We used a combination of deductive and inductive approaches to: a) evaluate the data against existing, a priori criteria for consensus-building and b) identify emergent ways in which the BBF Samoa committee may have achieved consensus. We identified 6 themes, 2 meta-subthemes, and 16 subthemes. The 6 themes, largely defined by the a priori framework, represented key components of successful consensus-building. The 2 meta-subthemes described two overarching methods of consensus-building: “process-led”  and “organic” (unique/specific to the committee). Lastly, the 16 subthemes described more specific ways that the committee reached consensus. The detailed manualization of the BBF process, its reliance on data, and its transparent and engaged committee process were key for reaching consensus on BBF scores and recommendations in Samoa. Our study contributes to the understanding of how effective breastfeeding policy recommendations are made, using a methodology that can be applied beyond the topic of breastfeeding.The Becoming Breastfeeding Friendly (BBF) initiative provides countries with an evidence-based toolbox to improve the national breastfeeding environment by assessing and developing a plan to effectively scale up well-coordinated national policies and programs. BBF is carried out by a multi-institutional, intersectoral committee of experts, convening across five committee meetings designed to produce policy recommendations that can be implemented in the country’s context. Samoa successfully completed the BBF initiative in 2018, resulting in the institution of breastfeeding policy in hospitals and the establishment of lactation rooms within government ministries. An important step in informing the success of future breastfeeding scale-up initiatives is understanding how consensus is built. This study aimed to investigate how the BBF Samoa committee built consensus. We conducted a content analysis of audio recordings of three BBF Samoa meetings , meeting minutes, and meeting notes using an  Serving as “personalized nutrition” for the developing infant, breastfeeding is a powerful intervention for improving child survival, health, and development. However, breastfeeding prevalence remains low; in low and lower-middle-income countries, 50–52% of infants under 6 months of age are exclusively breastfed . The BecThe BBF initiative is grounded on the Breastfeeding Gear Model, which proposes 8 essential elements or gears for the national breastfeeding “engine” to function well: 1) advocacy, 2) political will, 3) legislation and policy, 4) funding and resources, 5) training and program delivery, 6) promotion, 7) research and evaluation, and 8) coordination, goals and monitoring , so that you know what you are trying to do [promote breastfeeding] is effective?”Another key component of successful consensus-building was self-organizing discussions, such that participants in the process decided on objectives, tasks and other items together . We founThe expertise of the BBF committee members on the topics of breastfeeding science, policy, advocacy, among other things, was relied upon to make decisions during the BBF process. Both the BBF committee leader and committee members held extensive knowledge in areas relevant to the various gears and often would interject or add to open-ended discussions to help the committee arise at decisions.Committee member 1: Then comes our benchmark number nine. Number nine talks about the coordination and the integration of breastfeeding training programs. We have a 20-hour breastfeeding counselling training, which collaborates with the Ministry of Health and the National University of Samoa for staff members working in the maternity services. [However], we put [this training] as a need and [we must] find out from [name redacted] how often and how many times we have offered this training since 2006.Committee member 2: This training started in 2006, then was held again in 2014 and 2016.Committee member 3: Just to add, I think there was a change in training in 2009, 2011, 2014, and last year.During the meetings, the BBF committee chair (CSU) oftentimes intervened during presentations or during open-ended discussions to correct assumptions and improve the committee’s understanding of certain topics. The extensive knowledge of the leader regarding breastfeeding in Samoa allowed many questions to be answered and ensured that all committee members had full understanding of the various gears, benchmarks, and rules of the BBF process. This also ensured that decision-making in meetings was carried out smoothly and efficiently. The BBF process was set up such that a committee leader guided most of the process; thus, we designated this subtheme as the “purposive” meta-theme of consensus-building. One example shows how the committee chair gave feedback after a gear team’s presentation and asked them to consider other sources of data by the time of the next meeting:[Committee member finishes a presentation]Thank you. Well done. Thank you for your efforts to be clear [about] the differences of the gear. I think almost you already know your scoring because throughout the presentation you’ve been saying that it must be major. I think the final thing for your team is to put what you really said in the next meeting. So the other thing you mentioned is that you do this and that, it all needs the source of data, sources of evidence, then bring it forward on the next event [next meeting]. But other than that, well done.Committee chair: The committee prepared an agenda for each BBF meeting, which was explained at the beginning and brought up when conversations diverged from the schedule. For example, when discussions were too lengthy, the BBF committee leader mentioned the original meeting agenda to keep the committee members on track. An example of how intentional agendas were established early in meetings is shown below from the introduction of Meeting 4 when the committee chair welcomed everyone and briefly outlined the agenda for the day.Committee chair: “The first one [agenda item] is to go back to our different Gears and reach consensus on the outstanding benchmarks [–] The following section will be a presentation, which will be conducted by [name redacted] regarding our surveys that we filled in over the last two weeks. It will give us a snapshot of what we all feel and what we all understand, and what actual recommendations we will prioritize and rank by the end of today.This subtheme illustrates how committee members recognized and dealt with time constraints during meetings, so that a strict schedule was adhered to and time was not wasted. Stating that presentations and discussions had to be done in a timely manner allowed for meeting efficiency and ensured that the decision-making process went smoothly. Two examples are shown below:Committee chair: “Okay, we are not going to wait any longer, because it is now 10 o’clock. I am so sorry for some people’s lateness. I know they have lots of things to do, especially Heads of Ministries and different Organizations.”Committee chair: “Let’s move on. There is no time.”This subtheme refers to how committee members mentioned that additional discussion was needed outside of the meeting or at another meeting. Discussing topics outside of committee meeting goes beyond the requirements of the BBF process, thus this was categorized as the meta-theme of organic consensus-building. An example from Meeting 2 on the discussion of the Advocacy Gear is below:Committee member: “So if there’s any comments, then we will work through it. Because it’s still a preliminary score, we can always change the score in the second meeting as well, but we leave this here at ‘two.’”In summary, self-organizing and adaptive discussion in the 2018 BBF process in Samoa was supported through several process-led and emergent methods, including guidance from strong leadership, the use of an intentional agenda, the recognition of time constraints, and the designation of additional time outside of meetings for discussion.Keeping stakeholders actively engaged, interested and “at the table” is another key component of a successful consensus-building process . The BBFBBF committee members often employed humor during presentations or open-ended discussions. Often met with laughs from the audience, jokes were used to engage others, make points, and to “lighten the mood” of the meetings. Two examples are below:“Welcome everyone. Here we are now onto the gear which has many benchmarks. We are the most blessed team of all. [laughter from the committee]”“So we’re going to the first gear. Can you read our first gear? [a long silence ensues] Okay! Very enthusiastic! [laughter from the committee]”Questions were posed to the group with the goal of generating interest, participation or engagement. These questions–often rhetorical questions–asked committee members to consider their own personal experiences, encouraging them to relate to the tasks posed by BBF in a personal way. These types of questions were often used by the BBF committee leader to help keep participants engaged throughout the BBF process.How many of you in the room have four or five kids? There are many.BBF committee members brought up and utilized personal anecdotes to elaborate on points of discussion. These anecdotes ranged from personal experiences regarding breastfeeding and infant care, to experiences working with breastfeeding-related health initiatives. Two examples are shown below:Is there any special training for mothers that have problems with their breasts, which is why they couldn’t breastfeed their kids? Because it looks like these are the mothers who trainings are for. For example, the breast cannot provide any breast milk, even using the pump or medicine from traditional healers…Another [reason to breastfeed] is to [protect] from breast cancer. I just want to know some ideas or ways that can encourage [breastfeeding]…, because I have 8 kids. None have ever had a chance to breastfeed.”“Hello and good health. […] I have six kids, and I breastfed all six. I breastfed even when they were going to school. So today is very important because you must look at [what is healthy for the kids]. My daughter is now 16, and she is still strong and smart [in part because of breastfeeding].”“In summary, committee members were engaged in the BBF process through humor and sarcasm, questions to engage the group, and personal anecdotes, all of which emerged organically and facilitated a positive atmosphere for decision-making.Other key components of successful consensus-building are challenges to status quo and creativity in finding solutions to problems. For instance, committee members challenged other members’ scoring of gears and benchmarks when they did not feel it was accurate (“Question to the group about changing scoring”). This reflected the meta-theme of process-led consensus-building embedded in the BBF process since committee members were expected to interject with differing opinions about scoring of BBF gears and recommendations.In many cases, either the BBF committee leader or member asked the rest of the group if the scoring of a gear or benchmark should be changed. The purpose of this was to gather feedback and “check” the scoring for alignment with the committee’s consensus. For example, during a discussion on the Legislation and Policy Gear in Meeting 4, a committee member offered a discussion to change a score:I think I’ll leave it to the floor; I’m not going to decide. […] I’ll leave it to the floor for any or further comments or just put [it] under Partial. But definitely, [our score] is not zero.”“The BBF process also involved the incorporation of high-quality, diverse data and unified interpretation of the data. Committee members often referenced the operational manual when there were misunderstandings , a “process-led” method of consensus-building, and asked questions for clarification (“Asking questions”), an “organic” method of consensus-building. These methods allowed everyone on the committee to be “on the same page” regarding data presented by the various Gear teams and with the BBF process as a whole.When there were uncertainties in the discussion, the BBF director and committee members referenced the BBF operational manual. This manual detailed how the meetings should be conducted and offered examples of the scoring and recommendation process.If I look at page 73 in the manual, it says master trainers have received National or International Certifications as Breastfeeding Specialist or Lactation Consultant.”“Throughout meetings, committee members often asked questions to the group. These questions were used to gauge the thoughts and opinions of the group and facilitate decision-making:Are there any questions about this session? Any questions for that first gear?”“In some cases, a question was asked to gain Samoa-specific information, data or knowledge from members’ expertise:Can I ask if anyone can answer the question? If there is a trained or certified lactation consultant now in Samoa, or specialist?”“In other cases, committee members asked questions to clarify a concept or improve their own understanding. This sometimes involved relying on others’ knowledge:I think the word is formative research. Can you help [name of BBF expert]? Formative research is research that is evidence-based?”“a priori framework  Do you have anything to say about our scoring here, or are there any gaps that you think that might help with our presentation?NH: So I think the major questions  are: if there any other data sources that should have been considered, whether the other people in the committee can think of more sources, and then, do we agree with the scoring or is there any debate [about the scoring]?”The committee leaders and members frequently invoked ideas of community, teamwork, and togetherness. They often described the committee itself as a “team” and that the BBF process and breastfeeding improvement in Samoa required “teamwork”, was “a collaborative effort” and “was a great goal” for all. During Meeting 1 on the Training and Program Delivery Gear, the committee leader described how coordinated efforts are essential to improving breastfeeding-related training on a national level in Samoa:We are very thankful, and we are very happy that we have a group of people who are willing to push breastfeeding to the next level. And for Samoa, it’s a great goal for us to achieve with regards to our non-communicable disease crisis. Breastfeeding will help to reduce NCD [prevalence] among young children.”“In this study, we explored the question: how did the 2018 BBF Samoa committee build consensus and make decisions? Following BBF processes in other countries , 16, thea priori operational framework describing successful consensus-building [Through inductive and deductive coding, we identified 6 themes, 2 meta-subthemes, and 16 subthemes in total, all of which largely overlapped with the building , 14. OveFirst, we suggest that the structured or “process-led” meta-theme of consensus-building played a key role in facilitating the initiative’s success. Earlier work on decision-making theory in the 1970s and 80s described how providing groups with specific guidelines and adequately “structuring” a decision-making process can render the process simpler and more expedient. For instance, experiments have shown that when an “instructed” group (where a highly specific list of instructions were provided to aid decision making) and an “uninstructed” (control) groups were asked to complete a decision making task, the instructed group produced more high-quality decisions, exhibited greater creativity, and exerted greater caution when evaluating available evidence and making decisions –20. In cSeveral themes in this study reflect the power of “instruction” as explored by earlier researchers , 19. ForSecond, organic and committee-specific ways of building consensus contributed to the success of the BBF Samoa initiative. For example, committee members often used personal anecdotes to illustrate ideas and facilitate discussion, thus invoking their own experiences with breastfeeding and infant care as a method to guide decision-making. These findings reflect results of previous research, which has shown how personal stakeholder experiences shape their involvement in decision-making processes related to maternal and child health. In a large qualitative study of clinicians and staff across four health sectors in the U.S., authors found that stakeholders’ own experiences with breastfeeding, and the belief that breastfeeding and infant care was a personal/emotional issue, influenced their support for breastfeeding policy development . Along sValues of community and togetherness may have also contributed to the decision-making process in BBF Samoa. Social values play a large role in shaping decision-making in health policy. For instance in Chile and Columbia, values of individuality, free choice and human dignity shaped policymakers’ decisions on legislation regulating private health insurance . By framThere are several limitations of this study that warrant consideration. First, the audio files for Meeting 3 of the BBF Samoa process could not be located. During Meeting 3, the BBF committee presented the benchmark scores, reached final consensus on the benchmark scores, and calculated the gear scores. Thus, by not analyzing Meeting 3 audio transcripts, key parts of the consensus-building process may not have been captured by our qualitative analysis. We did, however, have access to detailed Meeting 3 meeting minutes, which allowed us to capture relevant outcomes from the meeting. Second, parts of the audio files had low quality, resulting in possible errors with transcription and translation. At times, this limited our ability to assess and understand the full conversation dynamics, including who was speaking. Third, these audio files only captured the main BBF meetings and not the gear team meetings or more informal conversations amongst committee members that happened outside of the designated meeting times. Despite these limitations, the loss of key information was minimized since BBF meetings are highly iterative and hence need to refer to each other throughout the process.a priori framework for understanding successful consensus-building, we conducted an inductive and deductive qualitative content analysis of transcribed and translated audio recordings of the BBF meetings, during which a 20-member committee met to reach consensus on scores of gears and benchmarks for breastfeeding scale-up in Samoa. Sixteen themes emerged from the transcripts, including, but not limited to: the use of humor, intentional agendas, values of community and togetherness, effective leader, and reliance on expertise. These themes encapsulated the various parts of successful consensus-building outlined by the a priori framework. The themes also represented both purposive and organic ways in which consensus was built. The detailed manualization of the BBF process, its reliance on data, and its transparent and engaged committee were key for reaching consensus on BBF scores and recommendations in Samoa. These findings contribute to our understanding of decision-making within the BBF initiative and underscore the group strategies that may have resulted in government policy action, which can be applied in future policy scale-ups.This study examined the consensus-building process during the 2018 Becoming Breastfeeding Initiative (BBF) in Samoa. Utilizing an


There has been a rapid increase in prevalence rates of online sexual abuse (OSA). Existing research has highlighted the negative impact OSA can have on victims. However, there is a gap in understanding the long-term impact of OSA when it occurred in childhood.This qualitative study comprised interviews with eight female participants aged 18–28  years recruited in UK NHS Trusts, and via mental health charities, University bulletins and social media. Each participant self-reported having experienced abuse through either the production or dissemination of sexual material online.Results showed that the longer-term impact of OSA was multi-fold, including negative impact on sense of self and broader interpersonal relationships, and significant impact on the participants’ mental health, including experiences of self-harm, anxiety, and low mood. Likewise, participants discussed long-term apprehension to taking images and the added fear and worry that their sexual images were distributed online. Seven participants had received mental health support but only two recounted a positive experience when receiving support for OSA.Future research using a quantitative longitudinal design is needed to further explore the prolonged impact of OSA. Clinical implications of the research highlight the need for support services to assess the impact of OSA and interventions that target OSA experiences. These harms include online sexual harms and online sexual abuse (OSA). The latter can be understood as any type of sexual abuse with an online element, such as online grooming or abuse through the production or dissemination of sexual images or videos. Data by UK charity the National Society for the Prevention of Cruelty to Children (NSPCC) found that online grooming has increased by 80% from 2017/18 to 2021/22 . BetweenThe impact of offline child sexual abuse (CSA) has been extensively studied. Existing research has shown that victims experience long-term mental and physical health challenges, as well as difficulties in adult interpersonal relationships . CompareMuch like offline CSA, victims of OSA often do not disclose the abuse until years later. In fact, in many cases, OSA is discovered through law enforcement investigations , rather Existing research exploring how OSA affects an individual during adulthood is nascent. There is a specific lack of research that explores the journey of impact; from the immediate impact following the abusive event to the long-term impacts in adulthood. Likewise, the delayed impact of, and support offered for, these specific experiences from the victim’s perspective is not well understood. Qualitative interviews are an established methodological approach when exploring novel research areas  and prov2.2.1.N = 8) through convenience sampling. Participants were recruited through either Child and Adolescent Mental Health Services (CAMHS) or a Sexual Assault Referral Centre from three National Health Service (NHS) Trusts in the Northwest of England. Recruitment also took place through nation-wide charity organizations, focused on providing mental health support or supporting victims of online/offline abuse, social media and advertisements posted on university bulletins. Participants were eligible if they: (a) self-reported experiencing online grooming and/or abuse through the sharing of sexual images or videos online under the age of 18; (b) were above the age of 16; and (c) lived in the UK.The study recruited participants . Recruitment took place between January 2022 and February 2023, principally through three NHS CAMHS and SARC services. After establishing contact with the relevant service, the study was presented to clinical teams where staff identified potential participants. Similar procedures were followed when recruitment occurred through nation-wide charity organizations, Social media advertisements were also posted on Twitter, Instagram, Reddit and advertisements were posted on university bulletins. Social media advertisements contained the authors’ email addresses through which participants were able to express interest. The advertisements included the phrase ‘unwanted sexual experiences online’ to be mindful of the sensitive nature of the topic and the range of experiences that can be considered as OSA.Participants who confirmed they would like to take part were given the option of completing the interview either in-person or remotely (online). A final sample of eight participants, all female aged 18 to 28 years consented to take part in the study. Following informed consent, interviews were conducted by author FS, audio-recorded and transcribed verbatim.2.4.The transcribed interviews were uploaded to NVivo 12, which was used to support analysis. Thematic analysis was used to analyze the data . Open-en2.5.A reflective log was kept documenting the overall experience of the interview, reflections on the topic guide, and emergent themes. All authors have research and clinical interest in developing interventions for individuals who have experienced OSA. FS also has expertise in developing policy interventions for OSA. We acknowledge that these experiences may affect the analysis and interpretation of the data. Additionally, we recognize that the similarities in age and gender of the participants and FS could have influenced the collection and interpretation of data. To minimize the impact of this, questions were presented in an open and neutral way, and participants were encouraged to explore both positive negative aspects of the topics discussed. The reflective log was also used to document how response influenced the researcher’s own views, which were held in mind during the analysis process.3.Interview length ranged from 35 to 60 min. Two interviews were conducted online and six in-person. All participants self-reported experiencing abuse through the taking or dissemination of sexual images or videos online. Five participants experienced online grooming, which for two participants involved coercion into viewing sexual content by an offender. Four of the online grooming experiences involved the non-consensual taking and the distribution of their sexual images. All participants who experienced online grooming met their offenders online, through either chat rooms, gaming platforms or social media. Two participants experienced non-consensual distribution of their sexual images. One participant had taken the images consensually; the images were then distributed non-consensually. One participant had experienced offline sexual abuse that was non-consensually recorded and distributed online. A further participant experienced being coerced into viewing sexual videos for the purpose of sexual gratification by their then partner. The experiences varied in length of time. For some, the abuse through sexual material was a one-time incident; for others, it lasted a couple of years. For those that experienced online grooming, the contact ranged from a couple of months to years. Participants were only asked if the experience occurred prior to the age of 18. Due to the retrospective nature of the interviews some participants did not recall their exact age at the time of the initial OSA exposure. However, participants did mention, the estimated years between the time from the occurrence of the initial OSA exposure and the interview taking place, which ranged from 1–20 years since either the abuse or the contact with the offender ended.3.1.Three interlinked themes were drawn from the findings: (1) the impact of OSA; (2) factors influencing disclosure; and (3) inconsistent experiences with support service. Themes and their sub-themes are displayed in a thematic map to show their relationships .3.2.Participants discussed difficulties within their interpersonal relationships, the psychological impact of their experience of OSA, their journey toward self-acceptance, and how these factors impacted their sense of self, both in terms of the immediate and longer-term impact.3.2.1.3.2.1.1.Participants recalled isolating themselves from family and friends after the OSA experience. For some, this was because they were unsure to what extent their parents had known about the experience, or because they were uncomfortable discussing the experience with parents. Some participants isolated themselves for fear of either the offender finding them, being identified by others who have seen their sexual image, or because of feelings of self-hatred and shame. However, some participants expressed a desire for peer support shortly after the experience but had felt let down as their friends had not noticed that they were struggling and therefore did not offer support.“I was annoyed at everyone but especially one person because in my head I thought they should have done more to help even though I know they didn’t know everything I thought” .3.2.1.2.Participants struggled to find positive and supportive friendships after the OSA experience. For participants who had an online peer network prior to the OSA experience, they had become more cautious seeking out online friendships thereafter. For others, it was a question of trust within friendships. Participants described feeling worried about what friends might think, and judgments they might make about them if they disclosed the OSA experience:“I also think like ‘oh what do they actually think of me’ even though they have not made like an impression that they think any differently” .Seven participants discussed the impact on their romantic relationships. Three participants spoke about having continuous ‘on and off’ romantic relationships after the OSA experience. Participants recalled that after the contact had ended with the offender, they felt as if all their relationships would be abusive, and they believed that was how a normal, healthy relationship would be in the future. Participants discussed difficulties in setting boundaries, often because of the manipulation and coercion they had experienced, and how the experience increased their feelings of being sexualized in relationships. This included the expectation of sex and ‘giving in’  to their partner’s wants. Additionally, participants discussed feelings of discomfort knowing that they will have to disclose the shared images to their future partners and being unsure how a future partner would respond:“If you don’t give them sex, they will go looking for sex elsewhere, and that would be your fault … so I let a number of my subsequent boyfriends push me sexually further than I might have gone otherwise” .“kind of made me feel like, maybe like weaker in every relationship I have been in, except well, well every relationship I was in until the moment I was kind of like started rethinking everything” .3.2.2.The psychological impact that participants experienced was heavily intertwined with the previous sub-themes of interpersonal relationships. For example, feelings of anxiety were amplified and triggered in response to general questions they were asked by peers regarding where they live or what school they attend.3.2.2.1.Participants described feelings of embarrassment and shame for sending the sexual images, and feelings of discomfort, confusion, and insecurity about the choices they had made. The shame and embarrassment participants felt at the time often contributed to feelings of self-blame:“It just, I wish I could change it, I know I can’t, I just, I just wish I could just speak to myself at 17 with the person I am now, and say you never ever needed to do, um, an it just-I just, I’m still insecure now probably because of that, because of the way that they saw me” .Participants also described feelings of embarrassment and shame for sending sexual images in the first place. Those who experienced online grooming described the difficulty coming to terms with the contact ending and felt as if they were processing the loss of a relationship. Participants described lacking motivation to do schoolwork or engage in hobbies in the weeks after the contact ended. Participants also described engaging in self-harm behavior following the OSA experience as a way of expressing the pain they were feeling once the contact had ended, or because of their struggle to feel understood either by friends or family or because they struggled with processing their own feelings about the experience:“I did start self-harming (…) but that was a way that I dealt with it because again I was made to feel like an outsider” .“(the experience) can also like have reinforced something that was already there, I think I’ve always been a little bit like(…) maybe on the insecure side, and maybe it (the experience) kind of like reinforced that so I feel weaker in relationships and um, might like contribute to low mood and self-harm” .3.2.2.2.Participants described not recognizing the impact the experience had on their mental health until much later. For many, it was not until they had reflected on the experience months or years afterwards that they recognized the impact the OSA experience had on their mental health, including feelings of anxiety, discomfort, low mood, and low self-esteem. For participants who experienced online grooming, they only began to understand the abusive nature of the relationship years after the experience.“… definitely still struggle with the aftermath of all this and it comes in waves, kind of randomly sometimes, but I think I have a really strong understanding of a lot of the ways that I think and the way that I behave now” .“I think it impacted me in other ways without me sitting there and ruminating about it so I can’t say that it helped me accept it that I hadn’t accepted it before, but I think if I’d never realised, I probably still would be in this cycle” .Most of the long-term issues discussed by participants related to ongoing feelings of self-blame and the struggle to accept they were not to blame. For participants who experienced online grooming, the betrayal and realization that the relationship was abusive was difficult and often required them to consciously overcome the feeling of self-blame. Participants who were asked for sexual images by the perpetrator knew the abuse was not their fault, but the words and tactics used by the perpetrator meant they felt like they had been an active agent in the abuse, which brought guilt around the choices they had made. Participants described feeling that it was ‘dumb’ to speak to strangers online and that as they actively initiated conversations, at some level they were at fault:“I want to say it was a sign of weakness-I didn’t want to show weakness in talking about it because it was my conscious decision to engage and have sort of conversation and relationships but as I say now looking back it wasn’t my fault” .Some discussed receiving mental health diagnoses such as anxiety, psychosis, obsessive-compulsive disorder, and post-traumatic stress symptoms. However, it was difficult for participants to delineate how specifically online abuse contributed to the specific mental health diagnosis they received. This was often because, even though participants brought up the OSA experience with their counselor, it was not a focal point in therapy:“I was having therapy on the hospital services for OCD and probably sort of mild depression but it was mainly sort of anxiety, (pauses) yea and they admitted that they weren’t really trained in that so we kind of talked about it … in different ways and I think I didn’t know what was helpful to me at that time, and he didn’t really know what to guess would be helpful so we kind of talked about but then we mainly just shifted towards OCD” .Some participants reflected on how the added element of online abuse significantly contributed to receiving a mental health diagnosis. For example, peers asked them general questions about where they lived or where they went to school, which contributed to them experiencing anxiety. Participants feared that once peers knew where they lived, they would become aware of the sexual images. Participants discussed how loss of control of the images, and image permanence, resulted on them feeling ‘exposed’ and ‘helpless’ with the knowledge that there was nothing they could do to remove the images:“it’s probably impacted me the most cause it still affected me now, cause I am also like paranoid about like who’s got pictures of me, like who’s looking at me, who’s giving me attention or whose not, and that is always replaying in my head” .3.2.3.When asked how the experience had impacted their sense of self, all participants described a long journey toward self-acceptance; sub-themes one and two were both woven into the discussion of self-acceptance. Participants described the social isolation from their interpersonal relationships (sub-theme one), struggles with their self-image after images had been distributed, and the how their overall perception of themselves impacted their mental health (sub-theme two).3.2.3.1.Participants discussed their struggles with self-image after the OSA experience; they often described feeling ‘weak’ and ‘worthless’. Much of the discussion of self-image was intertwined with feeling sexualized during the experience and overlaps with the immediate impact participants described in sub-theme two. As an example, participants recalled that offenders repeatedly asking for sexual images often made them feel as if their self-worth was wrapped up in their body and appearance were only worth their body.“basically just became very closed off book almost, I was before that and I am now a very outgoing, I would describe myself as quite confident, um, a person but that just completely changed me as a person, I had no confidence, hated myself, doing anything that…where people were looking at me I would avoid” .“I used to feel was like I can’t be sexualised like no one can see me as like pretty or like attractive, and now I am in a situation where people only want to use me for my body, so it’s like the total opposite … I was so like desensitised to showing my body, like you want a picture there you go, if that is all you want, that’s fine, that’s fine, take it” .The reactions of friends to discovering the participants sexual images also negatively impacted participant’s self-image. This included participants who recalled that peers had bullied and re-shared their sexual images. Participants would often believe the negative names that peers would call them, which contributed to their negative self-image and them ostracizing themselves from peers.3.2.3.2.When reflecting on the experience years later, participants noted that the OSA experience was the ‘catalyst’ in how they viewed themselves and the image that they perceived others had of them. It was difficult for participants to build a positive self-image that was not tied to their appearance. The negative view of oneself contributed to difficulties in interpersonal relationships and personal struggles with mental health problems. Likewise, the subsequent negative self-image that developed over time resulted in participants avoiding posting images of themselves on social media or being in images in general:“… the catalyst of issues with self-image, understanding how I perceive myself, how others perceive myself, um, I think yea … that’s where it hit the most” .“I wear baggy clothes a lot I am more comfortable in stuff that is not very revealing, I really struggle to be, I say complimented in inverted commas, but you know when you go out in the nightclubs and people pay attention, I don’t like that” .Participants described how the OSA experience made it difficult for them to identify with their culture or religion; it was difficult for some to accept that they had sent sexual images which did not align with cultural norms and expectations:“I was raised religious … the way I was raised, so that when anyone sort of speaks to you romantically their intention is to marry you, like they have pure intentions, you know they don’t mind if you don’t want to have sex, you don’t want to do things, so I was really naïve like I would speak to all these boys …it still haunts me now and stuff, um, of like me having this reputation especially in like the Asian community” .All participants described a journey of learning and growing in? confidence. Participants recognized confidence within themselves over time through feeling more protective over their body and establishing healthy boundaries around sex within relationships. Others expressed that connecting to religious groups was important in both fostering support and building a positive self-image. Participants described that, over time, feelings of self-blame around taking the images in the first place diminished.3.3.Disclosure often involved a process of discovering that sexual images have been taken non-consensually and that their sexual images had been distributed online. For many, discovering that sexual images had been circulated online impacted their mental health, often bringing feelings of worry and anxiety, as reflected in theme1 one and sub-theme two. Some participants recalled feeling ashamed when their friends/family informed them that the images they had taken and shared with the offender appeared online, which subsequently negatively impacted their relationship with their family/friends. Participants also recalled how they had been aware that sexualized images of themselves had been taken, but completely unaware that these images had been uploaded and shared online, only discovering years later that this had taken place.3.3.1.Six out of the eight participants discussed that their own understanding of the experience influenced their ability to disclose. For these participants, it was not until they were much older and started talking about their experience that they understood the abusive nature of the OSA experience and its impact. For many, the process of realization involved developing an awareness of online grooming and images being disseminated online:“… it started hitting me when I started talking about it, I started fully processing it and realising what had actually happened, because then it was just, uh, saying, it without any emotional attachment to, just saying ‘oh this happened, and I don’t ‘know if it affected me ‘but after talking about it more and more I-that’s when I realised that it did” .“I got a little bit older I did start to suspect that they could be on the internet … I started to really worry about what had happened to those pictures and videos and if anyone had seen them” .Participants described how the lack of physical contact/abuse led them to the perception that OSA was not a severe enough threshold to seek help. Participants said that they often did not mention their experience of OSA in therapy, or if they were talking about abuse, the focus was on contact abuse which felt like it had a more perceived tangible impact compared to online sexual experiences. As a result of not disclosing or talking about the OSA, many participants recalled not fully recognizing and understanding the severity of the experience until much later:“I watched a program where it was a documentary about a girl a similar thing had happened but she resulted in suicide but um, I was like’ oh this is familiar’, like yea, this happened and I didn’t even think about it in that way, um, so I can’t remember how old I was, about, maybe 19 or 20, probably before I actually re-evaluate” .Participants were hesitant to disclose to family and friends as they did not feel sharing their experience of OSA would be met with a non-judgmental and open conversation; avoiding disclosing to trusted others had a negative impact on these interpersonal relationships because participants felt they were keeping secrets or hiding a part of their life from family/friends. This created a distance in, and sense of isolation from, these relationships.3.3.2.Two positive themes emerged from the data, one regarding facilitators to disclosure and one regarding the positive impact disclosing had on participants. For many, disclosing experiences of OSA to family/friends had been gradual. Many participants were more likely to be open with their romantic partners than other relationships they had.“I think I became gradually more open over time … I think at the beginning I didn’t particularly tell my family that I had friends online and stuff, and … then eventually I would tell them, oh yea I meet this person on the game … I have always been really open with my partners; I have been really open with everything that is going on” .The decision to disclose varied for participants; some participants felt comfortable and in a supportive and trusting environment to make the disclosure. Others were tired of keeping a secret or family members had noticed a change in behavior that then led them to disclose. Through discussing the experience, participants described feeling relieved and mentioning that the positive reactions after the disclosure helped them feel supported:“the people that do know, are people that I am really close to, and, who are, yea, it definitively brought us closer and have all been very compassionate and understanding” .Talking about the experience in an environment that felt non-judgmental, open, and trusting created more positive interpersonal relationships for participants and helped them to process and understand the impact the experience had on them. Some participants chose to first disclose the OSA experience to a friend that they had suspected experienced a similar incident. For others, participants broached the subject by asking friends whether the relationship they had been in was normal and friends indicating that it was not.“I trusted her really intrinsically; um I knew that she would believe me, and she also had no power” .3.4.Participants described two main services that were involved in providing support for OSA experiences: psychological therapy and crisis support lines. Seven out of the eight participants had received some form of therapy but not necessarily for the OSA experience itself; in some cases, participants received support for emotional or mental health difficulties without bringing up the OSA experience. Only two participants said they had received support for the OSA experience specifically.3.4.1.Participants largely described negative experiences when seeking help for their OSA experience from support services, which, for most participants, impacted their overall processing of the experience. Participants described either not being able to access support, feeling misunderstood by a counselor, or being made to feel like the experience of OSA was their fault. These negative experiences of support in turn reinforced feelings of isolation and loss of control and reflected the experience of OSA itself:“It was but the way the counsellor spoke to me … I mean she obviously wanted to understand why I did it, which I explained to her, but then it was almost-she almost didn’t make me normal; she basically couldn’t understand why I did it, she made me feel like I did something really really wrong” .The negative experience of seeking support and the challenges that participants experienced in navigating the mental health system precluded further help-seeking:“I am not in therapy now, I feel like I should … just in general it’s really difficult with doctors here, it’s horrible. I have insurance and they still tell me that I need letter from a GP, and it takes a month to get that and then they say it is not their field of expertise, so they can’t give me a referral” .All participants described a gap in their understanding of the online element of abuse they experienced. For participants who did not seek therapy specifically for OSA, they struggled to talk about their online experiences because they felt that it was not understood by the person they were seeking support from. For those who did talk in therapy about the experience, the therapist acknowledged the experience but then did not explore this further or did not understand the nuance and subtlety of the impact:“The therapist was like ‘well I am sure that the police would just take them off the internet’ I was like ‘that is not how the internet works’ … that doesn’t make sense, and it did not make me very inclined to tell her any more about it, or to express more of my anxieties around the permanence of it to her” .“I found them a bit kind of, um, they basically told me that they can’t really help me unless, I think they, they didn’t understand the idea of like because I interact with people a lot online, a lot of my friends are online friends” .3.4.2.Six participants described a positive experience of help-seeking or of receiving therapeutic support, though the support they received focused mainly on managing their mood and general mental health and well-being rather than exploring the OSA experience directly. For the two participants that received specific support for OSA, the relationship they formed with the service and the counselor were critical to feeling understood and heard. Through this process, participants recalled improvements in mood and feelings of panic they had experienced. Other participants described that feeling understood, and a non-judgmental environment, helped. One participant found it helpful when the counselor checked their own understanding of the OSA experience:“I just I think (the service) is really good and they are very – they are very good at you know, like talking to you and actually-actually getting what it is you are trying to say, um, they are—um they are not judgement or anything” .4.This study sought to explore the short-and long-term impact of online grooming and abuse through the production or dissemination of sexual images by interviewing adult survivors of childhood OSA. To the authors’ knowledge, this is the first qualitative study asking adult survivors to reflect on the short-and long-term impact, including psychological impact, of a childhood OSA experience. This is also one of the few studies exploring the prolonged impact of OSA . Two maiA key contribution that this study makes to the existing literature is emphasizing the persistent impact of the taking and distribution of sexual images. Existing literature has extensively discussed the fear, worry and anxiety victim’s face when sexual images are distributed online  and the Our findings also revealed the prolonged impact on victims’ sense of self. Participants described struggling with feeling over-sexualized in subsequent social and romantic relationships. For some participants, this contributed to not wanting to take images with friends or wearing loose clothing to hide their bodies. Previous qualitative studies have also described victims’ struggles with self-image, body-image, self-esteem, and self-acceptance . These sThe negative mental health impact of OSA has previously been discussed within the OSA literature . This stAlmost all participants received counselling or therapy either through private or public mental health services. However, when talking about their experiences with support services, most participants were not asked about their online world or relationships directly. Likewise, when speaking about their online lives, only a few participants had a positive experience in how their therapists responded to OSA disclosures. This reflects existing research that shows that assessment tools are limited in questions prompting about people’s online world, experiences, harms or relationships, let alone online abusive experiences . Further4.1.The sample included a broad age range exploring the impact of OSA, allowing for a variety of views and experiences across the age range to be captured. A broad age range is also helpful in understanding the prolonged impact of OSA experiences and disclosing experiences. Additionally, the aim of the study was focused on understanding the impact of two types of OSA: online grooming and abuse through the production of sexual images or videos. Compared with the standard broader definition of OSA, this narrower definition allowed for the study findings to be directly applicable and not confounded with all types of OSA. Further, the qualitative design of the study allowed the nuances of the participants’ experiences and the variety of experiences to be highlighted. There are, however, some limitations that need to be considered. Our sample was all female, which is in line with existing qualitative studies on OSA experiences  and curr4.2.While most participants received some sort of counselling or mental health support in the years following the abuse, their online experiences were often unspoken, not acknowledged, or even dismissed. This finding underlines the importance of practitioners being trained in inquiring about online experience and harms and responding to disclosures of online sexual abuse . FurtherFuture research should capture the impact of OSA experiences in individual’s who do not identify as female. Although current prevalence rates indicate that females are more at risk of OSA experiences, some reports show that those of ethnic minority and different sexual orientations may also have an increased vulnerability . Future felipa.schmidt@postgrad.manchester.ac.uk.The datasets presented in this article are not readily available because to protect the anonymity of the participants. Requests to access the datasets should be directed to The studies involving humans were approved by NHS Research Ethics Committee (19/NI/0167). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.FS: Conceptualization, Methodology, Supervision, Writing – original draft, Data curation, Formal analysis, Project administration, Software, Validation, Visualization, Writing – review & editing. FV: Conceptualization, Methodology, Supervision, Writing – original draft. SB: Conceptualization, Methodology, Supervision, Writing – original draft, Formal analysis.


A new approach to treating post-partum haemorrhage is having a substantial impact on maternal deaths. Tatum Anderson reports. It is the mothers lost to post-partum haemorrhage (PPH) that weigh on Dr Hadiza Shehu Galadanci’s mind. Professor of obstetrics and gynaecology at the Aminu Kano Teaching Hospital in Kano State, Nigeria, Galadanci is often called in to help mothers, who – having just delivered their baby – are suddenly faced with the prospect of dying.“The birth of a child should be a happy time for the mother, but when the bleeding starts everything can change very rapidly,” she says. “The mother is very frightened and sometimes, despite our best efforts, she slips from our hands.”Commonly defined as blood loss of 500 ml or more within 24 hours after birth, PPH can be caused by a lack of uterine contracture after delivery, retained placenta, an inverted or ruptured uterus, and cervical, vaginal, or perineal tears.Often life-threatening, PPH is also common. “Of the 134 million births worldwide each year, around 14 million are complicated by post-partum haemorrhage, with most of the women affected living in lower-income countries,” says Dr Ioannis Gallos, a Medical Officer working in the World Health Organization’s (WHO) Sexual and Reproductive Health and Research department.According to Gallos, PPH is the leading cause of maternal mortality, taking an estimated 70 000 lives every year, equating to roughly 1 in 4 of the 287 000 maternal deaths globally.The overwhelming majority of these deaths occur in low- and middle-income countries, Nigeria alone accounting for an estimated 20 000. Women who survive can be left with life-long reproductive disability and trauma.“[PPH is] all the more tragic because it is preventable.”Ioannis Gallos“It’s all the more tragic because it is preventable,” says Gallos, listing interventions that include uterine massage after delivery of the placenta, the administration of oxytocin or misoprostol (both of which induce uterine contraction), or tranexamic acid (a blood-clotting agent).Skilled birth attendants also have the option of inserting a uterine balloon tamponade into the uterus and inflating it to compress blood vessels. As a last resort, surgical removal of the uterus may be needed to save the mother’s life.While not all these interventions are always available, many are and, according to Gallos, it is the way they are implemented that gives rise to problems.Galadanci concurs. “Broadly speaking, we’re too slow in responding,” she says, noting that three main reasons have been identified as the cause of the delays.The first is the failure to recognize PPH early enough. “More than half of PPH cases go unnoticed,” Galadanci says. “Health workers see the blood, but they underestimate the amount being lost.”The second cause for delay is the lack of preparation of the medical products needed or the paperwork required to obtain those products. “In many cases prescriptions or other paperwork needs to be signed by a doctor,” Galadanci says. “When medical products are not available on-site, patients’ relatives are asked to go to an outside pharmacy to find them.”The third main cause of delay is the wait-and-see approach typically taken to treatment. “We administer one drug, and then wait to see whether it is effective or not,” says Galadanci. “In the meantime, the woman is bleeding and before you realise it, she's in serious trouble, especially if there is limited access to services such as blood transfusion or surgery.”To address these gaps in response, researchers at the University of Birmingham in the United Kingdom of Great Britain and Northern Ireland, working in collaboration with WHO, and researchers in Kenya, Nigeria, South Africa and United Republic of Tanzania have developed a new protocol designed to accelerate PPH response times.The main aim of the protocol, known as E-MOTIVE, is to help reduce maternal deaths in line with sustainable development goal target 3.1 – a global Maternal Mortality Ratio (MMR) of less than 70 maternal deaths per 100 000 live births by 2030.“After improving for many years, maternal mortality trends have flattened over the last five,” explains Gallos, who headed up research on E-MOTIVE at Birmingham University prior to moving to WHO.Trends in maternal mortality 2000 to 2020) showed that global MMR decreased only slightly between 2015 and 2020, from 227 to 223 deaths per 100 000 live births.A report published by WHO and partners in February 2023  using the protocol but ended up seeing a 60% drop,” says Arri Coomarasamy, Professor of Gynaecology and Reproductive Medicine at Birmingham University, and head of the E-MOTIVE research team. According to Coomarasamy, some of the hospitals in the trial went on to achieve an 80% reduction in severe PPH.WHO is now working on guidance that will account for all aspects of E-MOTIVE implementation including cost-effectiveness. In the meantime, an implementation trial is being conducted in Pakistan, to verify that the protocol works in countries outside the African Region.There is evidence that the protocol may also be of benefit in upper middle-income countries, as indicated by a 14-hospital study carried out across the Western Cape, Eastern Cape and KwaZulu-Natal in South Africa.“After implementation [of the protocol] there were zero deaths.”Hadiza Shehu GaladanciAccording to Professor Sue Fawcus, at the Department of Obstetrics and Gynaecology at the University of Cape Town, who oversaw the study there, death from PPH is the second most common cause of maternal death in South Africa, but the most preventable, with 90% of deaths being clearly preventable through better care supported by a properly functioning health system.She observed multiple benefits from the protocol, including a reduction in the requirement for blood transfusions. “We observed an apparent reduction in PPH in the postnatal ward, where there are fewer staff and more patients, because cases are being detected while mums are still in the labour ward, enabling earlier intervention,” she explains.Another benefit was the obvious impact on midwife empowerment. “As midwives, we can immediately implement the bundle and don’t have to wait for a doctor to decide what to do,” says Sister Thea Williams, Operational Manager of the Maternity Ward at Vredenburg Provincial Hospital in the Western Cape, adding that doctors are not always available in the maternity ward where she works. “Being able to take decisions and act on them gives you confidence as a midwife, and the patient feels safer with you too,” she says.However, Williams also points to a number of challenges which will need to be addressed as the protocol is rolled out. Training is one. As nurse champion on the E-MOTIVE project in her hospital, Williams was in charge of overseeing training, and reports that doctors and nurses were so busy on shift, there was no chance to train them in how to use the new bundle and the drapes unless they came in on their days off.Fawcus highlights similar concerns, noting the need for constant training. “There’s turnover of staff, agency staff, new students. So, we were continually trying to keep people acquainted with the intervention,” she says, adding that the situation will improve when the E-MOTIVE approach becomes national policy backed by widespread teaching.Implementation will also need to address the issue of blood-collection drapes, which are single-use items and not biodegradable. In South Africa, the drapes are also imported, raising supply chain concerns. The Bill & Melinda Gates Foundation has agreed to supply drapes until a long-term sustainable solution is found.Such teething problems aside, there is considerable excitement about the new protocol, based largely on the clear impact it is having. In Nigeria, having seen the difference it makes, Professor Galadanci’s staff are anxiously waiting to see E-MOTIVE fully implemented in all maternity hospitals in Nigeria. “In one of the 19 intervention hospitals in the E-MOTIVE trial, 25 women died of PPH between January and June 2022 prior to implementation,” says Galadanci. “In the six months after implementation, there were zero deaths. Zero. I mean, wow.”


The World Health Organization (WHO) notifies the global community about disease outbreaks through the Disease Outbreak News (DON). These online reports tell important stories about both outbreaks themselves and the high-level decision making that governs information sharing during public health emergencies. However, they have been used only minimally in global health scholarship to date. Here, we collate all 2,789 of these reports from their first use through the start of the Covid-19 pandemic (January 1996 to December 2019), and develop an annotated database of the subjective and often inconsistent information they contain. We find that these reports are dominated by a mix of persistent worldwide threats (particularly influenza and cholera) and persistent epidemics (like Ebola virus disease in Africa or MERS-CoV in the Middle East), but also document important periods in history like the anthrax bioterrorist attacks at the turn of the century, the spread of chikungunya and Zika virus to the Americas, or even recent lapses in progress towards polio elimination. We present three simple vignettes that show how researchers can use these data to answer both qualitative and quantitative questions about global outbreak dynamics and public health response. However, we also find that the retrospective value of these reports is visibly limited by inconsistent reporting . We conclude that sharing a transparent rubric for which outbreaks are considered reportable, and adopting more standardized formats for sharing epidemiological metadata, might help make the DON more useful to researchers and policymakers. The first few days are often the most important to prevent outbreaks from becoming epidemics and pandemics; by warning the world early, countries can access resource stockpiles, funding mechanisms, and decision support tools; coordinate epidemic response and surveillance across borders; and prepare the public for imminent danger. All of these have the potential to be accelerated in the internet era, but only if institutions leverage digital communications to share accurate and timely information.The Disease Outbreak News (DON) is a public, online reporting system that serves as the only official outbreak record maintained by the World Health Organization (WHO). This system has been used since 1996, and shares event-based information provided by countries and other partners, which is organized by the WHO into prose that describes outbreak circumstances. Usually, these reports identify the geographic region affected; a known or suspected disease, or a syndromic event of unknown etiology; and some information about response, such as whether samples have been submitted for laboratory confirmation. This information helps international actors stay informed on health-related events and emergencies around the globe, and is also sometimes used by researchers as a public “database” of outbreaks . HoweveTo support global health research that uses and interrogates the DON as both a record of outbreaks and a library of documents in its own right, we compiled basic information about reports into a standardized database. Here, we present a stable version of this resource including newly-structured metadata for each entry, collated in a machine-readable format, and show three “vignettes” that highlight how researchers can ask questions with these data. We conclude by discussing several of the limitations identified while curating this database, and suggest directions for possible improvements to the DON itself.Our goal was to develop a metadata “skeleton” that stores key information about DON reports. To do so, we reviewed a total of 2,789 reports from the first 25 years of the DON (1996–2019), an interval that spans the start of their adoption as a formal system through the earliest days of the COVID-19 pandemic. We found that the data reported are often inconsistent within or between reports. For example, reports variously use all of the terms ‘Ebola,’ ‘Ebola Haemorrhagic Fever,’ ‘EHV,’ ‘Ebola Virus Disease,’ and ‘EVD’ to refer to the same clinical disease presentation. Similarly, geographic information may be inconsistent or unreliable: for example, DON reports often switch between spellings of cities or provinces .Given the challenges of textual data sources, we adopted a mixed system of standardized and subjective descriptors in our dataset. First, we standardized as many basic variables as possible that describe the identity and subject matter of a report:The identity of the report itself: Each report is stored at its own web address (URL). In the early days, these followed one standardized format . In later years, these have been changed to a system that instead directly represents the headline . For each report, we provide a unique identification number (“DONid”) that follows the original convention (even after it was no longer adopted). Headlines are given (“Headline”), and usually provide unstandardized information about the year, location, and disease in question. Sometimes, these give easily interpreted names for both diseases and countries  while other times they may deviate from this template . If a report contains multiple countries or multiple pathogens, we split these into separate rows with the same DONid, so that metadata corresponds appropriately (see below). We also report the date a DON was published (“ReportDate”) and the current URL (“Link”). In the event that reports for certain types of outbreaks spanned two or more calendar years, outbreaks were labeled using the start year of the multi-year event.The disease: Given that the DON database is likely to be used as a database of outbreak history, we chose to implement some standardization in this field, including retrospective assignments where they improved clarity. Wherever possible, we have adopted consistent names for diseases throughout the database, and applied these names in some cases in place of temporary names that fell out of favor . We use a two-tier system to address some nuances within naming conventions: for example, all “Influenza A” values in the DiseaseLevel1 field are accompanied, if possible, by more specific information on the HXNX subtype in the DiseaseLevel2 field. In some cases, a report may only describe an anomaly detected by syndromic surveillance; sometimes, outbreaks are never retrospectively resolved down to a causative agent. We adopt a set of six standardized “Syndromic” categories  for these reports, and give additional information as necessary at the second level. For example, DON-1996-10-15-a  is recorded as “Syndromic: neurological” at the first level of resolution, and “Meningitis: viral” at the second.The geographic area: Most reports provide a country in the headline (“Country”), which we matched to 3-letter ISO country codes (“ISO”), with country names updated as necessary to the most accurate conventions as of 2021. We labeled travel cases based on the reported location, unless genome sequencing of the pathogen was reported as showing a clear geographic origin of the outbreak. In certain cases, if events spanned multiple countries, all countries were listed in the labeling; however, if a report labeled an outbreak as a global outbreak, or more than 10 countries were listed in the DONs reports, we labeled the event as “Global.”  Additional regional locations used by the DON headlines that we preserved include “Americas,” “West Africa,” “African Meningitis Belt,” “Asia,” “Northern Hemisphere,” and “Central America.” Where possible, we also provide more detailed but unstandardized information on the reported geography (“OutbreakEpicenter”), based on the report text.In addition to this basic information, we include a handful of metadata that describes additional information contained in the reports, that are necessarily—like that information—even more subjective and unstandardized. This includes:Raw epidemiological data: Where possible, we record basic descriptors on case totals and associated mortality, across five fields: CasesTotal, CasesSuspected, CasesProbable, CasesConfirmed, and Deaths. In some cases, these may report rough estimates  We also note whether the outbreak describes a mass gathering event as part of the epidemiological circumstances, including a handful of cases where this is contraindicated (MassGathering).The timing of outbreak progression: For a set of different stages in outbreak progression, we record a mix of whether a particular event has been noted to occur and/or as much information is available matching that date. That includes the declared start date of the outbreak ; whether a report is specifically describing an outbreak’s detection (OutbreakDetection) and when ; whether or not an outbreak had been verified (OutbreakVerification) and if so when ; whether there was laboratory confirmation of a suspected pathogen (LabConfirmation), and if so, as of when ; whether national or sub-national authorities had been notified by that point , and if so, the first reported date ; whether the World Health Organization had been notified or not (NotificationWHO), which may sometimes be indicated by requests for confirmation, and the date of notification if so ; whether public communication was reported to have been undertaken by public health agencies (PHCommunication) and if so when ; whether public health interventions had been undertaken (PHIntervention), and if so when ; whether there was any report of community resistance to intervention (CommunityResistance); and finally, whether a report described the outbreak as having ended (OutbreakEnd), and if so, when . In many cases, the day field accompanying a reported piece of information is left empty because the report lacks specifics; more infrequently, the month field is as well.Any additional information: An unstandardized text field is reported from the researchers who coded the data (“Notes”) with any potentially relevant information about report content or quality control issues.As one final observation about data quality, we note that we chose to truncate our collection at the end of 2019, to both represent an even sampling interval (the first 25 years of the dataset) and avoid any potential changes that came with the Covid-19 pandemic. Around the same time, the World Health Organization began to migrate reports to a new location on their website, with a new URL convention. In the process, several reports have become un-indexed (presumably in error); the last currently searchable record is a June 13, 2019 record (“Ebola Virus Disease—Uganda”) followed by a January 2, 2020 record (“Ebola—Democratic Republic of the Congo”). At present, our database may be the only record of reports that span the second half of the year—the final two reports of the year are both from December 26, 2019—and their URLs have been updated to follow the same convention, even though these links are presently dead, with the expectation these reports will return soon online.While the total number of entries in the DON vary significantly from year to year, there has been no consistent increase or decrease over time. The number of reports published annually ranged from 59 reports in 2011 to 205 reports in 2014 , with anThe number of reports varies substantially among countries , and is per se. Though this means the DON is now a more faithful record of global outbreak surveillance, it loses some of the editorial aspects that have made these reports unique insights into the World Health Organization and its inner workings. Take DON-2003-06-26: “Update 89—What happens if SARS returns?”, which identifies five reasons that “should SARS return, it will not do so with a vengeance” . Mapping these clusters shows particular areas of shared global focus that are represented in the DON , and sent this matrix through a k-means clustering algorithm  and the Republic of Congo”, which describes outbreaks in these two countries reported in March and June 2011 respectively). Similarly, a report on avian influenza in Vietnam published on January 11, 2009 reports (presumably erroneously) that an individual first developed symptoms on January 28, 2009 and was hospitalized on January 31, 2009, several weeks after the report was published (DON-2009-01-11: “Avian influenza—situation in VietNam—update”). Other reports contain similar errors and chronological inconsistencies, such as the same report published twice on consecutive days (DON-2009-05-26: “Influenza A(H1N1)—update 39” and DON-2009-05-27-a: “Influenza A(H1N1)—update 39”).https://promedmail.org/) and HealthMap  are freely-available data sources, and the GIDEON database (https://www.gideononline.com/) provides access to global infectious disease surveillance data for a subscription fee. All of these sources are used for research and action—ProMed in particular was widely hailed as one of the earliest sources of public information on the Covid-19 pandemic —but are unofficial and for the purposes of outbreak reporting, fall under Article 9 of the IHR, which permits WHO to receive “other reports” and to seek verification from countries under Article 10, rather than official notifications from States Parties under Article 6 of the IHR.All of these aspects complicate the use of the DON (and our database of the reports) as a textual resource describing the global history of infectious disease outbreaks. It should therefore be unsurprising that researchers have often turned to other informal or privatized sources of information. For example, the International Society for Infectious Diseases’ Program for Monitoring Emerging Diseases . In the course of any given year, the WHO receives thousands of alerts about potential outbreaks; considerations about confidentiality, economic impacts, and public reaction are an important part of how this information is processed, but are difficult to reconstruct from outside the process. Perhaps more fundamentally, the value of the DON is directly proportional to the volume of information it contains. A concerted effort to increase both transparency and total information sharing through this channel could improve global trust in the WHO and confidence in its risk assessment process. A more comprehensive DON will also be more reflective of true hotspots of, and trends in, disease burden, making it a more valuable data source for researchers and practitioners.https://global.health/) project’s epidemiological line data may outpace the WHO’s own capacity to support outbreak research in global health.If the DON are indeed intended to be the global database of record for infectious disease outbreaks, changes to the structure of reports would also significantly improve their usability. Specifically, we believe that the WHO could improve DON reports by implementing a consistent and systematized reporting format related to epidemiological data. An appropriate place to start could be the criteria put forward by Smolinski and colleagues : case to


This article describes a seventeenth-century English woman writer’s interests inmedical care and the reasons that led her to publish texts on this topic. HannahWoolley offered guidance on a wide variety of topics in the domestic sphere,including recipes for health and beauty. Here we investigate the principles thatgoverned the preparation of these recipes, Woolley’s intentions in writing onthis topic, and the way in which academic medicine was translated and practicedby women routinely during this period. Defining these issues will help shedlight on the scenario in which literate female healers worked and the nature oftheir relationships with learned physicians. How were the medical theories that were popular in Western Europe during the modernperiod incorporated and practiced in everyday British life? And what tools wereavailable and used to combat disease by normal women without medical training? Thesequestions will guide us in the pages to follow; to answer them, I will utilize a textwritten and published by a seventeenth-century English woman that combined 111 medicinalrecipes in a section dedicated to medicine and surgery. Although the publications ofHannah Woolley (c.1623-c.1677) are highlighted, it is important to recall that manymedicinal recipes were produced by women during this period, as we shall see.In order to assess Woolley’s medical recommendations, we must briefly outline theprinciples that guided medical activities in England at that time. For the purposes ofthis text, we are most interested in the healing procedures that were widely used byerudite and empirical physicians, and the space occupied by women within this scenario,whether learned or non-specialized. Likewise, it is necessary to investigate theimportance of manuals containing medicinal recipes, and women’s participation in theauthorship of these works.Because these recipe books especially targeted high-class women, we must question how fartheir popularity extended among the female public, as well as the potential impact ofthis content on credentialed physicians. After all, as practitioners trained inuniversities, these men may have viewed the potential empirical activities encouraged bysuch works with suspicion, an attitude that gained traction in medical institutions suchas the College of Physicians in London.materiamedica . Alongsidethe medicinal herbs incorporated into the pharmacopeia, the Europeans adoptedpractices like “moxibustion, tobacco smoking and chocolate drinking”  and the discovery of blood circulation by WilliamHarvey (1578-1657) –, the foundations of medicine that were in vogue in Europe atthat time did not change , p.415. Although the four bodily humors  werecited in medical texts since at least Ancient Greece, the way these humors affectedhealth or illness was systematically contemplated by the Greek physician Galen. Galen examined the Hippocratic texts in detail in hisefforts to create a solid medical system based on the philosophical tradition,particularly Platonic ideals. Around 650, the medical theory and practice dominantin the Greek East and later, Islamic regions and the Latin West became known asGalenism , p.299.The “theory of the humors” can be summarized from three of its main supports:dietetics, pharmacology, and surgery , p.17. IFood played a crucial role in humoralist medical theory, since after ingestion it“was turned into blood by the liver and distributed to the body by the veins” , p.15. FIn broad terms, Galen attempted to classify drugs as simple or compound, indicatingthe differences between theoretical pharmacology and its practical applications. Inthis way, so-called “simple drugs” included herbs, animal products, or minerals thatgenerated a “unique action” resulting from their connection to the cosmos. Forexample, “substances linked with the first of the Five Ages of Humankind” (accordingto mythology) heated the body, thus eliminating excess water . Since simple drugs demonstrated limited effectiveness againstdisease, it was necessary to use compound drugs which involved a mixture ofingredients. They were recommended when contrary forces needed to be appliedsimultaneously, such as in wounds caused by venomous creatures , p.440.At the time when Hannah Woolley was writing her books on domestic subjects withmedicinal recipes, English society already had a solid tradition of this literarygenre. These books originated from “medieval books of secrets” that recreated“treasured medical, alchemical, or trade recipes” written in Latin that circulatedamong the elites . While men wereresponsible for the increasing publication of these books, women made their recipesknown “exclusively in manuscript until the middle of the seventeenth century” . But printing women’s texts became viable andeven lucrative after the Restoration in 1660; in this sense, it is important toremember that Woolley is considered the first woman to produce these publications ina “commercial enterprise” , a fact that isclosely connected to the popularity of this genre during the second half of theseventeenth century.Herbal, as well as a text on surgery. As an adult, Mildwaycompiled “many hundreds of medicinal recipes,” and was a healer to family members,friends, “and the poor in rural Northamptonshire” . The home consequently was a main site for medical care andsimultaneously the center of female authority on issues of this nature recalled that her governess encouraged her to read William Turner’ss nature , p.108.The era in which Woolley wrote was preceded by a scenario that favored women’swriting. During the 1650 a new generation of female recipe authors emerged,including aristocratic women ,p.150. The popularity of these books resulted from growing literacy in the country as wellas decreases in the cost of paper and other raw materials. The texts circulated inprint but also continued to be copied by hand. This genre was especially prolificduring the seventeenth century. Between 1600 and 1700, book publishers in London“issued over 200 medical recipe titles,” with roughly sixty new texts and around 170reprints, “making them one of the most popular genres of vernacular medical texts inearly modern England” ,p.13.While it is impossible to precisely state the number of recipe books published duringthe seventeenth century throughout all of England, we can state with certainty thatwomen were customary authors of this genre. The historian Jennifer Stine hasestimated that approximately one hundred books were produced by women in earlymodern England. Stine  also suggests that manyother anonymous recipe books in archives were written by women. One notable writerin this genre was Woolley, who was considered “the most popular domestic writer” ofthe late seventeenth century and “the first woman to publish a cookbook” , p.394.We do not have specific details about Woolley’s biography, but we do know that shewas orphaned at 14 years of age. Her musical abilities and knowledge of Italiansubsequently captured the attention of a noblewoman who hired her as a governess. Inthis position, Woolley nurtured and developed her interests in subjects includingmedicine.The ladies’ directory, was published in 1661; it was followedthree years later by The cook’s guide, which also targeted femalereaders .Her 1675 book entitled The second part of the book, entitled “The physical cabinet,” begins with thefollowing description: “Excellent Receipts in Physick and Chirurgery,” as well as“some Beautifying Waters, to Adorn and add Loveliness to the Face and Body.” Here Ishall investigate the medicinal recipes and advice directed toward women in order toassess the role they played in everyday healing and what these female functions cantell us about the medicine which was popular in England during the second half ofthe seventeenth century.cholithat revels the link between this humor and the choleric temperament . In the text, yellow bile isreferred to as “choler,” a reference to the ancient Greek perament , p.163. The humors were mentioned again in the second part of the book in recipe number 28,against “Kings Evil.” The main ingredient in this formulation was “BroomflowersDistilled:” the patient was to ingest this liquid in the morning on an emptystomach, since it would help “purge the evil Humour” and help to internally shrinkscrofula . The illness called Kings Evil referred to theswollen lymph glands known as scrofula, one manifestation of tuberculosis; itsmicrobial cause would be determined in the nineteenth century by the Germanphysician Robert Koch . Since medieval times, the kingsof France and England laid hands on scrofula with the intent of curing theirsubjects. But it was in modern times that the royal touch “assumed its determinedplace among the minutely regulated pomp the absolute monarchies surroundedthemselves with” , p.91.4Vinum Hippocraticum, as it came to be known among physiciansand pharmacists, was considered a pleasant way “to improve one’s health” : hippocras. Thispreparation consisted of spiced wine, and was well-known since the late Middle Ages. health” , p.333. cordis); their medicinal propertieswere prescribed to treat numerous diseases. Certainly for this reason, norecommendations for use were provided alongside the recipe for the “most excellentcordial” recommended by Woolley, the “Catholicon” , since itwas essentially a panacea.Liquid preparations are common throughout the book. Besides the constant use of wine,another common formulation in the medicine of this period was the cordial, distilleddrinks that could be diluted with water before serving. These liquors likelyoriginated in thirteenth-century Italy, and reached England in the fifteenthcentury, where they were known as “distilled cordials waters” . The medical benefits of cordials were not restricted to cardiac health  and āb (water), and initiallycontained three ingredients: water, sugar, and distilled rose petal extract , cordials are cited a dozen times in the book. Thejulep is derived from the Arabic word  extract , p.165.  extract , p.72. C extract , p.223, The ladies cabinet enlarged and opened explained that “theprinciple use of this water” was against all illnesses related to the cold. It wenton to state that Doctor Steven himself, who had been confined to his bed for tendays, healed himself with this compound and went on to live to age 98 ,probably a reference to the late-seventeenth-century Irish physician of thatname.A choice manual, or, rare and selectsecrets in physick and chirurgery. This recipe in turn referred to anunnamed “professor of medicine” . The Countess of Kent was Elizabeth Grey(1581-1651), author of the 1653 book edicine” ,p.198, The other mention was of “Gascoign Powder,” a panacea recommended against fever,measles, plague, and melancholy. This preparation was intended for a more restrictedgroup, considering the expensive ingredients: not only oriental bezoar, but alsocrab eyes and pearls. Although Woolley cited these two powders as different recipes,it is important to note that Gascoigne’s powder was also known as the Countess ofKent’s powder, according to the historian Lucy Besides the panaceas that used spices, the text presents another pharmacologicalrecipe that was well-known since ancient times: theriac. This preparation wasmentioned in parts one and two, and referred to by two different terms: “treacle”and “Theriacal extraction.” Theriac dates back to Galen’s time, and this compoundspread widely among Arab Muslims and Christians in the following centuries. It wastaken orally or used as a salve, and was originally believed to be an antidoteagainst venom; over time, it became a panacea and was administered until at leastthe nineteenth century ,p.441.Venice was one of the places known for the production of theriac, and Woolleymentions its preparation in part two in the recipe for “Plague-water” (recipe 52). Asimilar recommendation appears in part one (recipe 98), also against plague. In thiscase, Woolley highlighted “Andramachus treacle,” named for the Emperor Nero’s courtphysician who created theriac, according to Galen  proposed and used since the sixteenthcentury by Paracelsus , p.258. 93-1541),p.167. Other chemical preparations recommended in the book utilized absinthe and turpentine.The plant from which absinthe is derived has been known since ancient times,particularly for its antiparasitic function; its English name, wormwood, refers tothis property. The drink made from this plant, absinthe, spread across Europe duringthe Renaissance. Besides its recreational uses, advances in the process ofdistillation “purified and concentrated” the flavor of this drink, which furtherboosted sales alongside recommendations by physicians and pharmacists , p.116. Since many culinary and medicinal recipes circulated in handwritten form and oftenwithout indications of authorship, it is difficult to trace mentions of Woolley’sbooks. But another manuscript from the seventeenth century by Margaret Baker revealssimilarities to the text analyzed here. The recipe for fennel oil in Baker’s text,for example, is almost identical to Woolley’s , p.141. Woolley’s medicinal recipes also reveal an important topic in the medical practice ofthis period: the roles attributed to gender. In the case of women, care alwaysrevolves around two factors: how they were treated as patients, and their work ashealers. These functions in turn were linked to social class. After all, women withfinancial means were able to exercise certain options of choice in this scenario,whether this meant consulting with learned physicians or learning medicinal recipes.These options were much more restricted for women in the lower classes.Although women could be affected by various diseases, Woolley concerned herself withrecommending resources for “female diseases,” namely those related to obstetric andgynecological conditions. Since women might be uncomfortable subjecting their bodiesto examination by male hands ,p.233, Although Woolley did not utilize terms such as “practitioners” or “healers,” it isclear that the recipes were intended to be prepared by women and used by them or bytheir patients. A clear example is found at the start of the book, where Woolley states that ladies would find the text a guide “to help yourPractice.” The recipes that focus on women’s bodies can be divided into three largegroups: menstrual care, remedies related to conception, preventing miscarriage, andthe postpartum period, and frequent diseases such as cancer. The author also addedguidance on common childhood illnesses and conditions such as worms, fevers, andteething. Finally, there was a single recommendation for wetnurses in order tocombat fever in infants . Because these women played animportant part in infant care and health, they were carefully chosen, which isevident in manuals containing advice about wetnurses during this period , p.93.Because at that time fever was understood to be more of a disease than a symptom ofan illness, Woolley presented specific advice about fever and even malaria inchildren. Again, many common ingredients in Hippocratic and Galenic medicine werepresent. In this case, the directives were to be followed by the wetnurse and thechild. The wetnurse was to drink a frequent remedy: wine, with the addition ofpowdered crystal. Since wine was considered hot and wet, the same characteristicsseen in children, these patients were not to consume this drink. Instead, thesuggestion was topical: “Root of Devils-Bit” was to be hung around the child’s neck.The gentlewoman’s companion mentions “an approved Medicine ofLondon-Midwifes” to heal sore breasts . Inpart two, the instructions include various preparations against everything fromfever and dry cough to pleurisy and recent blindness in men (p.164). This book doesnot contain recommendation for women’s healing, but this does appear in anothertext.  breasts , p.169.The gentlewoman’s companion. Although she recognizes theexcellence of many authors in the subjects approached in this book – and includestheir names in her recipes –, The sources of medical knowledge Woolley used  can be seen, since physicians’ names as well as therapeuticrecommendations are frequent in both texts, from 1675a and 1673. Furthermore, sinceshe herself defended women’s right to education, female influence was alsoemphasized in her text, as in the case of the recipe for “the Countess of KentsPowder” . Finally and importantly, we must underscore her ownlearning in the healing arts. Her empirical training in this area is clear in thetext of The queen-like closet, we can better assessthis process of medical learning and healing practice she cites. The author statesthat she acted as “Physician and Chirurgion” in her own home and to the benefit ofher neighbors  that threatened the life of both mother and baby. But thanks tothe care received, the pain ceased and the delivery proceeded. After her firstmarriage to a teacher, Woolley practiced her healing arts on the children in herhusband’s school, where she treated illnesses like fevers, malaria, and smallpox.And she added an observation: “unless [the boarders] were desperately ill” theirparents trusted her work and she was able to heal them “without the help of anyPhysician or Chirurgion” (p.9).The queen-like closet  are citedin the supplement to e closet , p.10. Te closet , p.63 anThe accomplish’d lady’sdelight...). And in the supplement to The queen-likecloset, physicians who were fundamental to the construction andpractice of medicine popular at that time were also mentioned. Galen, Hippocrates,and Paracelsus were denoted “the Wisest Philosophers”  played animportant role in traditional healing, efforts to remove these groups from medicalpractice began from the Renaissance period. As such, by suppressing “spiritualdimensions” in medicine and science, “healers, magicians, and witches lost theirclaim to manipulate the spiritual forces of the world” and “the ground was preparedfor a mechanization of the world” , p.17.Although Woolley was not a licensed doctor, her daily practice seems to have occurredin a much more favorable setting than that of poor, illiterate healers who lived farfrom the big cities. In fact, there was a social recognition that linked domesticculinary tasks to the art of preparing remedies. In other words, a “good wife” wasexpected to make provisions to keep her family healthy. This network of knowledgeinvolved her “mother, relatives, neighbours, medical practitioners,” and naturally,recipe books , p.52. IEven if Hannah Woolley  recognized that many books on the topics ofcooking and medicine were published at the time she was writing, her initiative wasbold: to offer “all the Accomplishments necessary for Ladies.” Besides gatheringbeauty tips and advice, her text focused on women’s skills in healing themselves andothers through written instructions. In order to not lose sight of the scenariowhere this production occurred, we must add that the culinary and medicinal recipegenre highlighted female authority, allowing women to express their identity in “aprofoundly religious Society” that discouraged individual identity and“self-celebration” . The importance offemale protagonism is notable in the dissemination of knowledge as well as in itspractical implementation.Despite these tools to construct this medical knowledge among women, we cannotminimize the turbulent arena in which empirical practitioners worked inseventeenth-century England. In 1684, the president of the College of Physicians,doctor Charles Goodall, wrote a book especially dedicated to fighting against“Empiricks and unlicensed practisers” , whichindicates that there were enough such people to provoke a response from medicalinstitutions. Although Woolley combined various roles equivalent to physician,surgeon, pharmacist, and midwife, she did not write a single word about possiblesanctions or persecution. Nor was the sale of remedies by Woolley the subject ofdispute by learned physicians, characters who were interested in regulating thiscommercial activity and protecting it against lay practitioners . As we have maintained in this article, it is possible thather social class and the medical principles of the time that she adopted also actedto impede any hostile behavior.In this sense, we must be cautious with the notion that traditional female medicalknowledge was essentially different from normative medicine, and that womenpractitioners were widely “suppressed by male physicians” (Ehrenreich, English citedin One caveat is important about employing medical theories with such distinctsuppositions. Even though Paracelsus opposed ancient medicine and the principles ofGalenic theory, the chemical aspect gained ground among physicians in England duringthe seventeenth century. So alongside the presence of the philosophical foundationsof Galenic medicine, the emergence of other groups defending “experimental,chemical, mathematical and mechanical approaches to nature” can be noted , p.358. Thequeen-like closet, where she stated that she cured the injured leg of amason, since “because he was poor his Chirurgion gave it over” (Finally, we must recall the crucial role that women played in their communities andin society at that time. Woolley and other empirical practitioners occupied a spacein which learned physicians were seldom present. Although some doctors did attendpatients for reduced fees, documents of the time show “few examples of doctors whocharged no fee to poor patients” ,p.30. Wit over” , p.12. SThese are just two examples of many reported by Woolley. She was yet anothercharacter in this important group of healers from different social classes andworking in various areas of healing, from labor to postpartum, from creating curesfrom herbs to bedside treatment. All these women constantly “engaged in healing,assisted in childbirth, and comforted the dying” , p.29: a