A dominant narrative, referred to as “the standard tale,” prevails in popular representations about female genital cutting (FGC) that often contrast with how cut women traditionally narrate their FGC experience as meaningful in contexts where FGC is customary. However, scholarship has increasingly highlighted how global eradication campaigns and migration to countries where FGC is stigmatized provide women with new frames of understanding which may lead to a reformulation of previous experiences. This article subjects the storytelling itself to analysis and explores how participants narrate and make sense of their FGC experience in a post-migration setting where FGC is stigmatized.Semi-structured focus groups (9) and individual interviews (12) with Swedish-Somali girls and women (53) were conducted.The article highlights how the participants navigate their storying in relation to "the standard tale" of FGC in their efforts to make sense of their experiences. Navigation was conducted both at an intrapersonal level through continuous identity work, and in relation to the social context in interpersonal encounters, i.e., with service providers and others, among whom the standard tale has become a truth.The article places the analysis within broader discussions about anti-FGC work and considers the implications in relation to efforts to end FGC. Through decades of global efforts aimed to counter female genital cutting (FGC), a uniform portrayal of the practices has taken form within an international discourse of opposition that frames FGC as gender-based violence that victimizes girls and women due to its presumed negative consequences to women's wellbeing Leonard, . This coIn the article, “discourse” is used to denote knowledge, i.e., a particular set of ideas, assumptions, conceptualizations, and framings of a phenomenon that are collectively shared and taken-for-granted as truths  is an overarching term for a variety of genital alteration procedures performed on girls for non-medical purposes. It is practiced among different groups, for different reasons, and under varied circumstances . DespiteWhat is cut, how much is cut, at what age it's cut, with what implement, and by whom […] So is the litany of consequences: hemorrhage, shock, infection, infertility, sexual dysfunction, problems in childbirth, death, and so on. Leonard, ; p. 213Box 1infibulation where the labias are trimmed and sutured together with or without cutting involving the clitoral gland (type III cutting); excision of the labia minora/majora with/without cutting parts of the clitoris (type II), or excision of the clitoral hood and/or the tip of the clitoris (type I). Type IV includes all other procedures that injures the outer genitalia for non-medical purposes such as pricking , piercing, incising, cauterization, burning  or sunna cutting, that may include all other forms of cuttings other than type III. In practice, sunna cutting may entail an essential closure of the vaginal orifice, anatomically equal to pharaonic cutting . Practices are diverse but are generally divided into four categories according to the World Health Organization typology WHO, : infibuling WHO, . In Somaing WHO, .Desert Flower  with 2–17 participants each and 12 individual interviews with Swedish-Somali girls and women (16–65 years old) were conducted for a total of 53 participants. Most participants interviewed individually had also participated in an FGD. Some had lived in Sweden for many years whereas some had migrated to Sweden more recently. Most of the younger women attended or had recently completed upper secondary school. Some had full or part-time jobs or were unemployed, and a few studied at the University. Among the older women, a few had full-time employment and some had part-time employment, while others were unemployed or were enrolled in educational programs. The composition of participants reflects the situation in Sweden, where older Somali women have faced barriers entering the Swedish labor market . The representatives advertised the project, approaching members of the organizations, friends, acquaintances, neighbors, and other women they knew. Younger participants were also invited through school nurses working with young migrants and through a specially trained female Swedish-Somali research assistant using her network from her work as a Somali health-communicator in Sweden. Yet, others were recruited through previous contacts.Interviews were semi-structured with open-ended questions covering queries about previous knowledge and information about FGC, views on how FGC relates to health and sexuality, and the benefits and disadvantages of the practices. All interviews were conducted face-to-face by the first author and were conducted at facilities used by Somali community organizations, schools, libraries, or at participants' workplaces, as preferred by the interviewees. Interviews were held in Swedish, English, and Somali. In FGDs, discussions in Somali were immediately summarized into Swedish by the Somali-speaking women helping with recruitment and cross-checked with other Swedish-speaking participants. At one point, a professional interpreter was used. Two individual interviews were held mainly in Somali and were interpreted by an acquaintance chosen by the interviewee. Individual interviews lasted on average 60 min and FGDs lasted 1.5–3 h. Often but not always groups were held with young (often unmarried) women and adult women separately. With consent from participants, interviews were audio-recorded. In some cases, notes were taken, and interviews were summarized immediately after the interview.The current study is part of a PhD project that initially focused on young women . The project was gradually extended to also include older women. Ethical approval was provided by the Swedish Ethical Review Authority (Dnr 2020-00724). The present article is based on interviews conducted in two sets between 2014 and 2022, with the bulk of data being collected in 2020–2022. Participants gave verbal informed consent at the beginning of the interview, which was documented by audio recording. Participants were provided with an information sheet about the purpose and procedure of the study which was read together and discussed before the interview. The information included the right to withdraw the participation at any time without further explanation, information that participation is voluntary, and that participants may choose not to answer questions, would they wish so. All interviewees have been given pseudonyms and details have sometimes been changed in the presentation of the findings to maintain confidentiality of the participants. For a few participants, more than one pseudonym was assigned.what people say, and to how people say it, i.e., the meanings conveyed by the strategies employed when constructing stories  or refused and resisted  and may help illuminate the constructive elements people use when making sense of and constructing stories of their life experiences.Guided by these approaches to storytelling, an inductive analysis was conducted. Transcripts were read and coded, checking for recurring themes related to the study topic. In the first step of the analysis, the attention moved back and forth between the The analysis is structured under the following themes addressing how participants navigated dominant Western discourses on FGC: (1) Positioning own experiences to an image of the infibulated woman; (2) Narrating the FGC event as a commonplace story; and (3) Stigma.gudnin, and “sunna” and “pharaonic,” respectively, to denote the various practices included under the overarching term “FGC.” Few participants used “FGM,” “mutilation,” or the Swedish equivalent [könsstympning]. It did occur among those who had been engaged in anti-FGC work. When könsstympning was used, it was described as “the Swedish term.” To reflect the tone of the interviewee, the terms used by the individual interviewee will be used in the presentation of the empirical data, e.g., “sunna,” “sunni,” “pharaonic,” “mutilation,” “circumcision,” etc.When talking about FGC practices, participants of all ages commonly used the Somali terms A salient theme in the interviews was that participants negotiated notions of FGC as harmful to health and sexuality. Framed within a medical and religious narrative, interviewees condemned FGC, referring to it as “dangerous,” “traditional,” and “cultural” (as opposed to “modern” and “religious”). Many cited health risks associated with FGC, asserting, for example, that it “comes with a lot of problems,” “causes ‘pain',” and a “lack of sexual feeling.” Their position was attributed to a conviction that it is a harmful and unreligious practice, not least in relation to Islamic notions of “doing no harm.” Participants explained how notions of harm were based on personal experiences—their own, or heard from significant others, or through circulating stories about women with FGC in their local context, when in Somalia and/or in Sweden. Sometimes, these stories were framed in the form of “horror stories” of death, “lifelong suffering,” severe complications, painful wedding nights, “sexual death,” and broken marriages due to problems associated with FGC. The participants' position was also informed by anti-FGC discourses in Sweden, e.g., through campaigns, targeted sessions about FGC in schools, or anti-FGC initiatives targeting the Somali community, or more seldom through news media. Maano  said in an FGD:When I came to Sweden, I was 14, I was invited to a meeting after class. They talked about the law, that it is forbidden, of everything that can happen and the risks and everything—then I was informed about it. Because I knew nothing about it [before].Similarly, Aalihya  explained in an individual interview:Interviewer: What kind of information do you receive about this in school? What have you learned about gudnin [FGC] in Sweden?“Before I came here, I didn't think that this would affect my life in any way. I was 13 years old and hadn't heard anything about gudnin, because it was something no one talked about … So when I came here, I learned quite a lot: that you can have difficulties during sex … that it affects our ability to feel pleasure during sex, that it's not endorsed by the religion, which has been a major reason for FGC.”In addition, interviewees reported how they were influenced by discursive changes in the Somali group in the diaspora and in Somalia in which pharaonic cutting increasingly has been condemned, e.g., by imams, or in campaigns. Based on these sources, an image of the “cut woman” was constructed. In terms of harm, personal experiences of FGC were positioned against and made sense of in relation to this imagined other (infibulated) woman.Implicit in these narratives was that “FGC,” if not specified, generally was associated with pharaonic cutting. This was made visible, for example, in how health consequences were discussed as an obstruction due to a vaginal closure characteristic of pharaonic cutting. Common comments were that sunna cutting was “less harmful,” “nothing,” or “just a nick.” The exception was some younger uncut participants who tended to collapse all genital cutting under the umbrella “FGC,” or others who explicitly included sunna cutting, often in the context of stating opposition against all forms of genital cutting. In terms of their own experiences, discourses on health and sexuality were negotiated in relation to personal experiences of not necessarily feeling harmed themselves. When participants narrated their experiences, the presence of a seal was particularly central and personal experience was often related to how they imagined it to be for (other) infibulated women. The positioning varied primarily depending on the participant's own experiences of FGC.Young women with sunna cutting made sense of their experiences of FGC by positioning it against pharaonic cutting . Sometimes the positioning was explicit. This was most evident in Yasmiin's narrative. Yasmiin  was interviewed together with a friend from a non-practicing ethnic group. During the interview, she was careful to distance her experience of sunna cutting from pharaonic cutting and what she assumed were societal expectations of FGC. She described pharaonic cutting as something causing menstrual pain and sexual problems and simultaneously dissociated from an idea of herself as having been harmed—framing her sunna cutting as a harmless form of FGC:Yasmiin: well my [FGC], it's much better, or you know, it's not sewn all together. It's just like with the boys.' They just cut a bit and then they didn't touch anything.Friend: But do you feel anything ?Yasmiin: Yes, of course! You know, I'm like anyone else. Only that they touched a bit, but they didn't sew.With statements such as “this sunni, they just cut a tiny bit, so you mustn't feel sorry for me,” and “I don't think it can be compared with those who are sewn,” she distinctly “talked back” to discourses about cut women, stressing that it is not a monolithic experience. She further refused a categorization of herself as “other,” instead emphasizing sameness and similarities between her and uncut women. She said, “I don't feel any different, I don't feel different down there.” By these remarks, Yasmiin resisted the idea of herself as victimized, harmed, or sexually maimed.While not all young or older women with sunna cutting explicitly positioned their experiences against pharaonic cutting in this manner, the positioning was often made indirectly through relating their own experiences to that of an imagined, other infibulated woman. Most young and older women with sunna cutting dis-identified with “FGC,” sensing that the topic was not related to their own experiences. For example, Aalihya  who first canceled the interview, explained:At first, I thought of not coming so I canceled [the interview], because I thought I might not have anything to contribute. As I'm not pharaonic, I cannot speak [for women with FGC] and don't want to speak for someone else who has real problems.While many young women voiced how “FGC must end,” cataloging potential health problems, most participants simultaneously discounted their own experiences of sunna cutting as a form of FGC that had caused them long-term harm. Instead, what they had learned about the long-term health effects of FGC was spontaneously related to pharaonic cutting, and in this way also seen as unrelated to their own experiences of sunna cutting. Hani  expressed it thus:[With gudnin] there are so many bad things that can happen to your body. It can impact your body, it can affect your health, it can affect how you pee, it can affect your period, everything… and I think the worst thing is the first night when you get married, that's the worst thing.Interviewer: Are you yourself worried about this?Hani: Me? No, I'm not worried, but I'm thinking about how it is for the others.talked through dominant discourses of FGC as a harmful practice in the long term. The way participants related it exclusively to pharaonic cutting while excluding sunna cutting suggests that they were influenced by the discursive change from pharaonic to sunna cutting in Somalia, more so than by Western dominant discourse that also tends to emphasize harm imposed by interventions on the clitoris. Through this construction, it could be interpreted that the stigma of anti-FGC discourse was placed elsewhere—onto pharaonic cutting, which provided a yardstick against which their own experiences were storied. Yet, others expressed reluctance to divide experiences into sunna or pharaonic cutting, claiming the practices are the same in terms of anatomical change, stating that some so-called sunna cuttings still involve partial or essential closure of the vaginal orifice. This was even more so among the older women with sunna cutting, who often stated that there were only small differences between their sunna cutting and pharaonic by the time they were cut.Many of the young interviewees used the term “them” as opposed to an implicit “us” or “me,” when they narrated what FGC meant to them. Common comments were about feeling “fortunate” or “being grateful” that their parents had avoided pharaonic cutting and chosen sunna cutting for them instead. In contrast, pharaonic cutting was described with pity and sorrow. Young women expressed worry and sympathy for mothers, friends, and others with infibulation. Some imagined that infibulation would invoke shame or be a too-sensitive topic to discuss for infibulated women, as they imagined it to affect women's everyday lives, creating a “life-long suffering” or a “sexual death,” as described by one interviewee. In these examples, the young women with sunna cutting Few of the younger participants with sunna cutting thus narrated their experiences in terms of feeling harmed. More common was expressing doubts and worries about whether the FGC might affect them in future. These concerns were related to marriage and child-birth, and often related to being partially sewn closed. Yet, a few also worried about how sunna cutting would affect sexual desire and pleasure. In terms of health and wellbeing, when young participants with sunna cutting positioned their experience against pharaonic cutting, sunna cutting was simultaneously constructed as undramatic or unproblematic. The narration of one's own sunna experience as something that had not affected their health and wellbeing in any essential way did not, however, mean that participants necessarily stated support for its continuation. With only one exception, young participants with sunna cutting stated opposition against all forms of FGC, but not based on notions of long-term harm. Instead, opposition toward sunna cutting was expressed as the procedure being a painful ordeal in the short-term that no longer had any tangible meaning, as social pressure had eased with migration and religious teachings had made participants reassess the practice on a religious basis.The presence of a seal was central also in the narratives of infibulated girls and women. Many mentioned health complications they associated with being partially or essentially sewn closed, e.g., genital pain, pain and difficulties during menstruation and first sexual intercourse, childbirth, and/or urination. Others mentioned associated impacts on sexual desire and pleasure, relating to a socially ideal gendered norm of women with infibulation as sexually modest and passive, although many refuted this idea, stating other experiences. Once the seal was opened, however, many stated “everything will be alright.” Fawsia  who reported having been partially sewn closed during “sunna” cutting, said: “After I married, it's all good now. Now it's ok.” Anissa  who associated infibulation with difficulties during sexual intercourse and childbirth, looked forward to her planned defibulation surgery. She stated:You will be in pain [during sex] and have no sexual feelings. But they'll [the feelings] come back if you open [the infibulation]. I believe that.Interviewer: So as long as you open [the infibulation], then there's no problem?Anissa: Yes.Anissa echoed narratives among the older women with pharaonic cutting, many of whom expressed great concern over having been sewn closed; however, making remarks that difficulties were resolved after defibulation.While many described experiences of harm, others dissociated from such experiences. In addition to these narratives, personal experiences were related to the presence of a seal . Farhiya , for example, made sense of her absence of pain or troubles by narrating it as an effect probably due to the fact that some stitches had opened up after her surgery as she was out playing and running after the operation. Refuting the idea of herself as harmed, she still talked through Swedish and Somali narratives that associate infibulation with inevitable long-term harm.In terms of health problems, the meanings of FGC were contested among participants. Sometimes, they claimed ordeals of infibulation to be a collectively shared experience, Asha  expressed it thus in an FGD: “we're all in the same boat, we have been through this circumcision,”' suggesting she expected others to share similar experiences. In this sense, Asha talked through a dominant, supposedly known narrative. At other times, women such as Zahra  resisted generalizations, expressing in-group variations and FGC as a heterogenous experience. This was evident in FGDs among older women when some participants claimed to speak the “truth” about FGC—either it was stated as unavoidably carrying health problems or people emphasized FGC as a heterogenous experience:Woman A: It hurts very much the first time you have sex.Woman B: But it doesn't continue after that, it's after a few months, [changes her mind] only the first time, then it disappears, that pain.Woman C: We're all different, some are still in pain you know, others are not. So there you are different as individuals, you know. We're not all the same.Woman D: If you're healthy, some are healthy, they don't feel any pain. [Interpreter summarizes:] “That woman says that she is still in pain from time to time. ‘Sometime it's there, sometimes it's gone.' But it is different for different women.”Yet, others compared their experiences with uncut women, pondering about genital pain, menstrual pain, or sexual arousal among those who have not undergone FGC:Woman, older: We're all in the same boat, we've been through circumcision, but we want to know what it's like for women without circumcision.This group of girls and women expressed uncertainty about whether to interpret the presence of discomfort to FGC or not.Many participants, young and older, told stories about the moment of the cutting event in their own lives. When narrating their experiences, participants negotiated their personal experiences and also navigated storytelling in relation to assumptions about the listener's expectations and to dominant Western narratives about FGC and FGC experiences. In interviews, the FGC event was recurrently described as an expected and ordinary part of life, what can be called a commonplace story. For example, Jawahiir  expressed it thus:When I had this gudnin, when I was a kid, that was ok for me to have gudnin because it's religion and all the other girls also had it.Although many, such as Jawahiir, expressed that FGC was a painful ordeal, emphasis in the accounts was, with only a few exceptions, placed on the naturalization and anticipated-ness of the event. When participants were asked about their previous knowledge of FGC, a common comment was that FGC was something “everyone went through,” conveying a sense that life was expected to go on. Manoo  commented:Before I came to Sweden, this was something I never thought about. It was just something everyone had done. I didn't think that it would affect my body in any kind of way, or affect anything, it was just something that happened to all [girls].Through contextualization, participants rationalized their position by sharing an understanding of the cultural context in which FGC was a social norm. About the radically different discourses on FGC in Somalia and in Sweden, Aalihya  said:I don't feel like I'm proud that I have [FGC] but I think that this was their way, where I lived. And people are like that, that they can't do everything right all the time, so I can't say that I'm proud, or that I have had something that is beautiful or anything. That's not how I think. But at the same time, I think its like, I'm not the person who thinks that “Oh my God, I have been through some horrible stuff!” I accept [it] because I think that they didn't know any better.Through unprompted statements such as that of Aalihya or Maano, it seemed like participants commented on an expected grander narrative about how girls and women would relate to their FGC in childhood. In constructing the stories in this way, participants seem to speak to and negotiate what they assume to be shared ideas of FGC as the opposite —prompting them to make the clarifying remark implicitly stating, “it wasn't like that.”Many participants engaged in similar talking back to imaginations of FGC as unavoidably associated with feelings of victimization. Others, such as Khadra , were one of the few who clearly emphasized a victimized perspective. She participated in interviews on more than one occasion. During the first individual interview she was crying, saying “What I was exposed to was indeed very terrible, they took away everything.” Khadra stated that memories keep coming back. Throughout the interview, she emphasized the harm and sorrow she felt over FGC, such as health and sexual problems, and the recollection of the loss of close ones after FGC.Another recurrent theme stressed was how participants had looked forward to the day of FGC, given the context. Many emphasized their self-determination and desire in relation to having FGC performed. Haaweyo  remarked:we [sisters] who asked [our mom], she didn't force us to do this. We were the ones who thought we should do this, because everyone in the neighborhood would bully us if we hadn't done it.You know, it was Many described the moment of FGC as a painful event they regret, yet like in Haaweyo's account, the FGC event was primarily made sense of by stressing that it was something they felt happy about, anticipated, begged for, and were looking forward to, challenging the idea of themselves as a passive victim of violence.While many participants underlined their agency in relation to the cutting event, they simultaneously made sense of it as something out of their control, something “overdetermined,” that they had tried to resist in various kinds of ways. A desire to be like everyone else coupled with peer pressure and fear of stigmatization were some elements brought forward when participants described their desire to undergo FGC. Mothers who opposed having their daughters go through cutting also often explained how grandmothers decided on FGC against their will while living in Somalia. Jawahiir  explained:When I had this gudnin, when I was a kid, that was ok for me to have gudnin because it's religion and all the other girls also had it. But when I grew up and got married, I thought this was wrong. That you shouldn't cut. So when I had my first daughter and my mother told me I must have her cut, I told her you shouldn't cut. But she said “no, it's religion, it's important,” so I'm like “ok”.both agency and being determined by social norms and power-relations that required them to undergo FGC, describing having a lack of choice or feeling forced to undergo it.Through their storytelling, many participants refused victim status and emphasized agency, yet also described the position in relation to structural conditions such as cross-generational power relations and social pressures that constrained their power to prevent the event from happening. Countering ideas of themselves as passive victims, participants constructed their stories as having In storying the FGC-event, participants made sense of and conceptualized their experience in light of dominant Western discourses and presumed hegemonic ideas about girls and women with FGC as victims of a violent event. Some talked from a victimized position, others talked back to such a position. Common to all participants was that they each engaged in varying kinds of contextualizing and talking back to assumed shared ideas about FGC in their new social setting. The examples are illustrative reminders that the storytelling context prompts participants to tell a certain kind of story in a certain way. Some stories seem not intelligible to tell, given the cultural context, but need to be rationalized and contextualized for participants to think of them as plausible to voice in the interview situation.Condemnation through the eyes of the current context was another recurring theme permeating the material—and participants commonly engaged in various forms of “change talk”—accentuating how they now were thinking of FGC as a redundant event:It should not continue, it should end, stop. As we have now gained more knowledge, the people have received more information, so this [FGC]—no one does it anymore, even in Somalia, it has been stopped. (woman in FGD)Previous practices of FGC were made sense of in terms of being “backwards,” having a “traditional mindset,” and having a “lack of knowledge” as regards medical or religious aspects of the practices. Participants, young and older, positioned themselves against these imageries of the less known, by declaring how they or Somali people “now know better” and are opposed to FGC. Aalihya  clarified:Back then [in Somalia], you thought that [pharaonic] was required by religion, so we thought that what they say must be right—it [FGC] must be good. But then when we came here [to Sweden], and you became older, you have talked a lot about sex and stuff in class, and you have studied more religion and seen that it's not permitted.From the position of a “now better-knowing” self, participants described themselves, parents, or the wider Somali community, as having acted according to what they thought was in the best interest of the child and/or in accordance with religious teachings. Rukhaya  said:that educated that she knew what was right and what was wrong, so that's why we can't say to her “you didn't do good.”Now when we know it's not allowed in the religion, we [sisters] say to our mom “look what you have done” … but she's not so knowledgeable about religion so that she can tell exactly what is right. … she's not As Rukhaya drew on personal experiences, she also talked back to dominant Western narratives including the character of the evil villain or the uncivilized in a barbaric-civilized binary. Instead, the emphasis in her and others' accounts was on FGC as an act of care by loved ones. Drawing on discourses on what constitutes good parenthood and good religious practice, FGC was made sense of as rational given previous cultural scripts. Accordingly, participants staked out moral positions of being a good parent, having good intentions, or being a good Muslim acting in accordance with moral discourse. This could be interpreted as a way to accommodate both previous cultural scripts that required FGC, positioning it as desired and a social norm, and to the new position of opposition toward the practice and as something that is undesired and should end.Few participants spoke explicitly about stigma; however, the accounts showed how they navigated and related their experiences in different ways in relation to FGC being a stigmatized experience in Sweden. Few claimed to have taken part in FGC information through Swedish news media, TV, or newspapers; and only a few participants explicitly referred to “the media” as a source of stigmatizing messages about FGC. Instead, most related to an indirect, subtle, and internalized experience of stigmatization, given that FGC is not a social norm in Sweden.Some shared experiences of feeling stigmatized in relation to the criminalization of FGC. In an FGD with older women, they continuously referred to an anecdote about a Somali family in their hometown. The story went, as told by a woman in her 50's.:The daughter in primary school had told her teacher they would visit her family in Somalia during the summer. Suddenly the family was called in by the school nurse who had reported to the social authorities for fear of future genital mutilation. Social services told the mother they were not allowed to mutilate their daughter and they had to sign a paper to confirm they had received the information. “Not all Somalis want to circumcise their daughters, you know,” the women told me. “You feel suspected and haunted in a way, even though you're not approving of genital mutilation yourself.”Sometimes, as in the above example, accounts of stigma were related to safeguarding measures; however, such examples were rare. More often, experiences of stigmatization in relation to FGC were related to social aspects. The two sisters Maryam  and Bilan  came from a home where their parents had decided not to have any of their four daughters undergo any type of FGC. They related in an FGD:One time when I was in the store, a woman approached me... and she asked “why are you doing this [FGC]?” We said “it's a rule in our culture.” [She said:] “No, you must stop it, you must shout out to your country that this is no good” … and we didn't recognize the term [she used], but she showed us [cuts with her hands] so then we knew. [laughs]The older women's and the young sisters' accounts illustrate how they managed ideas from outsiders about them being secret upholders or proponents of FGC.Sometimes stigma was associated with the experience of having been exposed to FGC. When younger women talked about the stigma of carrying FGC, it was related to the prospects of getting married or having a partner. Yasmiin  accounted for how she navigated what she assumed to be Swedish-Somali boys' expectations in relation to marriage:When he asks if you are sunni or [pharaonic] and you're not sunni, he won't be happy … because this woman can't make you happy.Yasmiin based her reasoning on discourses about pharaonic cutting and diminished sexual pleasure learned in Somalia. Among older women, stigma in relation to having been exposed to FGC was particularly salient in relation to gynecological examinations. Women recurrently told how they at some point had felt different and alienated by healthcare staff during gynecological examinations. Older women expressed how they prepared for healthcare providers' preconceptions about FGC or strong emotional reactions. Here is an excerpt from an FGD:Luul: When they examine you, they cry.Khadiija: Saying, ‘I'm sorry this happened to you.'Luul: The nurses look [at you] and get all shocked.Khadija: You can tell they get sad.Luul: I'm afraid they will react like that.Interviewer: Afraid of their reaction?Khadija translates for Luul: Afraid that they will look, say stuff, the questions they ask, how much pain you feel.Participants repeatedly stressed that they sensed that FGC stigma was associated with the Somali group. A scenario often-cited was how young women—themselves, friends, or daughters—had been targeted by school nurses when seeking help for menstrual pain. Batuulo , who worked in a youth organization with anti-FGC advocacy and support in relation to FGC, related:I particularly encounter young women who tell me that they are treated in a [certain] way in the Swedish healthcare system, like “ah, maybe you'll have trouble giving birth because you're mutilated.” They say that without knowing, without having examined me, or just because I'm from this place [Somalia]—then they call me mutilated, just because I have menstrual pain, they'll bring this up [genital mutilation]. … so it's very dramatic.Many experienced that healthcare staff jumped to the conclusion that their symptoms were caused by FGC, regardless of whether having undergone any type of FGC or not. Most illustrative of this situation was probably the story of Filhan . She explained:I had appendectomy some years ago, but when I complain about still having aches, they sent me to the gynecologist to ensure it's not female circumcision. And I have already told [them]: I'm not [circumcised]! But they're like: “with these symptoms, it could be this [FGC]” … I have noticed among my friends from other countries, that they don't get these questions “are you genitally mutilated” … And [at the doctors] I'm like “no,” and they're like: “are you sure? Do you remember when you were a kid” and blablabla.In the case of Filhan, her story was not deemed trustworthy by the healthcare providers she encountered, as they kept insisting that her symptoms fitted their picture of FGC. What the girls' and women's stories also show is how they navigated outsiders' ideas about FGC where FGC stigma was attached to the women's bodies and Somali appearance, regardless of actual FGC experience. Batuulo related a situation in school where the teacher had targeted her in a general discussion about FGC:We had a teacher, and you could tell he wanted me to talk about it. “What do you think about this female genital mutilation?” I can see why he asked … but he singled me out … I told him it's not okay because I have noticed it only happens to Somalis, or Somali girls.A common comment about this situation was that “we cannot hide” from peoples' anticipations, referring to Somalia as a high-prevalent country of FGC. This association was endorsed and sympathized with by some and resisted by others. The advantage, some argued, is that FGC becomes acknowledged as a potential concern affecting the Somali group. Others talked back to representations associating Swedish-Somalis with FGC, for instance, by trying to detach FGC from Somali ethnicity by engaging in change talk (see previous section) or stating that it is not exclusively a Somali phenomenon. Yet, others expressed feeling stigmatized and sterotypified by service providers and others when “the first thing she [the nurse] asks when she looks at me: ‘Are you genitally mutilated?” as stated by Filhan.This study highlights how Swedish-Somali girls and women construct their stories about FGC in relation to dominant condemnatory discourses about “female genital mutilation” in their efforts to make sense of personal experiences. Personal experiences were narrated in relation to what participants assumed to be societal ideas about FGC, in particular in relation to notions of harm, agency/force, and victimization.talking through and talking back  identification seems available that can combine having undergone FGC with not necessarily feeling harmed. The exception was the young woman, Yasmiin. Drawing on discourses about health, religion, and modernity, the separation of pharaonic and sunna cutting seemed, for her, to provide a progressive, modern, and “whole” self-identity. On the contrary, for women with infibulation, there seems to be a repertoire of language and labels for self-categorization within the survivor or victim paradigm. Yet, the “mutilation” discourse—as implied by the very term mutilation—offers few other (positive) options for self-categorization other than maimed. Second, in efforts to end FGC, there has been a tendency to emphasize “worst case scenarios” Obiora, ; p. 53 oTelling Sexual Stories, sociologist Ken Plummer . Written informed consent for participation was not required from the participants in accordance with the national legislation and the institutional requirements. Participants gave verbal informed consent at the beginning of their interviews, which was documented by audio recording.BE funded, administered, designed the project, and edited and revised the manuscript for intellectual content. EE and CH supervised the manuscript, contributed to the conceptualization of the analysis, and edited and revised the manuscript for intellectual content. CP designed the research, conducted and analyzed the qualitative data, and wrote original draft and edited and reviewed the manuscript. All authors have read and approved the final manuscript.


Results showed that morning negative affect could be strongly predicted based on previous evening negative affect, whilst this carry-over effect was not observed for positive affect, indicating that negative affect shows a general tendency to persist overnight, while positive affect did not show such continuity. The overnight prediction of both negative and positive affect was not moderated by level of depressive symptoms, nor by subjective sleep quality.Emotions show a certain degree of continuity during the day, a quality referred to as emotional inertia, and that is typically elevated in depression. Little is known however about the extent to which our emotional experiences may or may not also persist overnight. Do our feelings continue from evening to morning or not? And how is this related to depressive symptoms and sleep quality? In an experience sampling studies in healthy subjects ( What does a night’s sleep do to how we feel? Do our feelings continue, or do they not after a night’s sleep? This question is important to understand the impact of sleep on our emotional life, and how this may contribute to emotion disorder like in depression. Using smartphones, we measured people’s positive and negative feelings in the morning and evening, and examined how a person feels in the morning can be predicted by how they felt the evening before. We found carry-over effects from evening to morning for negative emotions, but not for positive emotions. These carry-over effects were unrelated to depressive symptom level or subjective sleep quality. Future research should be more considerate about this interplay between emotions and sleep.How we feel emotionally throughout our daily lives seems to be mostly continuous in nature, as if one feeling state seamlessly blends into the experience of the next one. However, the only part of our lives where this may not be the case, is during our night’s sleep. When we wake up after a night’s sleep, do our emotions continue from the evening before, leading our emotional state from that time to be the best predictor of how we feel in the morning? Or is there no real relation between how we feel when we go to sleep and when we wake up the next morning? The answer to this question has crucial implications in light of understanding the interplay between emotion and sleep, as well as their role in mental health, and will be the central focus of this study.Emotional continuity is typically studied in terms of emotional inertia. Emotional inertia is defined as the degree to which a person’s current emotional state can be predicted by their previous emotional state (captured by the autocorrelation) . When inThe concept of emotional inertia has almost exclusively been studied during the daytime. Consequently, research on the topic of overnight emotions is very limited. Only recently, Minaeva et al.  investigAs far as we know, there is no direct empirical evidence addressing this question. It is also not known what the laymen’s opinion is on the continuity of overnight emotions. To address this, we performed a short survey in a convenience sample of 111 participants in which we asked whether positive and negative emotions tend to continue after a night’s sleep or rather return to a setpoint . To interpret the size of the prediction, we will compare this prediction to the opposite scenario, where evening mood is predicted by that same day’s morning mood across different days of measurement. This overday prediction spans a similar time difference as overnight emotions, with the important difference that people live an awake life in between with all types of possible emotional stimulation one encounters. Our second research question is whether the morning mood of people with higher levels of depressive symptoms can be predicted more strongly based on their mood in the evening (showing higher levels of overnight inertia), compared to people with lower levels of depressive symptoms. Our third research question is whether after a night with worse self-reported sleep quality, negative affect will be predicted more strongly and positive affect less strongly, whereas after a night with better self-reported sleep quality, positive affect will be predicted more strongly and negative affect less strongly.beep. Additionally, every morning, participants indicated their subjective sleep quality of the past night. Based on this data, we examined the within-person prediction of morning mood by evening mood (and vice-versa), and whether this is moderated by person-level depression severity and day-level subjective sleep quality.To answer these questions, participants’ level of depressive symptoms were assessed at baseline by means of the Center for Epidemiologic Studies Depression Scale (CES-D) . Next, pAlthough Minaeva et al.  providedConcretely, we investigated separately for positive and negative affect to what extent: (1) a person’s evening affect can be predicted based on his/her morning affect , (2) a person’s morning affect can be predicted based on his/her previous evening affect , (3) there is a difference between the prediction after a night compared to a day (cfr. research question 1), and (4) this is a function of depressive symptoms (cfr. research question 2) or (5) subjective sleep quality (cfr. research question 3).Participants were recruited by means of a public message on Facebook, asking for participants in a study on sleep and emotions . This resulted in a sample of 127 Dutch-speaking participants, located all over Flanders, Belgium. Four participants were excluded because their compliance was less than 50%, therefore the final sample consisted of 123 participants. All participants had a chance to win one of five gift vouchers of Bol.com, worth 20 euros each. This study was approved by “Privacy and Ethical Review” . Descriptive statistics are presented in Minterval = 11.82 h; as such, the interval in between two measurements was kept constant and identical for overday and overnight prediction, even though the exact timing could be chosen by the participant to fit their daily routine), for a duration of 14 days. Participants were able to choose the daily start and end times of the ESM sampling schedule that corresponded best with their sleep schedule, in order to reduce the time difference between the scheduled beeps and participants’ wake up and sleep time. Compliance was high . After completion, participants were debriefed about the main goals of the research and thanked for their participation.Because of the COVID-19 pandemic, the entire procedure was carried out online. To begin with, participants received a private message or an e-mail containing the informed consent and the instructions to install and configure the m-Path app . They weα = .93.The CES-D  was admihappy, relaxed, energetic, peaceful, enthusiastic, satisfied, angry, down, unsatisfied, stressed, tired, and sad. The mean score of the first six emotions resulted in a measure of positive affect, whereas the mean score of the latter six emotions resulted in a measure of negative affect. Within-person reliability of positive affect was .77, whereas the between-person reliability was .95. For negative affect, the within-person reliability was .56, whereas the between-person reliability was .96. Additionally, the first beep of the day asked to indicate their sleep duration on a slider ranging from 1 (‘Enough’) to 4  and sleep quality on a slider ranging from 1 (‘Good’) to 4 , both derived from the Athens Insomnia Scale (AIS) [The ESM questionnaire asked participants to indicate on a slider ranging from 1  to 100 (“Very much”) how much a certain emotional label applied to their state at the moment they received the beep. Based on the 12-Point Circumplex Structure of Core Affect, construed by Yik et al. , the 12 le (AIS) . The itele (AIS) , while ble (AIS) . The firDummy evening (E) specified whether a beep occurred in the evening (1), or not (0), whereas dummy morning (M) specified whether a beep occurred in the morning, after a night of sleep (1), or not (0). By introducing a dummy variable for each category (day and night), the coefficients are each interpreted as testing whether they are different from 0 (i.e. estimation), as opposed to traditional n-1 dummy coding where they are interpreted as being relative to a baseline (i.e. hypothesis testing). In the multilevel models, the level-1 predictors were person-mean centered and level-2 CES-D scores were standardized. Significance was tested against an alpha of 0.05. The descriptive statistics of all used measures are presented in Given the nested nature of the data, namely beeps nested in persons, we performed multilevel analyses using the lme4 package for R . To be aFor both positive and negative affect, we constructed a series of five linear multilevel (mixed-effect) models to test our predictions , suggesting that there is not significantly more or less continuity of negative affect during the night than during the day. In addition, the difference between dummy evening and dummy morning was not significant , indicating that no significant diurnal effects were found for negative affect.First, we found that negative affect in the morning significantly predicts negative affect in the evening (Model 1), and vice-versa, that negative affect in the evening significantly predicts negative affect the next morning (Model 2). These results imply that negative affect is self-predictive, both after a day and a night’s sleep, showing evidence for continuity of negative affect. The difference between the autoregressive effect after a day and after a night’s sleep was not significant , nor after a night’s sleep (Model 5). This indicates that the prediction of negative affect is not stronger for individuals with higher levels of depressive symptoms.Third, regarding the moderation by subjective sleep quality, the interaction between the autoregressive effect of negative affect and sleep quality was not significant, both after a day (Model 6) and after a night’s sleep (Model 7). These results taken together suggest that there is no association between negative affect and sleep quality.z = 0.70, p = .49). The difference between dummy evening and dummy morning was not significant , indicating no significant diurnal effects.Firstly, no significant effect of positive affect was found, neither after a day (Model 1), nor after a night’s sleep (Model 2). Combined, these results suggest that positive affect is not continuous during both day and night. However, when predicting positive affect with the combined model (Model 3), a significant effect was found during the day, as well as after a night’s sleep. Moreover, continuity of positive affect during the night and during the day did not significantly differ  and after a night’s sleep (Model 5) were both not significant. This suggests that positive affect is not more continuous in individuals with higher levels of depressive symptoms.Thirdly, regarding the moderation by subjective sleep quality, no significant interaction was found between subjective sleep quality and positive affect, both after a day (Model 6) and a night’s sleep (Model 7). These results combined, suggest that there is no significant association between positive affect and subjective sleep quality after a day, as well as after a night’s sleep.This study aimed to investigate, first, whether across multiple days people’s mood in the morning, after a night of sleep, can be predicted based on their mood of the evening before. Second, we examined whether people with higher levels of depressive symptoms’ mood in the morning, can be predicted more strongly based on their mood in the evening, compared to people with lower levels of depressive symptoms. Third, we examined whether after a night with worse self-reported sleep quality, negative affect can be predicted more strongly and positive affect less strongly, whereas after a night with better self-reported sleep quality, positive affect can be predicted more strongly and negative affect less strongly.Regarding our primary research question, we found evidence to conclude that people’s negative affect in the morning, after a night’s sleep, can be predicted based on their negative affect from the evening before, implying that negative affect shows continuity overnight in a sample of healthy individuals. The same cannot be concluded when it comes to positive affect, however. Namely, after a night’s sleep, positive affect does not strongly predict itself based on the previous evening, signifying that positive affect is not continuous overnight. These conclusions remain the same when considering daytime inertia. This result for overnight negative emotions links up with literature indicating that emotions tend to color our experiences and perceptions of the outside world in a mood-congruent way. Although this has been found for both positive and negative emotions (e.g. ), this mRegarding the second research question, no moderation effect of level of depressive symptoms on the continuity of both positive and negative affect was found, neither during the day, nor after a night’s sleep. Specifically, people with higher levels of depressive symptoms’ mood in the morning, cannot be predicted more strongly based on their mood in the evening, compared to people with lower levels of depressive symptoms. This could also be inferred from the study by Gordijn et al. , who repRegarding the third research question, the results did not indicate a moderation effect of sleep quality on the continuity of neither negative nor positive affect, both during the day and after a night. This means that after a night with worse self-reported sleep quality, negative affect will not be predicted more strongly and positive affect will not be predicted less strongly, whereas after a night with better self-reported sleep quality, positive affect will not be predicted more strongly and negative affect will not be predicted less strongly. This is again in line with what we expected based on the findings of Minaeva et al. . Indeed,Even though the current study accounts for several of the limitations of previous research, it has certain limitations as well. Firstly, while a 12 h time period in between observations was chosen to enhance the comparability of overday and overnight emotion prediction, in fact people are usually awake for more than 12 h a day. It is therefore possible that an event with a considerable emotional impact happened before the first observation in the morning, or after the last observation in the evening, influencing subsequent emotions. Future studies should take more care of making sure that participants report on their affective state right before going to sleep, and as soon as possible after they wake up. Secondly, we examined a relatively healthy, young, western sample of participants. While Minaeva et al.  accounteIt is necessary to point out that in the current study we did not consider  circadian rhythms, which have previously been found to interact with mood regulation . For insIn conclusion, in this study we asked the question whether our emotional experience in the evening continues after a night’s sleep. The answer to that question in healthy subjects is that negative affect seems to persist overnight to at least some extent, whereas positive affect more likely resets, and these findings are independent of sleep quality or depressive symptom level.zpac048_suppl_Supplementary_AppendixClick here for additional data file.


Myocardial infarction (MI) is a debilitating condition and a leading cause of morbidity and mortality worldwide. Digital health is a promising approach for delivering secondary prevention to support patients with a history of MI and for reducing risk factors that can lead to a future event. However, its potential can only be fulfilled when the technology meets the needs of the end users who will be interacting with this secondary prevention.We aimed to gauge the opinions of patients with a history of MI and health professionals concerning the functions, features, and characteristics of a digital health solution to support post-MI care.Our approach aligned with the gold standard participatory co-design procedures enabling progressive refinement of feedback via exploratory, confirmatory, and prototype-assisted feedback from participants. Patients with a history of MI and health professionals from Australia attended focus groups over a videoconference system. We engaged with 38 participants across 3 rounds of focus groups using an iterative co-design approach. Round 1 included 8 participants , round 2 included 24 participants , and round 3 included 22 participants .Participants highlighted the potential of digital health in addressing the unmet needs of post-MI care. Both patients with a history of MI and health professionals agreed that mental health is a key concern in post-MI care that requires further support. Participants agreed that family members can be used to support postdischarge care and require support from the health care team. Participants agreed that incorporating simple games with a points system can increase long-term engagement. However, patients with a history of MI emphasized a lack of support from their health care team, family, and community more strongly than health professionals. They also expressed some openness to using artificial intelligence, whereas health professionals expressed that users should not be aware of artificial intelligence use.These results provide valuable insights into the development of digital health secondary preventions aimed at supporting patients with a history of MI. Future research can implement a pilot study in the population with MI to trial these recommendations in a real-world setting. Myocardial infarction (MI) is the leading cause of morbidity and mortality globally . ExperieKey protective factors for MI include smoking cessation, increased physical activity, and a healthy diet . HoweverDigital health has become an increasingly feasible modality for implementing behavior change support in a clinical population in a cost-effective manner ,10. It cmHealth, a subset of digital health, is a highly used health care tool owing to its intuitive implementation, with most people in Western countries owning an mHealth device . mHealthKey barriers to the adoption of digital health are a lack of technology usability and user involvement during the design of the technology . One wayThis approach to intervention development is known as co-design or participatory research . The folOur study, deemed MiSmartHeart, aimed to identify the core needs of patients with a history of MI in the context of the prevention of subsequent MI events and explain how these can be addressed using features of a digital health solution, as identified by both patients with a history of MI and HPs.The MiSmartHeart study used a qualitative and iterative approach to refine the essential components of MI secondary prevention informed by end users. This study uses similar co-design applications as those reported in the specialized co-design literature ,30. For Round 1 was titled “consumer needs.” In this round, we attempted to determine what the overall population needs are by discussing real-world issues with involved parties, that is, patients with a history of MI and HPs. Round 1 was broad and exploratory, and the findings were consolidated by identifying overarching unmet needs. The results of this round led to an initial conceptual design developed by the research team.Round 2 was titled “desired functionalities,” and it involved obtaining more information about the core unmet needs identified in round 1 and methods to address these needs. Participants were shown visual conceptual designs created based on the advice from round 1. The research team explained to participants that these designs were intended to relay core concepts of possible digital health features identified in round 1, rather than depicting a visual mock-up of a designed intervention. Round 2 was more structured and less broad than round 1, as the discussion focused on elaborating on a few key unmet needs identified in round 1. The research findings were consolidated by identifying categories and subcategories and drawing conclusions into a simulated design. The results of this round led to the creation of an in-depth simulation displaying each feature of the proposed app to be discussed in the next round of FGDs.Round 3 was titled “simulation-informed feedback,” and it involved providing an example simulation to generate new ideas to address the problem and to gain additional feedback. The results of this round provided a comprehensive overview of the additional features and functions needed in a self-management app to support patients with a history of MI. These insights are broad and not bound to the key unmet needs elaborated on in round 2. These insights can be integrated into a fully digital health intervention. The key anticipated outcomes for each round have been described in A total of 38 participants were recruited across the 3 focus group rounds, with 11 participants recruited in multiple rounds. Inclusion criteria were (1) aged ≥18 years and (2) self-reported experience of an MI for which they were subsequently hospitalized or self-reported involvement in the care of patients with a history of MI. Participants were excluded if they could not speak English, did not reside in Australia, or did not own a device to allow communication with the research team .Round 1 included 8 participants (4 patients with a history of MI and 4 HPs). As this round was primarily intended as an initial scope to enable further exploration in future rounds, this sample size is within acceptable standards for the exploratory stages of co-design according to the specialized literature . Round 2We intended to recruit both new and existing participants in the study for various reasons. First, existing participants were needed in the study to amend or confirm that our representation of their advice from the previous round was accurate and achieved its intended purpose. However, new participants were recruited to reduce the potential for participant bias, that is, confirming the outcome because it is based on their advice rather than critiquing the outcome of their advice. New participant recruitment was also needed for a greater likelihood of generating new ideas and concepts that were not explored in the previous rounds. Amending and confirming previous participant advice with newly recruited participants provided more reliability in that the shared ideas represent opinions held by this population.This study was conducted between November 2020 and December 2021. The researchers conducted data analysis and obtained the results after each round to implement insights into the following round.Researchers conducted FGDs and qualitative interviews with patients with a history of MI and HPs . Participants were people living in Australia who were aged ≥18 years. Eligibility criteria was as follows: the patients with a history of MI must have a history of hospitalization for MI and HPs must have experience treating patients with a history of MI. Participants were consecutively sampled with either web-based advertisements on various cardiology-focused Facebook pages and social media websites, or in person, with flyers delivered to cardiology clinics and assisted living villages in Victoria, Australia. Advertisements prompted participants to fill out an expression of interest form, after which the researchers emailed the participants. Participants had no prior relationship with the researchers but understood that the study was a part of PhD research concerning behavior change.Semistructured FGDs and interviews were also conducted. FGDs were organized based on availability, with FGDs preferred over interviews to allow the exchange of ideas between participants. If the participant schedules did not align or they did not feel comfortable speaking with other participants, an interview was conducted instead. FGDs and interviews were delivered on either Zoom (Zoom Video Communications), a popular videoconference system, or a phone call with the participant if they could not use Zoom. All attendees in these FGDs and interviews were recruited as participants for this study. A question guide was created based on the research team’s expert knowledge of digital health, behavior change, and cardiovascular disease. The question guides from rounds 2 and 3 were created considering the advice provided from the previous round, with an emphasis on exploring the previously mentioned topics with more granularity. The full question guides outlining discussion topics for each round are available . FGDs weThe Monash University Human Research Ethics Committee approved this study , and all participants provided informed consent. Participants were reimbursed with an Aus $30 (US $19.12) shopping e-voucher. All data was deidentified upon data analysis and writeup.Our descriptive data analysis involved a flexible approach, which was found to be effective in obtaining rich data . The quaMultiple iterations were performed to determine which groups of categories were the most representative of the data. Each category consisted of subcategories (grouped codes under a category). When a consensus among the 2 researchers  was reached, key data were extracted into an Excel (Microsoft Corporation) sheet based on these key categories and subcategories. From here, categories were sorted from the most common to least commonly mentioned, which was used to prepare the results. The frequency of each category for each patients with a history of MI and HP group, along with illustrative quotes from the participants, was included.technology functions, (2) social, (3) user needs, and (4) user characteristics (n=133). HP discussions fell under four different categories: (1) technology functions, (2) HP involvement and research, (3) technology format, and (4) user characteristics (n=65). These were sorted from most commonly to least commonly mentioned. Feedback from round 1 (consumer needs) informed the discussions planned for the subsequent round 2 . The subcategories for each round are listed under each category (Discussions for patients with a history of MI fell under four primary categories: (1) category . A detaitechnology functions most extensively concerning artificial intelligence, notifications, personalization, and rewards (n=47). Patients with a history of MI mentioned that they would trust the general advice provided by artificial intelligence but would check specific advice with an HP:Patients with a history of MI discussed Does this tablet interact with something else? Asking a chat bot would be fine because they would know...if it’s something a little bit more to do with you personally I think you’d want to rely on a health professional rather than chatbots.patient with a history of MI 1, interviewNotifications were recommended primarily for medication and should be personalized according to users’ clinical characteristics, such as time since the MI, and users’ performance on the app, such as the rate of goal achievement. Points should be used in a rewards system, and patients with a history of MI explained how social competition and fundraisers can increase intrinsic satisfaction:It gives me little stars and rewards...you could get money or raise money or anything like that, but it was displayed on your page I guess for anyone who was sponsoring you to see.patient with a history of MI 2, interviewsocial elements regarding family, friends and the community, and HP care (n=30). They expressed a need for support groups and peer support, which are currently unmet: “You could find people in your area to go on a walk or you could find a local sports club” . Patients with a history of MI would use an interface with no HP interaction and would like the option to set reminders about what to ask their HP on their next visit. When asked if they would use a technology without HP interaction, 1 participant said, “You know, that would be good,” and later, “when you go in there you just blank out, you know when you go and see a medical professional” .Patients with a history of MI discussed user needs, including intervention modality, barriers, education, and tracking (n=30). Most patients with a history of MI preferred a simple app modality over other modalities because of its convenience. Barriers included the user’s technical ability to set up and use an app, containing relevant information for individual users, and the user’s motivation:Patients with a history of MI also discussed It was just so complicated. I just didn’t have the strength or the ability to go out and try and work out how to use an Apple Watch and then coordinate it to my heartbeat and then send it to him. So that was all in the too-hard basket.patient with a history of MI 4, interviewEducation on the effects of surgeries and medication, risk factors, exercise, cardiopulmonary resuscitation, and diet guidelines and the next steps in the users’ journey were identified as a facilitator for app use: “Sodium and stuff like that, what are good, what are levels sort of OK to have?” . Tracking was highly emphasized, including sleep, pain symptoms, medication, diet, exercise, smoking, pulse, oxygen levels, steps, calories, blood pressure, cardiac blues and mood, and weight.user characteristics, including the age of users, state of mind, and statistics of a future MI (n=26). Patients with a history of MI advised that some older adults would not have an issue with technology use and that experiencing an MI is often motivation enough to change negative lifestyle behavior:Finally, patients with a history of MI advised on It’s really hard in terms of like motivating, without having had...that big scare.patient with a history of MI 2, interviewEverything is going is all digital...look at it more rather than if you go and gave them a pamphlet.patient with a history of MI 1, interviewPatients with a history of MI were keen to receive statistics concerning the risk of recurrent MI episodes to stimulate behavior change. They would also welcome prompts that emphasize the need for behavior change in addition to surgical and medication treatments. Patients with a history of MI emphasized extreme depression, anxiety, and loneliness after their MI:A lot of anxiety that people may have never had, especially when you learn to be on your own after a heart attack and you’ve got to be prepared if you have another one...the people who are alone might need that extra support.patient with a history of MI 4, interviewtechnology functions most extensively regarding the use of artificial intelligence; rewards; personalization; tracking; and provision of education and support from family, friends, and the community (n=36). Some HPs were unsure whether patients with a history of MI would understand artificial intelligence: “I think 50/50 [would use artificial intelligence]...I think we give the person the choice” . They suggested catering to education levels by providing relatively easy content to understand. HPs suggested that a family member of a patient with a history of MI can be made into a “champion” over the app, where they can keep track of the user’s health goals. Patients with a history of MI can have a “champion in their app that they connect the patient to one of your family or friends and they get like a very good message, supportive and motivational from their supporters, from their champion. This is one of the ways that we can like reinforce their behaviour change as well” . An incentives program would motivate patients with a history of MI with rewards, including a fruit hamper or a personal training session. The app should be personalized based on time since MI and specific user goals:HPs discussed The most important element is time. What sort of information or education the person needs in the first 24-48 hours after discharge...[where] we do expect recurrence of the heart attack much more than what would happen in the months after.HP 3, FGDHPs mentioned that tracking capabilities should include a digital Webster pack and daily diary.HP involvement and research were discussed, including communication with an HP and using a theory-based approach (n=11). They emphasized the importance of the output being clinically sound and interpretable by HPs: “It should be clinically sound and logical, so the information they get should be meaningful and interpretable by a healthcare professional” . They also suggested that theoretical approaches are necessary, such as the “diffusion of innovation theory” , which tailors different approaches to patient technology adoption behaviors  time of 45 minutes that you already plan, it’s like someone is cutting a tree, that it makes you somehow guilty.HP 4, FGDuser characteristics should be considered in app development, such as socioeconomic demographics, older adult population, comorbidities, and users’ state of mind (n=9). To make the app affordable for all socioeconomic groups, developers should consider whether subscriptions or one-time purchases are appropriate. Some older adults would need to be guided on how to download an app. HPs stated that health needs should be determined based on each user’s comorbidities, and self-care, uncertainty, and mental health symptoms such as health-related stress should be supported. It is common that patients with a history of MI will “not know what to do about the condition. Frightened to ask for more care. Lacking confidence and continuing to be independent” .Finally, certain social, (2) app development, (3) mental health, and (4) artificial intelligence. These were sorted from most to least commonly discussed. These categories were applicable to both patients with a history of MI (n=230) and HPs (n=256) because the targeted line of questioning was designed to elicit specific and detailed responses.The advice from round 1 (consumer needs) was discussed with patients with a history of MI and HPs concerning round 2 . In round 2, we walked participants through a conceptual design and asked for specific advice about features that were emphasized in round 1, such as social support. Example screenshots of this design are available in social support features, including the creation of a “champion,” discussion forum, success stories, and support groups (n=76). Patients with a history of MI preferred the term “buddy” to champion, stating that a buddy should have experienced an MI and can communicate with the user over the app:Patients with a history of MI detailed Somebody who’s actually had the experience, because my wife’s holding me accountable. She doesn’t understand how I feel half the time.patient with a history of MI 5, FGDAn artificial intelligence buddy was suggested for users who wanted only information and reminders rather than a personal connection: “If you want total objective-type support then an automated agent would be really good” . Patients with a history of MI had a high interest in the discussion forum, suggesting filtering discussions based on conditions and receiving personalized notifications about liked threads. They mentioned the importance of short success stories and support groups with consistent scheduling systems. Patients with a history of MI preferred the support groups to be structured with presentations from HPs, followed by a patients with a history of MI–led question and answer session:I would prefer the presentation and then people can join in and ask questions...that will really get people talking.patient with a history of MI 2, interviewapp development, including additional features, development, app features, and collaboration (n=57). Additional features include explicit references to personalization capability, links to social media, journaling functions, and further tracking features, including blood pressure, oxygen, subjective pain, and other sicknesses. Patients with a history of MI expressed the need for developers to store large files on a server or YouTube to reduce phone storage requirements: “Make the app not chunky with megabytes...there’s premium space on a lot of phones” . Features included downloading a report to show their HP and GPS tracking for the user to avoid their personal, habitual smoking or alcohol locations. One patient with a history of MI said the GPS tracking can inform users to “‘Quit, turn around. Go the other way. Avoid at all costs.’ Probably a warning of some form could pop up” . Finally, collaborating with a corporate partner would facilitate app development and rollout.Patients with a history of MI discussed mental health, including additional features, lived experience, mental health states, and tools (n=51). Additions include fun exercises that can raise mood, progressive muscle relaxation to improve sleep, and encouraging hobbies : “‘Have you done your exercises today?’ just because you know, that releases the endorphins or something and makes you feel good” . Patients with a history of MI stated that isolation is particularly anxiety-inducing because of the looming fear of death. Along with anxiety, patients with a history of MI mentioned other mental states that should be addressed, including mood, depression, social uncertainty , sleep, maintaining positivity, mortality, and memory loss: “A lot of it’s the focus on how do you cope with your condition? But we have to think about the people we interact with, how they cope with the condition?” . Mental health modules should address these issues and can be organized based on the lived experience. Mindfulness exercises should emphasize the perception of the body and heartbeat so that patients with a history of MI can notice heartbeat abnormalities. Mindfulness of the body can help patients with a history of MI to “go and get help earlier. Probably a simple equation, you know something’s not right and get it fixed. Get it looked at and in doing that, that’s what saved my heart muscle” .Patients with a history of MI spoke about the importance of artificial intelligence was discussed, including behavior patterns and a chatbot (n=46). Visualizing user patterns of behavior can motivate improvement, with diet, exercise, mental health, smoking, and drinking identified as the most important to visualize. Patients with a history of MI are willing to use the chatbot, particularly for subjectively uncomfortable or embarrassing questions that they would not ask an HP. For example, asking “a question you think is a really dumb question, or you’re not sure. You can start with the chatbot and you get a response and you don’t feel like you’re embarrassing yourself because it’s just a machine” . The chatbot should use links and information from trusted sources and should mostly answer general questions, “as long as they’re not sending me links to Wikipedia” . Patients with a history of MI stated that it should be adaptive, for example, if a low mood is recorded, it should suggest an intervention for low mood. However, patients with a history of MI would seek an HP’s opinion regardless of the chatbot, and there is a concern that the chatbot may not understand the user’s questions: “If I get stuck in a vicious cycle, the chatbot should somehow be configured to understand that it’s caught in a loop...then issue an alternative resource link or number” .Finally, social support, including additional features, a “champion,” a discussion forum and a support group (n=95). Additions include outdoor activities such as park runs and promoting healthy restaurants to try with friends. HPs labeled the “champion” as a “buddy” who should undergo training, have a positive attitude toward change, and be matched to the user based on needs. This can include the “opportunity to have a little bit of training about motivational interviewing, etc. Like, you don’t want someone saying, ‘Oh, you know, that’s hopeless. How come you started smoking again?’...maybe they’d have access to a ‘be a champion app,’ which would give them hints what to do when someone’s not achieved a goal” . They suggested that users can find a buddy from the support groups or discussion forums rather than appointing a family member  or use the chatbot as their buddy. They emphasized the need for a disclaimer on the discussion forum for potential misinformation and the ability to flag an item to be removed. The support groups should be a combination of (1) an open forum to share experiences and (2) presentations from an HP with a question-and-answer session. There should be group polls to choose discussion topics and a calendar for these recorded sessions running with an HP moderator: “Ahead of [the] week, we can ask them couple of questions and ask them which topic they prefer to talk in the next session” . The app should include an introductory recorded session to encourage users to participate.HPs detailed app development including additional features or changes, legalities, other organizations, and the use of app features (n=66). Additions include a simple daily plan, blood pressure tracking, a monthly report, and a road map for the future:HPs discussed Having that long-term vision and knowing that they’re on the right pathway and they’re doing the right things can be really beneficial. I’m all for having a really clear plan.HP 6, FGDHPs advised on further visual appeals, such as larger headings and videos. HPs emphasized privacy regulations and consent if support groups are recorded and suggested involving cardiac rehabilitation staff for advertisements:People aren’t going to stumble across it. Yeah, and maybe you should think about getting it as endorsed as a product through ACRA or Heart Foundation or linking with some of those organisations so that people are actually channelled there.HP 6, FGDGPS tracking to avoid the habitual smoking or drinking locations of patients with a history of MI is very novel and could be useful with large warnings to alert the user when nearing these locations.artificial intelligence, including behavior patterns and a chatbot (n=49). Artificial intelligence should not be labeled or obvious to users. Personalized behavior patterns are likely to be used and should report on overall health, for example, patterns for chest pain symptoms and types of exercise. HPs suggested that the chatbot should both (1) enable specialist appointment booking and (2) answer both general and specific questions tailored to the user. The addition of an avatar can make the chatbot more personable: “Have an avatar and make it look like a person” . Overall, many patients with a history of MI will not completely trust the chatbot but may use it:HPs discussed To me a chatbot is another tool in a large toolbox, so people may not use it. You don’t need a screwdriver every single day. But you may need a screwdriver one day, and if you know how a screwdriver works, then you will refer back to it.HP 3, interviewmental health, including mental health states, support from family members, tools, and usefulness (n=46). Patients with a history of MI can struggle with mental health more than with physical health:Finally, HPs discussed Being in cardiac rehab for the many years...this is the biggest part of it. Now, it’s going to always be more mental than physical.HP 8, FGDThe feelings of patients with a history of MI of being broken, uncertain, and alone, along with the effect of quitting smoking and a changed sex life, should be addressed. HPs stated the app should support family members, who may also experience declined mental health, with dedicated modules :Cover family emotions as well...because there’s often been a bigger event for the family than it has been for the client, which sounds funny, but it’s because they obviously don’t remember any of it. Whereas, the family, say a wife who’s witnessed it, or maybe done CPR and stuff like that, it’s been a really horrific event for her.HP 9, interviewMental health modules should have problem-focused outcomes based on the experiences of patients with a history of MI. HPs stated that mindfulness exercises should be tailored to mental health states, for example, different audio recordings for depression and anxiety. Overall, mental health was highly regarded by the HPs.barriers and solutions, (2) app use, (3) engagement, and (4) suggestions (n=286). Whereas HP discussions fell under three categories: (1) development and rollout, (2) novelty effect, and (3) concerns (n=96). Feedback from round 3 is listed in subsequent sections, sorted from most to least commonly discussed.The advice provided from round 2  was extrapolated into a simulated design that was critiqued in round 3 (simulation-informed feedback). In round 3, we showed participants a mock-up prototype that they could interact with and asked for advice about features that apply to the full application, such as engagement features. The information derived from round 3 is presented in the following sections. Results from the patients with a history of MI were displayed in four primary categories: (1) barriers and solutions to these barriers, including complexity, privacy, encouraging app use, and motivation (n=112). Patients with a history of MI suggested gradually introducing new features based on progress, for example, “Somebody who started off perhaps with the simple concept, once they got the hang of it and became familiar with it and comfortable, would then step up to the next level” . Users should be able to choose a specific page that automatically loads every morning. Patients with a history of MI mentioned that upon setup, the app should ascertain features that users would use and only display these features. Push notifications can be used especially during extensive idle periods, for example, “It’s been a month since you last did a health check. Would you like to go to the to the quick check page?” . Organizational health sponsors can provide patients with a history of MI with a percentage of their product if goals are achieved.Patients with a history of MI discussed app use, including its features and functions (n=101). Many web-based resources are based on standards from other countries, for example, the United States; Australian standards and education are required: “It’d be good to have an Aussie one because the nutritional information is quite different” than American information . Patients with a history of MI mentioned that their family members and carers should have their own app log-in to receive relevant support and education. Correlational graphs could show the link between biometric health data and activity levels or medication use:Patients with a history of MI also discussed So just being able to add different things into this section is good as well...then it shows you know, if you’ve missed a tablet, the effect of missing that tablet is your blood pressure goes up.patient with a history of MI 13, FGDengagement, including competitions, gamification, and rewards (n=51). Patients with a history of MI were unsure if they would compete with a large group. Rather, they would play a game or a competition against themselves or a buddy. The app should provide participation achievements rather than specific outcomes  because “everybody’s different in their ability, in what they’d be able to do” . Overall goal achievement across the app can mitigate negative self-talk, for example, “62% of users reach their food goals, gives you an indication that that’s okay. It’s literally only just over half. Therefore, the fact that I didn’t reach my food goals is probably not that big a deal. But by the same token, you know, hey, it’d be nice to be in that 62%” . Patients with a history of MI suggests that with consistent app use, the user can earn a gamified level, such as “guru,” displayed on the discussion forum. Rewards can include obtaining a percentage of certain brands, entry to a relevant health conference, or a one-on-one with the app’s HP:Patients with a history of MI spoke about increasing Medals are good, but they tend to have the lifespan is not great...in the long run, it’s just an achievement on an app...especially if you’re dangling like bigger, will say the carrot or fruit in front of it, you can have a one-on-one with a cardiologist...which is very, very valuable even the private system and in the public system.patient with a history of MI 13, FGDConcern that users would cheat led to a discussion on nontangible rewards. Nonmonetary rewards could involve expressive emojis, and medals were perceived as childish.suggestions, including added content to the app and technical changes (n=22). Content should include other contributors that affect physical symptoms : “It’s the inflammation [caused by] I think the variations in climate that we get from all in one day” . Patients with a history of MI suggested including a page for resources and emergency contacts for each user. The app should be relatively small and enabled to synchronize with the cloud, the phone’s calendar system, family members’ calendars, the Apple or Samsung Health app, Bluetooth devices, and other fitness apps. The app should allow the recording of heart rates for enabled phones.Patients with a history of MI provided additional development and rollout of the app, including the involvement of HPs, the likelihood of app use, and technical app development (n=39). An HP should be able to communicate with patients with a history of MI through the app for a check-up:HPs discussed the You know, building in those specialist follow ups, and maybe that would be something that when you talk about the journey, that that may be something that we could build into that journey as well, because it is able to be tailored and customized.HP 5, FGDThe app should be introduced during or near the end of standard cardiac rehabilitation and framed as ongoing support. The app can “be that sort of bridge for when people do finish [cardiac rehabilitation], that they’ve got somewhere else to go and you know, some of the options available to them” . HPs stated that patients with a history of MI can meet potential app buddies with others involved in cardiac rehabilitation, creating a personal connection. Notifications should decrease in frequency over time and be titrated to determine how often the patients with a history of MI complete their goals.novelty effect, including fostering engagement and integrating the app into the user’s lifestyle (n=33). Competitions without associated disappointment can foster engagement with the app, but if the leaderboard becomes demotivating, it can be removed:HPs discussed ways to overcome the My concern is for those people that are lower down on the leaderboard each time. Is that going to be something where they start to go, “oh, well, I’m not achieving like those people” and set them up for that disappointment.HP 5, FGDThe app should have the functionality to see friends’ activity levels to motivate the activity levels of patients with a history of MI. Points can tie in with a heart-healthy sponsor for discounts, but HPs are unsure whether patients with a history of MI require this external reward for effective behavior change. Upon installation, videos of a navigator should be used to guide new users through activities and modules. Patients with a history of MI “wanted somebody to guide them through what each stage meant, and what they would get out of it. So that they went into each section of [a] module and, perhaps the same for this, knowing what they expect to get out of it” . This navigator should be a “patient. It’s actually a consumer, consumer who’s guiding people through” . HPs suggested integrating goals on an adaptive figure of a heart that changes based on goal progress, for example, a healthy heart is displayed if goals are achieved.concerns, including interest, motivation, superfluous features, and the transition to technology (n=24). They suggested that a dedicated health care team presenting content not otherwise available would maintain the interest of patients with a history of MI in the app: “Are you actually going to be doing your own videos?...I think it’d be great if, yeah, as much as possible” . HPs stated that no features or functions are superfluous, although reducing manually entered information, visual clutter, and redundant notifications could maintain the interest of patients with a history of MI:Finally, HPs discussed No, I don’t think it’s overwhelming...I think it’s better to have more than less, I think sometimes you go on apps, and you think I’d just like to have this but it’s just not availableHP 10, FGDA companion website could simplify manual data entry, but the transition to technology will depend on each user with variability in affinity with technology. One participant asked if “you have to do it all on your phone, like you can’t go online and enter stuff in?...I’m just thinking practically, like, you’ve got people [that] don’t want to be typing on their phone” .This study aimed to specify the key needs identified by patients with a history of MI and HPs for the secondary prevention of MI using digital health technology. The results from the 3 rounds of FGDs provide rich information about the various primary needs of end users, the methods and structures on how to provide these needs in digital health technology, and the practicalities of rolling out the app to patients with a history of MI. We will organize the discussion of findings according to two main themes: (1) topics that patients with a history of MI and HPs agreed on and (2) topics on which patients with a history of MI and HPs had differing opinions. For theme 1, these topics included addressing mental health; the fit of the intervention within current health care ; and features of the app, including a focus on family members and engagement. For theme 2, these topics included a lack of social support and the use of artificial intelligence to deliver support. We start by discussing theme 1 in the context of prior research.Research emphasizes the impact of MI on the exacerbation of mental health problems and that decreased mental health can lead to poorer heart health outcomes ,35. HoweBoth patients with a history of MI and HPs agreed that incorporating the app during or immediately after cardiac rehabilitation would ensure the best likelihood of habit formation and long-term use of the app. A similar app provided directly after cardiac rehabilitation was able to demonstrate this habit maintenance and low attrition (n=2) after a 1-year follow-up, with improved peak oxygen uptake, exercise performance and habits, and self-perceived goal achievement in comparison with a control . ParticiBoth patients with a history of MI and HPs agreed that family members of patients with a history of MI are often neglected in postdischarge care. By incorporating app modules or a version of the app designed for family members with a focus on promoting education and mental health for these family members, they will be best able to provide frequent support to patients with a history of MI in their recovery journey. This need is reflected in previous research, in which cardiac rehabilitation educational programs for patients and family members have been theoretically developed . The invFinally, strategies to increase engagement with digital health were similarly discussed between patients with a history of MI and HPs. There is limited research addressing engagement in the MI literature, but research on engagement  to increase physical activity has shown promise ,41. PatiPatients with a history of MI emphasized the lack of support from their health care team and a lack of understanding from their family and community more strongly than HPs. Negative health outcomes are exacerbated in patients with a history of MI without a support network ,43. HoweArtificial intelligence is increasingly used in cardiology research . PatientA strength of this study was its iterative approach, with key needs being refined and confirmed with both participant groups multiple times. Participants involved in subsequent rounds were either the same participants from the previous rounds—where their comments could be clarified using a visual design—or new participants, where new advice could be provided. Therefore, the information derived from the rounds was rich with new insights and feedback provided in each round.Participants were relatively young for an MI target population. The mean age of patients with a history of MI across all rounds was 47 (SD 12.13) years, whereas the average age at the first MI was 65.2 years . This maWe gathered insights from patients with a history of MI and HPs regarding the need for a digital health solution for the secondary prevention of MI. Both patients with a history of MI and HPs highlighted focusing on mental health, collaborating with heart health organizations, involving family members in postdischarge care, and increasing engagement in simple games. These results can inform the development of a valued digital health secondary prevention strategy for patients with a history of MI. Future research should conduct a pilot study using the findings of the MiSmartHeart study to guide intervention development.