Then, a broad data-generating question was first used: “Please tell me about your experience of taking care of patients with COVID-19”, and open-ended follow-up questions were used to obtain detailed descriptions. Various probing techniques were utilized to enable physicians and nurses to explicitly express their experiences and enhance the depth of the discussions. The interviewer ended the interview by asking participants whether they want to add any story. Examples of these questions are shown in The interviews were performed by three researchers  who had prior experience in qualitative research. To enhance the validity, training was conducted to all researchers about how to conduct the interviews in the same manner. The interviews were conducted at convenient times to both the participants and the researchers between January and April 2021. The interviews were recorded after getting consent from all participants. Participants’ age, marital status, and years of work experience were obtained at the beginning of the interview.® by the research team. Then, the transcripts were double-checked against the recorded interview by different research team members to ensure their accuracy using the Arabic language. Two independent researchers  analyzed the data using the following steps as guided by Smith, Flowers and Larkin (2009) [The meetings were recorded and transcribed verbatim to Microsoft Office Wordn (2009) :(i) Read and reread the transcript several times to allow familiarity with the data and get a better understanding; (ii) During the reading rounds, significant phrases, words, and insights in the transcripts were annotated and highlighted; (iii) Notes were prepared carefully and documented; then, researchers searched for connections between the notes and clustered them in groups to allow identification of the emerging subthemes; (iv) Researchers searched for connections between the emerging subthemes using strategies such as abstraction, subsumption, and polarization; (v) Same steps were repeated with each interview transcript; (vi) The last step involved reviewing the subthemes from all interviews to establish connections between them using abstraction, subsumption, and polarization to cluster the subthemes into major themes. Once the process was completed, the two researchers met and discussed differences in the analysis until they reached a consensus about the themes, subthemes, and exemplars used to describe the theme or subtheme. Inter-coder reliability was approximately 90%, and the whole research team met and reviewed the overall analysis process to ensure its clarity.Several strategies were used to ensure credibility and trustworthiness. Credibility was achieved by in-depth interviews followed by peer debriefing. Two coauthors analyzed the transcripts independently. Findings were then compared and discussed by the team until reaching consensus on themes, theme clusters, and categories were achieved. The researchers used also the “audit trails” approach by detailing the methodology and analysis sections. A team member, who is an expert in qualitative research, was asked to audit the methods and data analysis before giving positive feedback about the clarity of the methods and data analysis sections. The last technique used was “grounding in examples” to allow readers to make conclusions about the quality of the analysis. The themes were presented with actual participants’ statements from the transcripts to support each theme and subtheme.Transferability was established by considering variations of participant characteristics and sufficient quotations collected through in-depth interviews. The audit trail was maintained to ensure all analysis steps could be traced back to original interviews. To maintain the trustworthiness and credibility of the findings and avoid inaccurate translation issues, translations into English were performed after generating themes .The present study was approved by the research ethics committee at Yarmouk University, Jordan. The study objectives and voluntary nature of the study were explained to participants. Written and verbal informed consents were obtained from all participants before recording and conducting the interviews. Anonymity was maintained as the researchers did not collect any personal information from the participants. All recorded interviews and transcripts were saved on a password-protected computer in the office of the principal investigator. Throughout this study, we followed the standards for reporting qualitative research in accordance with the Consolidated Criteria for Reporting Qualitative research Checklist (COREQ) . All stuOur sample consisted of 26 participants (10 physicians and 16 nurses). All participants took care of patients with COVID-19 in the hospitals at which they were employed. Physicians were deployed to COVID-19 wards from medical and emergency wards (ER), while nurses were deployed to COVID-19 wards from various wards including medical, surgical, ER, and outpatient clinics. Participants differed by socio-demographic characteristics as illustrated in The mean age of participants was 29.9 years, and the average experience duration was 6.5 years . Six themes emerged in the current study from interviewing 26 HCWs working with COVID-19 patients; (i) emotional reactions; (ii) preparation; (iii) source of support (iv) extreme workload; (v) occupational challenges and (vi) work-related concerns. The themes and sub-themes are summarized in Dealing with COVID-19 patients for the first time was associated with many feelings among physicians and nurses. These feelings included fear, tension, anxiety, and worries resulted in increased stress levels.The feeling of fears, worries, and anxiety.• Most of the participants expressed a fear feeling of being infected or spreading the infection to their family.It was a mixed feeling of fear and anxiety, especially the worry about consequences on my wife and children… I experienced huge psychological stress and anxiety from the idea that I might be a carrier of the disease (COVID-19). My fear developed into an obsession, especially after I have collected several positive samples” . This feeling extended to be a fear of being a source of infection to other patients; this was clearly reported by a male nurse who was working in the operation room: “I felt anxious and fearful from the possibility of transmitting the infection to additional patients through the operation room”.““In fact, I did not exhibit any worries. At the beginning, I dealt with COVID-19 patients just like any normal working day, supported by the idea; it is my duty, and I must bear it”. With time, some participants started to cope with the new work conditions. A female nurse stated: “This feeling (fear and stress) began to fade with time, as I became more familiar with the disease, and I became competent in wearing protective gears and other PPEs”.Meanwhile, few participants faced the situation and tried to minimize its effects by accepting it, telling themselves that it is their duty. A female physician who works in the hospital said, Factors increased the fear, stress, and anxiety.• , “I worried about spreading the infection to my family, they are old and have chronic diseases. If they got the infection, it might threaten their lives… in fact, this point was the main source of my stress”.Most participants used rationalization as a defense mechanism by stating the cause of their feeling of fear, stress, and anxiety in different ways. They verbalized having an old age parent with co-morbidity as the cause of their fear: A female nurse said“The situation was a bit confusing and stressful, mainly because there was not enough information about the disease… every day we hear something new about the disease (COVID-19)… mode of transmission and treatments”. Although some participants expressed inadequate knowledge and unclear situation, they tried to calm, comfort, and reassure their patients. A female physician in the hospital said, “In the beginning, everything was not clear to me, so I had a sense of fear about my health, but despite that, I was trying to show the patient a feeling of comfort and reassurance so that he could receive treatment easily… we all know that psychological status of the patient can affect their immunity level”.Some participants expressed that lack of knowledge about COVID-19 increased their anxiety and stress. A male physician who works in the hospital said, Health care providers in the current study articulated two types of preparation that enhanced their resilience: organizational and personal.Organizational preparation.• “the hospital provided all means to reduce infection and motivate us; this included all medical information , and all preventive equipment was available to HCWs ”. A male nurse said, “Availability of PPEs, masks, gloves… all these gave us a feeling of support and increased our resilience… reduced our stress”.Most participants stated that the organization provided adequate personal protection equipment (PPEs) which played a role in reducing stress. A female physician in the hospital said, In the beginning, the hospital was not fully prepared, but after the repetitive claims, all protective equipment was provided… this was a great response. I felt more comfortable”. A female physician.The response of the organization by meeting the needs of HCWs was also an important factor that enhanced resilience: “The PPEs did not allow me to move freely… had difficulty in using it… it made me feel suffocated”. Providing appropriate response and adequate care for colleagues who got infected with the virus was another factor that helped in alleviating participants’ stress and made them feel reassured and comfortable. A male physician reported, “when one of the healthcare providers got ill, I felt reassured due to the high level of care they received”.Although the availability of PPEs was a positive factor to support resilience, some participants were challenged with using PPEs . A female nurse said, “Personal preparation.• “I was concerned about infection even while wearing PPEs. So, I was committed to applying all precautionary measures of wiping and proper washing of hands”. Additionally, some of our participants followed a healthy lifestyle . A male physician said, “I tried to be positive in everything, I started listening to the Quran to replenish my inner feeling, I started to follow an exercise program, eat a lot of fruit and vegetables, drink a good amount of water…”. On the other side, some participants isolated themselves from their families. A male physician said, “For four months, I have sent my wife and kids to her family house, I’m living alone. Every week, I do the PCR test and when the result is negative, I go out using a face mask, gloves, and maintaining social distancing… being a physician means to sacrifice… and our homeland deserves this giving”.Healthcare providers in the current study tried to enhance their resilience by following safety precautions at work and everywhere else. A female physician said, There were many sources of support to our participants who worked with COVID-19 patients .Family and friend support.• , “We were encouraged and got support from family, friends, and patients… their words of thanks were very motivating to us “. Besides, a female physician said, “The family has been very supportive to us ; perhaps we have not been in constant contact with them, but every day we have some time, even if it is short, to contact children, parents, brothers, and friends. This contact increased satisfaction at work and motivated us to give more to protect them”. However, few participants reported that they did not need any support as the COVID-19 pandemic is a special situation and professionally they must be responsible, and it is their duty. A female nurse stated, “I did not get any support… I did not even need any… I work with this situation because I have to sacrifice for my country… this is my professional responsibility… working with COVID19 patients was my choice… they asked us if we want to work or not”.Many HCWs who engaged in the current study expressed that their family provided encouragement and support to them through a variety of methods . A male nurse saidOrganizational and colleagues’ support.• As colleagues, we were very cooperative; when I felt tired during work, my colleague did my job and asked me to get some refreshing air”. Participants have also perceived their organizations as an important source of support when they provided HCWs with all needed equipment. A female physician said, “I received support from everyone in the hospital and community associations… all required equipment and requirements were available to all staff… and everyone was happy to help… the support was not only material, they carried out some activities and honors to raise our morale… the work division and organization was one of the most important things that helped the crew to feel comfortable, which led to increasing our giving”.Physicians and nurses in the current study viewed support from colleagues as another source of support that encouraged them to work. A male physician said, “Other sources of support (community and self).• Most participants expressed that the greatest support was coming from His Majesty the King of Jordan, Abdullah II bin Al-Hussein, who gave the HCWs a push to work hard.The greatest psychological support came from the words of His Majesty the King, who is the leader and inspirer in the field. His Majesty was leading the battle against this virus” . Although our participants articulated different sources for support, some of them complained of lacking financial support. A male nurse said, “I think we needed financial support because we did not get any day off, but, unfortunately, we did not get any”. A male physician reported, “I think there was a kind of important support that we needed… but we did not get it… it was financial support. There was a nurse who worked with us for 17 days… she has kids… I think that financial support can compensate for hard work, decrease most stress, and may lead to job satisfaction”.“In the current study, health care providers stated that long working hours with COIVID-19 patients had affected various aspects of their life .Social impact.• Of course, long working hours had a great influence on our social relations, whether at home or with family, by virtue of the fact that it was possible to be a carrier of the disease without having symptoms. For example, I could not visit my mother even though she was living a few meters away from my home… it was a bad feeling and, undoubtedly, it greatly affected our focus”.Long working hours have harmed the participants’ social life by reducing their socialization. A male physician said, “Physical impact.• I worked for 16 h daily, without getting enough sleep, … because of the high tension, continuous thinking and lack of sleep, I started having hair loss”. Some participants complained of having headaches and muscle pain, so they started using analgesics. A female physician said, “As a result of long working hours, the helmet caused a terrible headache, so I used Panadol Extra 4–6 pills per day, and sometimes I used muscle relaxants to reduce pain in the lower extremities”. Some health care providers behaved in a maladaptive way. They started using sleeping pills to overcome their insomnia. A female nurse said, “Throughout my work in the isolation department, I suffered from insomnia, and I was unable to sleep… the maximum number of hours I slept was 3 h using medications to help, such as anti-histamines… Most of my sleep attempts were unsuccessful because I woke up terrified with nightmares, I do not remember anything of them, but they are all related to the virus”. Other participants reported changes in their eating habits which resulted from their fear and stress. A male physician said, “I felt horror to the extent that I did not eat as usual and did not feel hungry either (loss of appetite), despite the small amount of food that I ate”.Many physical changes were reported by health care workers because they worked for long hours and being mentally occupied. A male physician reported, “Psychological impact.• Working in the isolation department was psychologically harmful to me, I had great anxiety, tension, and fear of entering the rooms of COVID-19 patients (fear of being infected)… I had difficulty working under this kind of psychological pressure… and because of the aversion of dealing with patients, some of them looked at me with resentment”. A female nurse from the isolation unit reported, “I felt their (patients’) fear, depression, and some of them verbalized having depression. They were depressed even though their health was excellent. I imagined myself in their place and how I would need support and communication with the surroundings. The idea of isolation is very annoying, even if they can communicate on the phone, but that does not substitute for direct contact with their loved people”. Additionally, the patient’s psychological and physical status affected the psychological wellbeing of the health care workers. A male physician said, “some cases stayed more than 50 days in the hospital…, this greatly affected my psychological status… those patients had a state of depression mainly after each time when they got a positive PCR result… Another patient was a young boy who was crying and had a panic-like state…, the whole team felt sad and was sympathetic with him”.Our participants stated that long working hours adversely affected their psychological status; they had anxiety, tension, fear, anger feeling, and nervousness. A male physician said, “Cognitive impact.• All my thoughts were centered on the infection with the virus, transmission of infection and the occurrence of complications… for me, the rest period was a source of great psychological fatigue because I was left with my fears and anxieties, and I was waiting impatiently for the PCR to make sure that I was not infected”.Dealing with COVID-19 patients for long hours had a negative impact on the way of thinking of HCWs; it affected their concentration and thoughts. In terms of concentration, some of our participants reported their focus to be directed to the virus and its associated infection (a tunnel through and vision), even their ability to focus on other jobs than the virus was reduced. A male physician said, “More frankly, as a result of working with COVID-19 patients, I had a hygiene obsession, I sterilized everything around me with alcohol and avoided touching anything, I doubted the correctness of my steps while taking the PPEs off, and I was afraid of taking it off in the wrong way: for example, I suspected that I touched myself while taking it off and I felt panic, so I sterilized my whole body using alcohol”.Other participants expressed that they got obsessive thoughts which led them to practice ritual behavior to get rid of those thoughts. A female physician said, “Behavioral impact.• The average number of smoking cigarettes increased during the day, there was fatigue during duty… I was drinking a large amount of coffee to keep alert and maintain the quality of work”. In addition to all of the above impacts, HCWs in the current study expressed having a learning impact; they learned many lessons from working for long hours with COVID-19 patients, such as realizing the importance of health. A female nurse said, “life is short, everything could be changed suddenly… the most important thing in life is the person’s health… See how a small virus that cannot be seen by the eye, but did all these problems worldwide”. Some of them learned issues related to work such as the importance of teamwork, providing support, effective communication, adaptive coping, and new experience: “I learned the importance of teamwork to manage difficult situations and improve communications skills” .Some maladaptive behaviors were adopted by our participants as a result of long working hours and stress . A male physician said, “This crisis added a new experience and I consider it as a success story to tell in the future… I am proud that I was one of the first medical staff who dealt with the pandemic in its early stages” .“Participants in the current study articulated many work and personal-related challenges during working with COVID-19 patients.Work-related challenges.• There were many challenges… All were not easy for me and for the work team as well… the acceptance of the people to be diagnosed with the disease (COVID-19) and refusing treatments were among the daily challenges”. Reporting PCR results to patients was a great challenge health care encountered. A male physician said, “When I wanted to inform an old man about his PCR result, I was worried and afraid of his reaction… another patient was young; however, when I informed him about the result, he got frustrated… I tried to encourage him and offer support… However, at that moment, I was stressed”. Meanwhile, other participants communicated the effectiveness of the existing treatment as a challenge. A female nurse said, “The biggest challenge was coming from the doubt about the efficacy of the given treatment that we provided… we had a lack of confidence in this treatment… we had a constant fear about the patient and what was the best treatment for them… at that time, the stages of disease progression were ambiguous… I think everyone had the same feeling”.The patient’s response and acceptance of being diagnosed with COVID-19, dealing with patients from different age groups, and reporting PCR results to the patients were the main challenges reported by our participants. A female physician said, “Personal-related challenges.• My personal challenge was my attachment to my family… It was one of the biggest psychological challenges I went through, as I stopped meeting them in reality, which made me stressed, but I tried to overcome it by giving work more time… this led to results that pleased me a lot and made my family proud of me”.In addition to work-related challenges, participants were challenged by their attachment to their family and being the source of infection. A female physician said, “Social stigma related challenges.• In my area, one person got the virus… Oh, that caused a complex feeling; I felt that all fingers of accusation were pointed towards me… another story happened when I went to a pharmacy to buy some stuff… the pharmacist had bothered me when he knew that I worked in the Corona department, so he showed discomfort and his facial expression meant a lot”. A male nurse mentioned, “People around us, when they know where I’m working… they try to avoid dealing with me… it was a difficult situation that adversely affected me”.Most of the health care workers who engaged in the current study reported that they were challenged with facing social discrimination as a result of working with COVID-19 patients, such as blame and being avoided. A female nurse said, “I felt fear and isolation after I got the Coronavirus infection… I felt that people blamed me for my infection with the disease as if I chose to be infected… They blamed me for my infection because it was my fault and my negligence of the instructions… I was very disappointed”.Some of the participants felt social stigma, mainly when they got the infection. A female physician said, “In terms of the society view, they have the right to stay away from us. We deal with sick people continuously. The possibility of infection is high. We cannot refuse their reaction… We understand people’s concern for themselves and their families… It is a normal feeling, and it is our duty also to distance ourselves from them to reduce the spread of the virus” .However, some of them tried to rationalize and accept the way of dealing with them in the community: “Impact of hearing news about the collapse of health sectors in some countries.• Frankly, there was a feeling of great fear and tension that we would fall into the same thing as Italy, and as we know Jordan has limited capabilities in general but thank God… we were aware of the Ministry’s excellent work so that the Ministry of Health became called the Ministry of Corona; this matter gave us some reassurance”. However, this news was motivating to some participants in the current study and increased their confidence in Jordan’s health care system and its ability to face the pandemic. Their confidence came from maintaining safety precautions and faith in God.The collapse of health sectors in some countries and the news about it was the main concern of our participants; this news was stressful for some participants in the current study. A male physician said, “Governmental decision to close outpatient clinics.• It was a correct decision 100%… this prevented the spread of COVID-19 which would increase the workload pressure. Now, after opening, we received many patients and the workload increased but we managed it appropriately”. A female physician said, “Closing the outpatient clinics was one of the most important steps taken by the Ministry of Health. This reduced large numbers of gatherings in hospitals and relieved pressure on health care providers because the hospital is considered one of the most dangerous places at this time”.Closing the outpatient clinics was the other main concern of our participants; the HCWs in the current study agreed with the government decision in closing the outpatient clinics since it helped in controlling the spread of COVID-19 in the community; however, they reported that this decision increased their workload. A male physician said, “This study aimed at exploring the lived experiences of physicians and nurses caring for patients with COVID-19 in Jordan given their little experience in dealing with infectious diseases. The current study provides a significant contribution to knowledge as it is one of the few studies to explore the perceptions of health care providers in Jordan towards caring for patients with COVID-19 infection. To facilitate comparing our findings with other literature, we present our discussion in a structured manner per main themes.Emotional Reactions• Jordanian HCWs feared infection and worried about their families, but they are still willing to join the battle, took up their responsibilities, concentrated on their duties, and showed professional commitment. This result is consistent with results from a Chinese study aimed at exploring the experiences of physicians and nurses towards caring for COVID-19 patients . In addiThe results showed that living with old parents is one of the factors contributing to stress among healthcare providers during the COVID-19 pandemic. This finding matches the findings of a previous study that aimed to understand nurses’ lived experiences during the COVID-19 pandemic . HCWs haFurthermore, inadequate training in dealing with infectious diseases was another factor that increased anxiety and stress among healthcare providers caring for patients infected with COVID-19. This finding is consistent with a study from Palestine which found that healthcare providers with no training about the response to the COVID-19 pandemic have higher levels of stress . AdditioPreparation• The results showed that the level of stress is alleviated with adequate organizational preparation in terms of PPEs’ adequacy, PCR random testing of healthcare providers, meeting the needs of healthcare providers, and providing appropriate and adequate care for colleagues who got infected with COVID-19. This finding is supported by a Canadian study which found that nurses with inadequate PPE’s are more susceptible to depression . HoweverIn terms of personal preparation, the results of this study showed that the healthcare providers tried to increase their resilience by adhering to the necessary precautions such as handwashing, masking, and wearing gloves, in addition to some spiritual practices and positive thinking. This result was congruent with an Australian study which found that adhering to the needed precautions and doing spiritual practices are necessary to cope with the stress during the pandemic . MoreoveSource of Support• The results showed that the families, colleagues, organizations, self, and community’s support play a significant role in motivating the HCWs during the pandemic. These findings were consistent with a previous study which found that the different types of social support make the healthcare providers feel they are not alone, and more safe . In addiOn the other hand, our results revealed that some of the participants reported the need for another type of support, that was, the financial support. This result is congruent with a Brazilian study that concluded that nurses needed financial recognition during and after the pandemic . SimilarExtreme Workload• Our study showed that long working hours is harmful to the HCWs’ social life. This result is consistent with a previous study which found that the pandemic affected the healthcare providers and made them socially isolated . Our resThe long working hours with COVID-19 patients has harmed the physical health of the healthcare providers. For example, they complained of headache and muscle pain, and they started using analgesics; they complained of sleep deprivation and as a result, they used sleeping pills. Moreover, the long duty affected the HCWs’ eating habits and appetite. This finding is congruent with a review paper which concluded that healthcare providers are risky for physical complications . In addiPsychologically, the long working hours have increased the healthcare providers’ anxiety, fear, and nervousness. The reasons behind the increased nervousness might be social isolation, wearing the PPEs for long hours, and the associated discomfort. Our result is consistent with a previous study which found that the pandemic has caused anxiety, depression, and suicidal ideation among the healthcare providers . AdditioThe long working hours with COVID-19 affected the cognitive abilities of the healthcare workers, way of thinking, concentration, and thoughts. They were not able to concentrate and focus on patient care as they are supposed to. This result is in agreement with a previous study which demonstrated that problem-solving abilities are affected among the HCWs who delivered COVID-19 services .In the current study, long working hours and associated stress had a behavioral impact on the HCWs. They behaved in a maladaptive way such as heavy smoking and drinking large amounts of coffee. For complicated reasons, healthcare workers usually practice at a well-known stressful environment ,51,52, wOccupational Challenges• The results showed that one of the main challenges encountered by the participants is the patient’s denial of being diagnosed with COVID-19. The results showed an additional challenge, the healthcare providers were in doubt about the effectiveness of the available treatment. The reason behind the healthcare providers’ doubt might stem from the doubts about the available treatments such as Remdesivir , DexametFurthermore, results revealed that the participants encountered social stigma. For instance, HCWs were encountering social discrimination because of working with COVID-19 patients; sometimes they were blamed or avoided. They also felt social stigma when they got infected with COVID-19. This result is congruent with a previous study which aimed at exploring COVID-19-related stigma and its associated factors among Egyptian physicians .Work-Related Concerns• Our findings revealed that the HCWs were stressed because of hearing news about the collapse of health systems in some countries. This finding is congruent with a study which found that using social media as a source of information about COVID-19 is correlated with stress . On the A challenge of conducting our study was using an online platform to interview participants. It was more difficult to build a rapport with participants over the online meeting, and non-verbal cues could not be documented ,61. AddiThe health sector’s policymakers are advised to consider and implement the following recommendations: (i) regulations that enhance working conditions and support occupational safety, (ii) ensuring that the mental health of the HCWs is under regular supportive monitoring by trained psychosocial staff, (iii) providing timely and accessible mental health and psychosocial support services to HCWs who are in active fight against the COVID-19, (iv) capacity building of HCWs through well-structured positive psychology training programs that enhance personal resilience and coping skills to deal with various psychosocial stressors at work , (v) providing HCWs with appropriate incentives subjective to their increased workload during the pandemic crisis, (vi) continuous assessment of the health workforce needs in order to maintain sustainable working environment in healthcare settings.In conclusion, HCWs in Jordan working in the wards and care centers designated for patients with COVID-19 experienced mental and emotional distress and were practicing under inadequate work conditions. This distress could be multifactorial with personal, organizational, or cultural origins. Our study findings may guide policymakers in taking into consideration the potential factors that significantly affect the working environment in healthcare settings, the physical and mental wellbeing of HCWs, and the required professional training that may help in enhancing the HCWs’ resilience and coping strategies amidst crises.


Oral antiplatelet and anticoagulant drugs are widely used in a large number of patients visiting the dentist, and there has been much controversy over the years towards their clinical management. The aim to carry out a literature review in order to develop an update on dental management in anticoagulated and / or anti aggregated patients, focusing on oral surgery.A bibliographic search was carried out in PubMed on studies published between January 1, 2018, until December 10, 2020, using the keywords (“antiplatelet” OR “antiplatelets”) AND (“dentistry”), and (“anticoagulant” OR “anticoagulants”) AND (“dentistry”).The number of studies included in this review was 13, and the number of patients among all of them was 3.497 patients under treatment with some type of antithrombotic drug, who underwent different oral surgery treatments.There is a low risk of peri- and postoperative bleeding events during basic oral surgery treatments in antiplatelet or anticoagulated patients, which can be easily managed through the use of local haemostatic measures. Key words:Oral surgery, antiplatelet drugs, anticoagulant drugs, dental treatment. The number of anticoagulated patients is increasing worldwide every year, representing approximately 1,9% of the population in Spain, since it is known that today there are between 800.000 and 1.000.000 patients in Spain receiving chronic treatment with some type of anticoagulant drug . Due to Even though routine dental treatments are usually low-risk procedures with a little tendency to drawbacks, patients with bleeding disorders, whether they are inherited or acquired, require careful attention when assessing the risk of bleeding; hence a correct surgical management by the professional can avoid these possible adversities . It is eBefore any surgical procedure it is important to establish a proper control of haemostasis, especially in patients with high risk of bleeding, in which greater caution must be exercised and all necessary measures must always be available. Before starting the intervention, the risk of bleeding should be assessed according to the type of intervention to be performed, considering as low risk of bleeding some of the most common treatments in daily practice such dental extractions, root scaling and implant surgery, and as high risk of bleeding the extraction of more than 3 teeth, surgical dental extractions, placement of more than 3 dental implants, bone and tissue grafts, sinus lifting, and bone regeneration techniques.In cases of low risk of bleeding, altering the dose of the drug is not usually indicated . HoweverIn these cases in which it is necessary to modify any treatment with antiplatelet or anticoagulants, it is essential to ask the responsible doctor of that treatment, who will be the one in charge for its modification or not. Nevertheless, the dentist must take special care in assessing the risk of thromboembolic events which, although being rare, can lead to severe complications for the patient. Therefore, it is important to act with caution since the risk of thromboembolism increases as the drug is discontinued -8.Some authors have tried to categorize the type of surgical haemorrhage according to the perioperative time when bleeding occurs, being classified as primary when they take place at the time of surgery, secondary when they occur in the next hours after the surgery, and reactive when it takes place up to 2 weeks after surgery, being normally as a consequence of infectious processes or persistent inflammation ,6,9-11.The aim of this review is to assess the published literature in order to establish an update on dental management in anticoagulated and / or anti aggregated patients, focusing on oral surgery.A bibliographic search was carried out in PubMed on studies published between January 1, 2018, until December 10, 2020, using the filters available in the mentioned database, marking the fields “humans” and “custom range” on the date of publication, selecting the range between the aforementioned years and using the following keywords: (“antiplatelet” OR “antiplatelets”) AND (“dentistry”); (“anticoagulant” OR “anticoagulants”) AND (“dentistry”) The inclusion criteria covered all articles about anticoagulants and / or antiplatelet drugs in dentistry, published between the mentioned dates, carried out in human patients, and written in English and Spanish. On the other hand the exclusion criteria covered articles on animal studies, those which did not belong to dental practice or did not deal with antithrombotic drugs in relation to oral surgery and those which were not case-control studies, cohort studies or clinical trials.Any disagreement was resolved through discussion and consensus between JCT and VSDF. In case a third opinion was required or stalemate, BGN, AED and EJS were consulted to sort out any discrepancy.Using our search strategy, a total of 276 results were obtained. Of these, 42 corresponded to those found using the keywords “antiplatelet dentistry”, and 234 corresponded to those found using the keywords “anticoagulant dentistry”. After reading the titles, 12 of the 42 results obtained using the keywords “antiplatelet dentistry” and 29 of the 234 obtained using the keywords “anticoagulant dentistry” were selected , the use of non-absorbable sutures, and the availability of local haemostatic measures such as gelatine sponges, thrombin, collagen, cyanoacrylate, or oxycellulose.et al. , which if it exceeds 20 minutes , the surgical act will be delayed for 3-7 days.Regarding the guidelines to follow in the days after the intervention, it is highly recommended to rinse with an antifibrinolytic such as 5% tranexamic acid, 2 minutes / 4 times a day, for 7-10 days. Paracetamol and / or a mild opioid such as codeine are recommended for pain control, avoiding as far as possible prescribing ASA or other NSAIDs due to the increased risk of bleeding they present. Currently, most protocols also recommend the prescription of systemic antibiotics as a prophylactic measure, since the presence of infection is itself an inducing factor of fibrinolysis.Based on the results obtained in this review, there is a low risk of peri- and postoperative bleeding events during basic oral surgery treatments in antiplatelet or anticoagulated patients, which can be easily managed through the use of local haemostatic measures. Therefore, it is not recommended to modify the dose or administration of antithrombotic drugs due to the possible adverse effects that could take place which, although infrequent, involve severe consequences for the health and life of the patient. However, in the case of requiring the modification of any treatment with antiplatelets or anticoagulants, it should always be done under the surveillance of the responsible haematologist or specialist doctor.It is important to know the type of drug used by the patient as well as its possible interactions with other substances that could alter its potency or effect. However, it has not been demonstrated in the studies included in this review that there is a greater predisposition to bleeding according to the type of drug used, or in relation to the presence of associated comorbidities.


Interviews were thematically coded for themes pertaining to parents’ perceptions of their child’s diet and oral health. Findings of this study indicate that the process of taking photos helped Latinx caregivers to better situate the barriers and behaviors influencing everyday food routines in their children within the context of relating to their overall oral health. Via their active participation in the research process, parents were empowered to note strategies they could employ that would directly impact their child’s oral health outcomes, such as reducing juice intake and monitoring sugar consumption. Therefore, visual research methodologies are an important strategy for researchers to consider in order to empower participants to be part of the research process and part of the outcomes, and to offer better understanding of the lived experience of populations underrepresented in the literature, such as Latinx children with and without ASD and their families.Diet and food choices significantly impact teeth, including enamel quality and development of dental caries. However, studies focusing on diet and its relation to oral care in Latinx children with and without Autism Spectrum Disorders (ASD) have been minimally addressed in research. This qualitative study used an inclusive visual methodology to explore what Latinx caregivers learned about their child’s diet preferences and food routines in relation to their oral health. As a secondary aim, the study sought to explore whether notable differences in diet emerged between Latinx children with and without ASD. Participants were 32 Latinx caregivers from 18 families with children with and without Autism ( Throughout this article, we use Latinx, a gender neutral term to indicate someone of Latino/a ethnicity) children with and without Autism Spectrum Disorders (ASD) have been minimally addressed in research. However, this is a key area to focus investigations, as Latinxs , you just, you know, you just answer or ignore him sometimes, and I’ve found that he was very curious … he was asking me more, ‘Can I help? Can I help?’ And I should have been like, ‘okay, yeah sure.’ But sometimes you get busy. And I need to include him while he still asks me about it.”“Here, she was able to critically reflect on the fact that she should capitalize on the fact that her son wants to be involved in the food process while he is still at an age where he wants to be engaged in learning.It costs me more to get them vegetables. They are so expensive. But they are good for you, and make your body and your teeth healthy. And I do the most I can, but I do have to learn to prepare the vegetables in a way they like, and not like I already know how to.” Celia further expanded on the cost of fresh fruit being an issue because her all four of children loved certain fruits, and she felt badly when she could not afford to provide them for her kids. She also noted that the fruit that she found most affordable, apples, was a “good for you” food to include in her child’s diet:For Celia, she lamented the high costs of fresh fruit and vegetables, and regretted that she only knew how to prepare food in the ways she learned from her own mother, and not in ways that were appetizing enough to entice her neurotypical daughter, 7-year-old Ana Sofia, to actually eat any vegetables that she did manage to purchase. Celia’s predicament was that she knew that vegetables were part of a healthy and nutritious diet, but did not know how to incorporate them into Ana Sofia’s diet due to costs and food preparation limitations. Celia described: “They love fruit … they love oranges, plums, mangoes, grapes, strawberries. All kinds. But they like fruit so much that it can get expensive to buy so much for them. I wish I could buy them fruit all the time. Usually we have just what I can afford, like apples. But don’t they say that apples are good for you?”“Here, Celia is describing a crucial predicament pertaining to the high cost of healthy eating, especially as it involves buying nutrient dense food for multiple family members or growing children with hearty appetites. Valentina, mother of 11-year-old neurotypical Ximena, also acknowledged that healthy food often comes with a high price tag, or is less readily available, and wished she had more resources to spend on the expensive food. She described a picture of a naturally squeezed juice with a story:This picture is a juice with kale, spinach and lemon. We were in Whole Foods yesterday making our weekly purchases, and it’s so lovely that they make fresh juice there, so we paused to have a juice. [The juice] has only 170 calories, but they are all good calories because the juice is pure vegetables. They even let us try to the juice to see if it was too acidic, because they had put a good amount of lemon in there. How nice of them, right? But the juice is expensive. Thirty dollars for the 3 of us to have a fresh juice. And the thing about Starbucks is they are cheap, and they make things in whatever way they make them, with all the calories, and they just give you the drink and say ‘here it is, take it’. But Starbucks is everywhere and it is popular, and Whole Foods is expensive, so we go there less.”“Cost of food also impacted Isabella’s meals for her son, Zach, age 8 with ASD. Isabella said:Changing diet is kind of hard as well, because sometimes you don’t have the money for it … even though you’re supposed to eat one food or another, how do you afford it? … Especially salmon. Like, that’s their favorite, and just a piece of salmon is, like, $23, $24. And they don’t just eat that little portion, it has to be a big portion. But if I cannot buy salmon, then I buy a cheaper fish, so they can still get the nutrition.”“Julia is so independent. She eats what she wants and grabs it for herself from the refri[gerator], does it all by herself. I wish I helped her more. But, at least she eats healthy. Her favorite food is vegetables. Sometimes I walk in and just find her eating carrots.”Araceli wanted to be more involved in her 7-year-old neurotypical daughter Julia’s eating process by determining more of Julia’s meal contents, but did not know how to insert herself into Julia’s routine more. Araceli said: “Notably, this comment about independently preparing and consuming food was not one shared by parents of children with ASD. For example, Valeria wanted to encourage her 11-year-old son with ASD, Juan, to eat more nutritious food, and wished she did not give in to his demands so frequently. In reviewing the pictures, Valeria commented:I noticed not enough veggies. He’s still very like against veggies or even tasting it, the textures or the taste of the vegetables. He just won’t have it … An example is going to the mall, because one day we did go to the mall and he had Hotdog on a Stick and I’m just like ‘Oh my god, I can’t believe I let him have that.’ He’s such a picky eater but he knows where to go to if we go to the mall. That made me think like ‘okay what should I change? Should I not give in to him when he wants to eat all these things?’ Especially these things that are just not even remotely good for him.”“He is actually pickier than what I thought. You know, like I was like ‘oh I didn’t know he wasn’t crazy about this food’.” Similarly, parent Carla described her neurotypical 8-year-old daughter Samantha by saying “she pretty much eats the same thing. I saw so many blueberries in all the pictures, she eats them all the time.”This theme pertains to VM as opportunity to learn more about children’s eating patterns. Here, parents discussed their observations of their children’s dietary habits, and how the photo taking process expanded what they knew about their child’s preferences and routines. With the camera in their hand, parents took on the role of active observers, and were able to discuss the particularities of their child’s food preferences with the research team. These comments were invaluable to understanding more about food selectivity in the child participants. Actually, several parents of both children with ASD and TD children noted how selective their children were about what they consumed. Violeta (parent) was asked to describe anything else she wanted to note about the process of taking pictures of food, and noted her realization about her 12-year-old son with ASD, Justin. Violeta said, “Another parent, Camila, with a 12-year-old son with ASD, talked about one photo she took of son Stefan’s food by saying:This salad includes lettuce, spinach, and carrots … He’s very picky. He has gotten pickier. Especially with vegetables. The most vegetables that he eats is lettuce, spinach, and carrots. That’s the only three vegetables that he eats … And carrots. Uh-huh. He’s very, very picky. He don’t [sic] like green beans. He don’t like bell pepper. He don’t like broccoli or squash. Even cucumber. He don’t like cucumber. And tomato. He don’t like the tomato. I didn’t know about the tomato.”“Celia also described how particular her neurotypical 7-year-old daughter Ana Sofia was when talking about a picture of food from McDonald’s.Well, this is a picture from McDonald’s. They always want McDonalds, and my husband says, ‘no, that place is not healthy. A better idea is to go to Subway or something. And Ana Sofia will say ‘no, I don’t like such and such place’ and if we go to Subway, she gets a ham sandwich and then has us take off all the vegetables … and we go out from time to time, when we can afford it, but she always wants McDonald’s … and at McDonald’s she only eats chicken nuggets, and even then, it’s only so she can get the toy from the happy meal. Or if we get Panda Express, she only eats chow mein. That’s it.”“Valentina commented on her 11-year-old neurotypical daughter Ximena’s food preferences, and noted the nutritional components of each option, including describing sugar content:… There are two things she really loves to eat, and I learned that it depends on where we are, what she eats. One is Starbucks, and the other is natural juices. From Starbucks, we already know the drink is really delicious, but it has too much sugar, too many processed elements and ingredients that are bad for your teeth and for your health. And the other option she loves is fresh natural juice.”“From these comments, it became apparent that food selectivity and picky eating was commonly mentioned across the sample of children, and not unique to only the children with ASD.obviously we already kind of knew we ate a lot of frijoles and that most of the time, we eat rice. But that’s better than like, dessert all the time.” She also went on to describe how she was pleasantly surprised with how they had reduced the amount of times they ate out at fast food “unhealthy” restaurants on a weekly basis, and attributed this habit change to the fact that her mother-in-law was visiting from Latin America and had largely taken over food preparation activities for the family. Adriana was grateful for the support offered by her family member in preparing nutritious and healthy meals, and said:All content in this theme pertains to VM as opportunity to highlight strengths of family’s eating patterns. Adriana, mother of 10-year-old neurotypical daughter Cristina, jokingly declared: “I just realized that actually when I was taking the pictures and thinking about what is the restaurant you frequently visit, I was asking my mother-in-law, and I go, ‘When was the last time we went out to eat? Cause like I can’t remember.’ [The food journaling process] asking me to document these things made me see how much my mother-in-law cooks for us now. And then, oh yeah, I did notice the changes that we were eating more here at home, and it’s food that is better for us, you know, the home-made arroz y frijoles [rice and beans] and not the greasy stuff from fast food. So at home, we eat better, you know? And maybe just once, maybe twice in a month is the most I think we eat out now that she [mother-in-law] is here.”“Other parents were also pleased with the outcomes of reviewing the food photos during the PEI. Armando, father of 7-year-old Perlita with ASD, described how they felt all the pictures were accurate to their real life daily experiences. Armando noted:Well, we are vegetarian, and so we eat a base of vegetables and lots of legumes. So that is what you see in every photo, because that is what our life is like. We also eat lots of dairy products like cheese and milk, and also eggs. Also we eat a lot of seeds, nuts, and almonds. We try to eat healthy, live healthy. We even brush our teeth after every meal. And we think it shows in our pictures.”“This theme surrounds how VM highlighted how parents realized the negative impact of consuming too much sugar, and how it could affect their children’s oral health status. Parents also discussed their strategies for reducing sugar consumption in their children. Mia, mother of 11-year-old neurotypical Xochitl, described sugar by saying: “it is the worst thing for her teeth. The very worst thing. So that’s why I barely let her drink soda. Because of all the sugar.” Sara, mother of 8-year-old Marco with ASD, noted that:We do a lot of peanut butter and jellies, he eats a lot of fruit. I didn’t think I did a lot of snacks, but like watching and like looking at their actual food journal and having to take pictures of everything else, I was like, mm, maybe I am offering too many snacks, maybe I could offer him more veggies, or you know, less sugary things instead. Because sugar, man, it gets you.”“Another parent of a neurotypical child, Celia, commented about a strategy that she used to avoid sugar late at night, while also being cognizant of her food budget:They love fruit and juice. But it gets so expensive if they drink it all the time, more than I can afford. And juice is too sugary. So after 4 pm, no more fruit. And they have to have water with dinner. Those are the rules.”“During her photo elicitation interview, Jennifer elaborated on her goals for her 7-year-old son with ASD, Luca, and her candid thoughts on sugar:I’d just like him to have a balanced diet. So good amounts of sugar and good amounts of carbohydrates, and I would rather have him learn how to properly learn what’s good for him, so-because I think all of our parents say, oh, eat fruits and vegetables. It’s so good for you. And then you realize when you’re older and you’re, like, oh, my gosh, even fruit and vegetables even have a lot of sugar in them, and sugar is the devil …”“After looking at a picture of maple syrup that she uses on Luca’s breakfast pancakes, Jennifer explained more about the pitfalls of sugar:Oh my God this syrup has 48 g of sugar in it! Do you know your child is only supposed to have, like, six [grams of sugar] or something? … and you know apple juice has, like, 46 g of sugar in it. And I’m, like, ‘I know we water Luca’s sugar down’, we water down his juices when we give it to him … but still, like, that’s not counting his peanut butter, that’s not counting his bread, that’s not counting his syrup, that’s not counting like, all these other things, and I’m just like, ‘oh, dear God.’ And from what I understand, which is, you know, I feel like sugar just sticks to your gums and your teeth and it just resides there, and then bacteria says, ‘oh, yum, sugar. Well, let’s dig in,’ and then starts eating away at your body basically, starting with your teeth.”“Oh yes, he loves the camera, seeing the camera. So food became fun, because I was taking his picture when he ate. He did not complain at all. He even tried more food because I was taking his picture.”This theme pertains specifically to comments made by parents of children with ASD, about using the process of VM as a means of creating change and encouraging their children to try new foods. Some parents noted how the photo journaling process facilitated meal time with their children who were normally much more selective about their food choices. Parent Paola noted how her child seemed more responsive to eating once she introduced a camera to document the activity. In showing off a picture of her smiling 9-year-old son with ASD Teo holding a plate of food, Paola said: “Normally he has his sensory thing where he won’t touch mushy food, like vegetables that have been cooked too long. But when I got out the camera, he thought it would be funny to pose with my plate and put his fork into the mashed potatoes, because he loves attention and being funny. I mean, he did not eat the mushy food … but at least he was playing with it, you know?” Mother Estefania discussed her 8-year-old son with ASD Cristobal, as a picky eater who usually eats the same thing “meat and rice everyday”, but also how the camera served as a distraction to reduce his food selectivity. Estefania said: “He only likes certain flavors and textures. But he saw the camera and me taking pictures of his food, and let me put some salad on his plate. I think it’s because he was more caught up with the camera being there that he wasn’t so resistant about what I served him.”Parents with children with ASD also noted how the process of documenting food intake affected their children who were food selective to be slightly more open to trying new foods. Mother Susanna described her 6-year-old son Aiden as “a little less fussy” when she was taking pictures of him eating. She related: “n = 13 children), pizza (appearing in photos from n = 12 children), and McDonald’s (appearing in photos from n = 13 children). These items were evenly distributed across the sample, appearing in photos from both TD children and children with ASD with similar ratios. Conversely, foods that were disproportionately skewed across groups were watermelon , water , fries , soda , cookies n = 5; n = 5 ASD and n = 0 TD), and milk .Additionally, the research team also completed a table to record the types of foods documented in the photo journals. Notably, the foods that were documented the most were juice  has issued guidelines that recommend intake of free sugars (highly sugary products) to provide less than 10% of total food intake daily, and suggest further reductions to less than 5% of diet content to protect dental health throughout life . In thisdid not drink. Children with ASD have significantly more feeding problems and eat a narrower range of foods than children without ASD [n = 13 of 18 children), but children with ASD consumed even a greater amount of sugar than their peers because of the disproportionate ratio by which they consumed sweets. For example, of the eight children noted as having soda appear in their food journals, seven of those children has ASD. Similarly, of the five children who had cookies in their journals, all five came from the ASD group. A noteworthy observation is what was missing from photos from the ASD group, in that, of the eight children documented as drinking water, only one of them was from the ASD group; the remaining seven were from the TD group. Comparatively, this means that 87.5% of the TD group drank water, while only 10% of the ASD group did. Granted, as the journals were not completely comprehensive, is that the appearance of a photo in the food journal does not provide conclusive evidence that it was eaten; similarly, photos of food and drink that were consumed could be missing from the journals. However, it is a unique finding of our research that so few children with ASD were documented to drink water, and aligns with previous research about children with ASD consuming more sugary food items.Lastly, in line with previous research on food selectivity among children with disabilities including ASD ,49, we ahout ASD ,24. Prevhout ASD . In our The finding that parents of both children with ASD and TD children mentioned pickiness in their children is also noteworthy; in our study, food selectivity was not solely observed in the ASD group. However, families of children with ASD did make some comments about their child’s sensory sensitivities making it difficult to introduce certain foods into the meal time routine, or how the presence of the camera sometimes increased their child’s willingness to be served different foods. Notably, parents of children with ASD did sometimes reference how their child “ate the same thing”, or had “sensory things” that made them completely avoid certain foods.Major strengths of this study included collecting rich, detailed information on perspectives of Latinx parents of children with and without ASD regarding their diet and food consumption practices. However, the current findings are not likely generalizable to all Latinx parents and caregivers of children with and without ASD, and should only be interpreted as expanding the body of current research. Moreover, aside from confirming a previous clinical diagnosis from a licensed profession, no diagnostic assessments were performed the children with ASD, nor were any intelligence or communication scales used. Therefore, all reporting on characteristics on the ASD group are from parent report and participant observations by the research team. Moreover, as time has passed since the participants were originally interviewed, these opinions are no longer the most current, and opinions or situations could have changed over this time period.Additionally, given the self-expressive nature of the visual photo food journal, the type and quality of the photos taken across participants varied greatly. Notably, the families took photos of what their children were served, and not necessarily what was actually consumed by the children. Moreover, there were no questionnaires given to the families to describe meal components. Thus, noting the exact types of foods consumed, food preferences, and habits of the child was not measured nor standardized. Future research on diet can incorporate a form, such as a food frequency questionnaire or food recall form, that documents food consumption, food preparation information, environment where food was obtained, and amount of food consumed on each day. It would also be relevant to further the work on diet choices between neurotypical children and children with ASD and other developmental disabilities such as that explored by Bandini and colleagues ,51.The Latinx population has many unmet oral health needs deserving of more research to improve their health. The food selections made by Latinx parents and caregivers for their children or by the children, and the factors that impact these choices, including personal preference and systematic barriers, were analyzed using food journals and photo elicitation interviews. Visual research methodologies used in this study, such as photo journaling and photo elicitation interviewing, provide researchers with information that is authentic to the lived experiences of those providing the data , and invFor example, the photo journaling process that we used helped parents to be more aware of both the positive and negative aspects of their child’s eating habits, the harmful impact of an overly sugary diet on oral care outcomes, and ways to encourage their child with ASD to try new foods and address food selectivity. Another important takeaway is about the food choices of the children themselves. While Latinx parents noted both their TD children and children with ASD as “picky” eaters, this study furthers the literature on food selectivity in ASD by showing how Latinx children with ASD consume more sugar and drink less water than their neurotypical peers. This finding has clear implications on oral health outcomes in Latinx children with ASD due to the negative impact of sugar consumption on caries development, and is an area that merits further research to create targeted education or intervention programs to reduce caries risk.By introducing a visual methodology to the Latinx family dynamic, this study provided an opportunity to explore how this medically underserved population engages in the research process. Via their active participation in the research, parents were empowered to note strategies that they could employ that would directly impact their child’s oral health outcomes, such as reducing juice intake and monitoring sugar consumption. Therefore, visual research methodologies are an important strategy for researchers to consider in order to empower participants to be part of the research process and part of the outcomes. Particularly, visual methods, like photo journals, could be helpful in better understanding the lived experience of populations underrepresented in the literature, such as Latinx children with and without ASD and their families.


Off-the-books, untraceable “ghost guns” can now be manufactured at home, easily, and in large numbers; they contribute ever more frequently to firearm violence, including hate violence and domestic terrorism. The Bureau of Alcohol, Tobacco, Firearms and Explosives estimates that in 2019 alone, law enforcement agencies recovered more than 10,000 ghost guns. The manuscript describes the current situation and suggests specific actions that state and federal governments can take to avert disaster. Suppose I wanted to produce rifles and pistols in large numbers, clandestinely, to arm violent extremists or a hate group in the United States: Donald Trump’s erstwhile shock troops the Proud Boys, for example, members of the Three Percenters or boogaloo movement, or any of scores of private so-called militias and neo-Nazi organizations. You might think this would require a substantial investment and high-level technological expertise on my part. Far from it.For $2100 I can buy a GhostGunner3—a computer-controlled milling machine not much bigger than a desktop laser printer—that will let me “manufacture firearms with confidence and ease, in the privacy of [my] own home.”  calls them—"80-percenters,” as they are known colloquially—are considered nothing more than pieces of metal or plastic. I can buy them for as little as $50 to $75 each, and I can get volume discounts.If I don’t have the money to buy a milling machine, I can rent one, or I can buy inexpensive jigs and produce finished receivers with a drill press and hand tools. All the other parts that get me to a durable working firearm are readily available. Home manufacturing of firearms for personal use is legal under federal law and requires no license, and supplying parts to home builders and customizers is a growth area for the firearm industry.Here’s the key: Because I make them myself, these firearms are not required to have serial numbers or other identifiers, which makes it impossible to trace transfers of ownership. Because I want to cover my tracks, I keep no records of their existence. They are guns without a history, coming from nowhere. Ghost guns.Unserialized firearms, as they’re properly known, are not a new phenomenon. For decades, firearm manufacturers  have sought clarification from ATF on the question, When in its production process does a piece of raw material become a firearm in the eyes of the law? There has never been a clear answer; ATF rules on a case by case basis. Originally, the agency held that a substantial amount of effort—work that took ATF’s own experts more than an hour to accomplish—had to be left to the buyer for a partly-finished receiver or frame not to be ruled a firearm. Beginning about 15 years ago, however, ATF not only lowered the bar but provided specific, written instructions on how to come as close as possible to it’s-a-firearm status without crossing the line  singled out “domestic violent extremists [as] presenting the most persistent and lethal threat” of terrorist violence in the United States The following specific legislative reforms or administrative actions, if taken soon, would reduce the risk of disaster; 5 states have already taken preliminary steps. Federal and state governments should prohibit unlicensed manufacture of firearms. ATF should establish a clear point, early in the production process, at which unfinished receivers or frames are defined as firearm precursors and further finishing work is defined as manufacturing firearms. Firearm precursors must be given unique, permanently-affixed serial numbers, and individual production and disposition records must be kept. The purchase restrictions now in place for fully functional firearms must be applied to firearm precursors. Owners of the existing stock of ghost guns and unserialized firearm precursors should be required to declare their existence and receive, affix, and record unique serial numbers. After an appropriate delay for implementation, possession of an unserialized firearm or precursor should be a crime for which a conviction prohibits further ownership or acquisition of firearms, precursors, and ammunition.The firearm industry operates under a regulatory structure that was largely set in place more than 50 years ago. Time and technology have moved on. In February 2020, a high-ranking DHS official described domestic terrorism this way in testimony before Congress: “it feels like we are at the doorstep of another 9/11 …we can see it building and we don’t quite know how to stop it.” (Neumann, Americans learned 20 years ago, as we are learning now with COVID-19, of the terrible penalty that can follow failure to recognize and respond adequately to an emerging threat to the public’s health and safety. Ghost guns pose such a threat, which extends beyond political violence to criminal violence of all types—produced clandestinely and untraceable, ghost guns are tailor made for the criminal gun market. Now is the time to do something about them.


This letter identifies the potential of qualitative eating disorder research to work within a transformative paradigm that naturalizes the state of living with an eating disorder. The number of qualitative research publications with persons living with eating disorders have increased, however, a substantive proportion of this qualitative research follows traditional research paradigms that are built upon the assumption that eating disorders signify a personal deficit. Transformative qualitative eating disorder research has potential to include those living with eating disorders in all stages of the research process to ensure that research leads to the de-stigmatization of eating disorders promoting health, wellbeing, and quality of life for persons living with eating disorders. This recognizes eating disorders as a natural phenomenon, a valid state of being, and promotes autonomy and self-determination surrounding treatment and recovery.In recent years there has been an increase in qualitative eating disorder research  which exHistorically, eating disorders have been positioned as individualised, being caused by personal deficits , 2, 4. IIn my work with disabled and autisticnormal [Inspired by academics in the field of Critical Autism Studies , where anormal . I have normal , action normal , and posnormal , could qI encourage future eating disorder researchers to involve stakeholders in their research , 10, to


Considerable attention has been paid to inequalities in health. More recently, focus has also turned to inequalities in ‘recovery’; with research, for example, suggesting that lower grade of employment is strongly associated with slower recovery from both poor physical and poor mental health. However, this research has tended to operationalise recovery as ‘return to baseline’, and we know less about patterns and predictors when recovery is situated as a ‘process’. This paper seeks to address this gap. Drawing on data from the UK Household Longitudinal Study, we operationalise recovery as both an ‘outcome’ and as a ‘process’ and compare patterns and predictors across the two models. Our analysis demonstrates that the determinants of recovery from poor health, measured by the SF-12, are robust, regardless of whether recovery is operationalised as an outcome or as a process. For example, being employed and having a higher degree were found to increase the odds of recovery both from poor physical and mental health functioning, when recovery was operationalised as an outcome. These variables were also important in distinguishing health functioning trajectories following a poor health episode. At one and the same time, our analysis does suggest that understandings of inequalities in recovery will depend in part on how we define it. When recovery is operationalised as a simple transition from poor health state to good, it loses sight of the fact that there may be inequalities (i) within a ‘poor health’ state, (ii) in how individuals are able to step into the path of recovery, and (iii) in whether health states are maintained over time. We therefore need to remain alert to the additional nuance in understanding which comes from situating recovery as a process; as well as possible methodological artefacts in population research which come from how recovery is operationalised. •There is no consensus on what recovery is and how it should be operationalised.•Understanding of inequalities in recovery across health conditions remains scarce.•We operationalised recovery both as an outcome and as a process.•We found robust inequalities in recovery across the two approaches.•Considering recovery as a process revealed more nuanced patterns in inequalities. Drawing on data from 229 people discharged from hospital after acute myocardial infarction (AMI), Despite speaking to a diverse range of illnesses and conditions, the literature on inequalities and determinants of recovery appears united by two key issues. First, whilst the term recovery is frequently used , it is not always defined. It is often left implicit that it is something akin to an ‘outcome’ or ‘return to baseline’. Conceptually, this risks negating the numerous complexities and ambiguities surrounding recovery and mental/physical health. For example, whilst the clinical literature often situates mental health recovery as the amelioration of symptoms so that a person can resume activities within what is considered a normal range , policy Second, it is unclear whether known patterns and predictors of mental/physical health recovery are dependent on the way in which recovery is operationalised in analysis. This resonates with early discussions of inequalities in health more generally. Over 40 years ago the Black Committee proposed four types of explanation of class differences in health  . A ‘hardThis study looks to engage directly with these issues by using large-scale, representative data to operationalise recovery as both an ‘outcome’ and as a ‘process’ and to compare patterns and predictors across the two models. We ask: (i) Can multiple, unique, trajectories of recovery be identified? (ii) How do age, gender, ethnicity, marital status, education and employment status relate to these trajectories of recovery? (iii) How do findings from these process models compare with models that explore odds of moving from a poor health state to a good health state (recovery as an outcome)? This dualism of ‘process/outcome’ reflects the fact that complexities surrounding recovery are often summarised in terms of a series of either/ors. For We prioritise self-report measures over clinical measures within this study. Whereas existing population work on inequalities has tended to err towards ‘from’/’clinical’/’outcome’, qualitative work has emphasised the everyday importance of recovery as a process; something which is more personal, unique, and complex . Followi2We draw on data from the UK Household Longitudinal Study, which is designed to be representative of the UK population, including all ages, areas of the UK and educational and social backgrounds . ApproxiThe initial analytical sample  comprised those respondents who were included in Wave 1 and had at least one subsequent health functioning variable in Waves 2 to 9 see . As our The predictors of recovery included six indicators of participants' demographic and socioeconomic characteristics: age, gender, ethnicity, marital status, educational attainment and employment status. Age, which ranged from age 16 to age 101 in Waves 1–9, was classified into three groups: 39 years old or younger, 40–64 years old and 65 years old or older. Gender included two groups: female and male. Ethnicity data distinguishes between five aggregated ethnic groups: White , Mixed , Asian or Asian British , Black or Black British  and ‘Other’ ethnic group . Marital status was coded into four groups: partnership , widowed (including surviving civil partner), divorced/separated (including from civil partner) and never married. Highest education qualification was recoded into five groups: degree or above, A-level or equivalent, GCSE or equivalent, other qualification and no qualification. Employment status was recoded into employed, unemployed, retired, family care (including maternity leave), full-time student and ‘other’ . Gender and ethnicity were considered as time-invariant variables, whereas age, marital status, educational attainment and employment status were considered as time-varying variables.33.1Building on the approach adopted by 3.2Reflecting the idea that individuals have varying pathways in how they recover from poor health over time, we identified latent ‘recovery trajectories’ among the study population. Participants' first poor health observation during Waves 1–8 was considered as a starting point of the trajectories. Thus, 1–8 subsequent health observations after a first poor health observation constituted participants' recovery trajectories. The trajectories were based on raw (continuous) PCS and MCS scores, and we used group-based trajectory modelling (GBTM)  for idenWe used multinomial logistic regression analyses to estimate inequalities in the identified trajectories, looking both at bivariate and multivariate associations. All statistical analyses were performed using Stata version 16 . Whilst health variables remain central to this method, the interest is in identifying different trajectories and exploring whether membership is associated with inequalities. Of key import, we do not make ‘a priori’ assumptions about whether some trajectories represent recovery and others do not – a point we return to in the discussion.44.1When examining recovery as an outcome, unconditional results showed that 39-year-olds or younger (ref. group), males , Asian/Asian British ethnic group , never married , those with an A-level or equivalent education  and full-time students  were most likely to recover from a poor physical health state . When exConcerning recovery from poor mental health state, unconditional results showed that 65-year-olds or older , males  and widowed  were most likely to recover . Similar4.2By using GBTM, we selected 3-trajectory solutions as best-fitting models for recovery after the first poor physical and mental health observations . The traWith respect to mental health, unconditional results showed that 65-year-olds or older , males , Black/Black British ethnic group , widowed  and retired  had the highest odds of belonging to trajectory group 3 . Again, 5Despite a breadth of focus, large-scale research on inequalities in recovery has tended to operationalise recovery as an ‘outcome’ and something akin to ‘return to baseline’. We therefore know less about patterns and predictors when recovery is situated as something more fluid, and which varies from person to person (‘a process’). The present study is among the first to explore patterns and predictors of ‘recovery as a process’ whilst simultaneously exploring the role of methodological artefact as a possible mechanism for difference.Analysis identified discernible trajectories whilst also highlighting the key role that demographic and socioeconomic factors play in determining those trajectories. When operationalised like this, then, recovery is seen as both heterogeneous and shaped by the socio-structural conditions of living. These conditions and determinants reflect much of what is already known. For example, it is unsurprising that marital status played a key role in differentiating mental health recovery trajectories, given that support and reciprocity with family members have been shown to be important to the recovery process . Whilst Current findings also raise questions concerning mechanisms. Whilst the role of employment is clear in differentiating trajectories, the literature on employment and recovery is complex. Supported employment is considered to be an evidence-based intervention in mental health  and for With respect to artefact as possible mechanism, our analysis demonstrated that the inequalities in recovery from poor health state are robust, regardless of whether recovery is operationalised as an outcome or as a process. When looked at as an outcome, being employed, especially, increased the odds of recovery both from poor physical and mental health state. Similar to However, and notwithstanding this, a ‘soft’ version of the methodological artefact may still run true. Whilst trajectory models were primarily used to approximate recovery as a different process, they also provide a window onto what happens if outcome models are extended over a single time point. These models would suggest that recovery from poor health was more pronounced and long-lasting when the baseline state was less severe, corresponding Limitations of this study need to be considered. Missing data are always a concern and potential source of bias in longitudinal research. In our analyses, missing data in predictors were rare (≤0.1% of participants), apart from education in which 16–18% of participants had missing or inapplicable data. Imputing missing educational data by creating an extra class yielded similar fully adjusted results as our main analyses see . ConcernThe subjective nature of the PCS and MCS measures is, however, also a strength, given that recovery itself is a personal experience including variety of meanings for individuals, and that cannot fully be captured objectively . The goo6Our research contributes to understandings of inequalities in recovery. At the same time as continuing to highlight the importance of age, gender, marital status, education and employment in recovery trajectories, this paper evidenced the need to pay close attention to the meanings of recovery. Our study also illustrates how it is possible to bridge the gap between qualitative/conceptual discussions of recovery and large-scale secondary analysis. There is a need for more population level research into the complexities of recovery – especially considering the current emphasis on ideas of recovery in the midst and after the pandemic, and concerns of widening health inequalities i.e., . Secondahttps://www.understandingsociety.ac.uk/documentation/mainstage/user-guides/main-survey-user-guide/ethics.The Understanding Society study protocol is scrutinised by a number of research ethics committees to assure that ethical and legal obligations are respected at all times. The ethical approval statement is available from the Understanding Society websites: Salmela Jatta: Data curation, Formal analysis, Investigation, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing. Brunton-Smith Ian: Methodology, Writing – original draft, Writing – review & editing. Meadows Robert: Conceptualization, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing.The authors have no conflicts of interest.


Amy S. Thompson , 2021, xiii+163 pages, ISBN: 978-1-80041-117-3The Role of Context in Language Teachers' Self Development and Motivation: Perspectives from Multilingual Settings, is the result of 10 years of diligent work of collecting and analyzing the narrative data from English as foreign language (EFL) teachers in seven diverse sociopolitical contexts. The focus of the book is on individual differences, specifically motivation and the development of self, in bilingual/multilingual contexts.It has been argued that research on teacher motivation and identity (re)construction requires the expansion of its traditionally psychological boundaries and embarks on the sociolinguistic and critical viewpoints borrowed from language learning, language teaching, and language teachers' lives in bilingual/multilingual environments. To cross these boundaries, Amy S. Thompson's monograph, entitled This monograph includes a warm-in-tone forward, a preface, and nine chapters. Chapter 1 problematizes the complexities of integrating context, self-development, and motivation, by providing their germane theoretical underpinnings and a comprehensive overview of the pertinent issues such as non-native speaker status quo, formation of the idealized teacher identity and self, as well as context-specific teacher trajectories. Synthetizing the studies conducted on the interplay of context and self which were published in 17 journals from 2009 to 2020, the author cogently argues that there has been a dearth of empirical studies in some contexts which is the focus of this book. The chapter also reviews the empirical studies conducted in Africa, Southeast Asia, Latin America, the Middle East/Turkey, and Eastern Europe. Furthermore, the chapter elucidates the data analysis procedures, presentation of the narratives of NNS English language teachers in a variety of underrepresented contexts, as well as the methodology of collecting the narrative data from English as foreign language (EFL) instructors. Serving as a mentor, the author stated that the data were collected from a group of EFL teachers who attended an exchange program at the University of South Florida in the spring of 2010.The participants of this monograph were EFL teachers from different contexts, including Senegal, Egypt, Argentina Ukraine, Estonia, Vietnam, and Turkey.Set in Senegal, in Chapter 2, Thompson reports that her EFL teacher conceptualizes the ideal English teacher self as someone who “believes that sharing a first language (L1) with students leads to an understanding of what they need, has a positive attitude toward English and speaks it whenever he can, and expresses that English is needed to succeed in various aspects of life, such as jobs, diplomacy, and exams” (p. 40). Chapter 3 focuses on the EFL teacher from Vietnam who opines that “the younger generation has more opportunities to learn English well and loves English after first conceptualizing it as a tool” (p. 51). To this EFL teacher, making an interpersonal relationship with students plays an important role and language learning is a “passport” to a brighter future, which culminates in a happier life.Chapter 4 delineates the cognitions and perceptions that make the identity of an EFL teacher in the Egyptian context. This EFL teacher cogitates that “a person's education is often judged by their English level and that English is necessary in the globalized world” and “people do not ‘learn' a language but ‘live' a language” (p. 65). In Chapter 5, an EFL teacher from Argentina strongly believes that learning English “makes them empathetic to their students' processes” (p. 78) and that teachers need to feel accountable to foster teacher-student interpersonal relationships by creating positive attitudes and encouraging students. The context of Chapter 6 is Turkey where the two informant EFL teachers reflect that “English is a tool but can also create emotional attachments” (p. 90), and they believe that native English speaker is an advantage in hiring practices. The author recapitulates the attitudes of these two EFL teachers by stating that “Even though some people are opposed to the widespread use of English, most realize that it is currently a necessity for economic development on an international scale” (p. 102). In Chapter 7, two Ukrainian EFL instructors state that teacher-student interpersonal factors are vital to creating a positive and cheerful classroom atmosphere and that “English will open doors and is a mechanism for understanding people” (p. 103). Set in Estonia, the penultimate chapter explores how two EFL teachers feel about the role of motivation, context, and identity formation. They express positive attitudes toward English and argue that “sharing a first language (L1) with the students helps them know the specific difficulties that might arise” (p. 115). The closing chapter summarizes the sociopolitical, context-specific experiences of these EFL teachers from seven countries, argues that context is not a monolithic phenomenon, and elucidates how the construction of interpersonal relationships cannot be segregated from contexts. This chapter presents how the EFL teachers' images and visions of their professional and ideal selves have evolved in their sociopolitical contexts. The author concludes that “multilingual identity should be at the forefront of pedagogical discussions” (p. 135) and she believes that “emphasis should be placed on understanding the complex and dynamic relationships among language systems, as well as attitudes toward the different languages in a multilingual speaker's and/or teacher's repertoire” (p. 135).I believe that this monograph is thought-provoking in that it delves deeply into the professional and academic trajectories of EFL teachers who come from diverse sociopolitical, emotional, cognitive, and behavioral backgrounds. Furthermore, the qualitative data were collected from teachers from seven countries which were underappreciated in the literature, so the findings can be novel and insightful. If the author had taken into account reflexive positioning—individuals' positioning of themselves—and interactive positioning—individuals' positioning of others into account (Kayi-Aydar, The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.