However, the filtering strategies and software used to prioritize high-confidence variants vary from study to study. In an effort to establish recommendations for rare disease research, we explore effective guidelines for variant (SNP and INDEL) filtering and report the expected number of candidates for de novo dominant, recessive, and autosomal dominant modes of inheritance. We derived these guidelines using two large family-based cohorts that underwent whole-genome sequencing, as well as two family cohorts with whole-exome sequencing. The filters are applied to common attributes, including genotype-quality, sequencing depth, allele balance, and population allele frequency. The resulting guidelines yield ~10 candidate SNP and INDEL variants per exome, and 18 per genome for recessive and de novo dominant modes of inheritance, with substantially more candidates for autosomal dominant inheritance. For family-based, whole-genome sequencing studies, this number includes an average of three de novo, ten compound heterozygous, one autosomal recessive, four X-linked variants, and roughly 100 candidate variants following autosomal dominant inheritance. The slivar software we developed to establish and rapidly apply these filters to VCF files is available at  Isolating the small subset of causal variants from the numerous inconsequential variants in cohort exome and genome datasets remains an analytical bottleneck. The decreasing cost of sequencing has resulted in a dramatic increase in the number of groups analyzing sequence data from rare disease families. Because of alignment and variant calling artifacts3, careful filtering is required to extract an accurate set of causal variants. Each research group may choose custom strategies, use ad hoc software, or one of many tools designed to facilitate the filtering, including seqr (https://seqr.broadinstitute.org/), GEMINI4, and genmod (https://github.com/moonso/genmod). This leads to innumerable possible outcomes when analyzing the same cohort.Rare human diseases are often caused by de novo or inherited variants in a single protein-coding gene5 examined filtering strategies on variant call files (VCFs) but did not provide a set of parameters that can be widely applied across cohorts or the expected number of candidate rare-disease variants expected. Here, we introduce a minimal, but effective set of filtering parameters and report the resulting number of candidate variants for each mode of inheritance. We sought to provide a set of variant filtering parameters that would reduce variability across studies and provide a common baseline for research across different tools and research groups. We have avoided several common filtering strategies that are either cohort-specific, or potentially too strict; for example, although prioritizing predicted loss-of-function (pLoF) variants7 can reduce the search space, many pathogenic variants in ClinVar8 are not pLoF, so most analyses must include a broader set of variants. These filters were found to have nearly identical performance in two whole-genome cohorts and also in two whole-exome cohorts. The resulting set of recommended, data-derived filters can be used in any tool as a standard practice for variant filtering. The strategies we describe establish a baseline expectation for variant counts per trio for each inheritance mode.Even within a single tool, different parameter values can affect the number of candidate variants, which in turn, can impact variant prioritization and the ability to reach a genetic diagnosis. A previous studyThroughout, we note that counts of autosomal dominant candidates differ by orders of magnitude from the number of candidates from de novo dominant and recessive modes of inheritance. Therefore, researchers exploring autosomal dominant candidates will require additional filtering or prioritization, though here, we limit our explorations to simple, strict filtering and report the resulting counts.9 to be homozygous for the reference allele, yet the child was predicted to be heterozygous. Because we expect between zero and two true de novo variants per exome trio2, Mendelian violations in excess of this expectation are predicted to be false positives. Alleles that were heterozygous in the child and in only one parent were considered to be transmitted from the parent to the child, and treated as true positives. We varied allele balance  cutoffs before declaring a variant to be either a Mendelian violation or transmitted variant , we labeled variants as potential Mendelian violations when the parents were predicted by GATK10. Nonetheless, to our knowledge, it is the first data-driven derivation of filtering cutoffs.These results established a genotype-quality (GQ) cutoff of 20 or higher and an AB between 0.2 and 0.8 (the purple point in each figure) as a rational trade-off between precision and sensitivity, as it removes many of the Mendelian violations  while retaining most (98.6%) transmitted variants (true positives). In fact, this is likely a conservative threshold, as even the more stringent threshold of 0.3–0.7 has a very high transmission rate, and an estimated false negative rate of ~1.41%. In our testing, this range performed well for both exome and genome data (see below). We performed the same analysis on an independent cohort of 36 whole-exome trios from a study of congenital heart disease at the University of Utah. We verified that the curves were similar and that resulting thresholds were similarly effective  or moderate  impact of the resulting protein. Such variants are henceforth referred to as “impactful.” Combining these additional requirements reduces the number of candidate de novo mutations from a mode of 3 to a mode of 1 per exome trio  at the expense of a higher number of Mendelian violations  to ~30X coverage, as part of the Rare Genomes Project (“Methods”). In order to explore additional options for WGS variant filtering, we considered calls from DeepVariant14.With our means of choosing transmitted variants as true positives, it is possible that the additional transmitted variants in GATK relative to DeepVariant are merely false positives shared between parent and child. Yun et al. found that while GATK makes more calls than DeepVariant, DeepVariant actually has a higher recall, indicating that many of the extra GATK calls are actually potential false positives9 retained most transmitted variants and removed a large percentage of Mendelian violations reported when no sequencing depth requirement was enforced across cohorts and tools , AB, genotype quality, AF, and parent allele-balance reduced the number of putative de novo variants from both GATK and DeepVariant calls  or to nonstandard inheritance patterns .We have shown that simple cutoffs on GQ, AB, depth, impact, and gnomAD AF are sufficient to drastically reduce the number of candidate variants in a typical family, while retaining the vast majority of transmitted variants Table . We havede novo variants  to a manageable number. While we expect these to vary by cohort, the numbers are similar across our whole-genome and whole-exome cohorts. For our whole-genome cohort, we find a mean of 13.1  and 18.3 , for DeepVariant and GATK, respectively . However, our analyses demonstrate that overall performance is not affected by the exact choice. For example, one could choose a GQ of 15 and an AB range of 0.3–0.7 and achieve a similar enrichment of true positive variants. Most likely, cohorts with lower sequencing depth would need to lower the depth cutoff of 10 . This will be an avenue for future research.8 pathogenic variants. This cutoff is easily changed by users of slivar by editing the default impact order; the ordering used in this study is included in Supplementary Table While the exact choice of what is impactful will affect the results, the set of impacts used for this study would retain 98.83% of ClinVarIn summary, we have derived a set of best practices for variant filtering in studies of rare human disease, and report the expected number of candidate variants across different modes of inheritance. In addition, we have developed slivar, a new tool for rapidly applying these filters and extracting variants that meet each inheritance mode. We facilitate application of these recommendations with the continued development of slivar software.We have complied with all relevant ethical regulations. We have obtained informed consent from all relevant participants. The clinical exome data obtained from ARUP Laboratories for the main exomes for this study was approved for de-identified research use by the Institutional Review Board of the University of Utah.20, which is a nim language wrapper for htslib. While slivar uses hts-nim for reading and writing VCFs, it also embeds the duktape javascript engine (https://duktape.org) to enable user-defined expressions on each variant. slivar expects a pedigree file that indicates the phenotype status and the family relationships; from this, it infers each possible trio and family. Then, for each variant, it fills a javascript object for variant and for INFO and for each trio, it consecutively aliases the samples with the labels “kid,” “mom,” and “dad” and then applies the user expression. For example, a minimal expression to call a de novo variant in the kid would look like:Slivar is implemented as a command-line tool. It is built on hts-nimkid.het && mom.hom_ref && dad.hom_ref && \ kid.GQ > 10 && mom.GQ > 10 && dad.GQ > 10 && \ variant.FILTER = = “PASS” && INFO.gnomad_popmax_af < 0.001This expression requires that: the child is heterozygous while the parents are homozygous; each sample has a GQ > 10, and that the alternate allele for variant is observed at <1 in 1000 frequency in gnomAD. Slivar automatically discovers each trio from a pedigree file and applies this expression to each trio, for each variant. For any variant that meets these criteria for a given family, slivar appends the sample name of the kid to the variants INFO field in the VCF file. The attributes available for each sample  and for INFO and variant are enumerated in Table denovoThis allows the distribution of a set of best-practices functions for de novo, compound heterozygotes, recessives, X-linked, and other modes of inheritance.The trio mode described above is a special case of a more general framework within slivar for families. A family in slivar is any set of samples with the same family identifier in a pedigree file; this can be a single sample, or a large, multigenerational pedigree. This framework enables a more flexible set of expressions that handle most use cases, for example, finding a segregating, dominant variant in a single sample, a trio, a larger nuclear family, or a multigenerational pedigree is handled by a single javascript function.Another mode, that we call “groups,” is an additional way to handle sets of samples that do not meet a normal family structure, for example, a cohort of cancer patients with a “normal” and “tumor1,” “tumor2,” “tumor3” to indicate three tumor time-points. These groups can be defined in slivar via a tab-delimited file where the header indicates the labels and each row indicates the sample IDs those labels are applied to. For example, a cohort with ten quartets would have a header line with four columns  and ten rows, each with four sample IDs. The user expression utilizing the labels “mom,” “dad,” “kid,” “sib” would be applied to each of the ten quartets for each variant.A user can specify multiple group, family, and trio expressions, each with a label that is added to the INFO field for each passing expression. For example, if an expression labeled as “denovo” is evaluated as true in a trio, then denovo = $kid_sample_id would be added to the INFO for that variant. Multiple samples (trios) passing the same expression are joined by commas.21, VEP22, or bcftools csq23 in order to group variants by gene. It then uses the pedigree structure to phase variants to ensure that the two alleles in the compound heterozygote are on different haplotypes. In addition, it supports variant pairs where one side of the compound is a de novo. As with the standard slivar mode, this adds an annotation to the INFO field indicating the sample and the variant pair that are part of the compound heterozygote.Because slivar expressions operate successively on each variant, there is a separate subtool to find compound heterozygotes. It expects gene annotations as added by snpEffhttps://m.ensembl.org/info/genome/variation/prediction/predicted_data.html). In addition, the exact ordering is less important as a user will be interested in a variant that is stop_loss or frameshift should it appear. We have chosen the cutoff for impactful to be quite lenient, and the ordering and cutoff are both customizable by a simple text file. slivar will automatically detect and parse these annotations if they appear in the VCF, iterate over each consequence and add an “impactful” flag if any consequence is above the cutoff. This can be used independently of the family-based analyses to annotate variants of interest. If multiple annotations are found, for example from both VEP and snpEff, slivar will use the highest impact across tools to determine impact. This simple flag allows the user to find variants of interest without checking for an exact consequence of “missense,” “stop_gained,” etc.Annotations added by VEP, snpEff, or bcftools are automatically parsed by slivar and evaluated for “impactful-ness.” In slivar, we have collected all consequence annotations , given them a severity order, and split them into “impactful” and not. This ordering is somewhat arbitrary, as for example a case could be made that stop_loss annotation indicates a more severe impact than frameshift or vice versa, but we have based it on the ordering indicated for variant-effect predictor  make them substantial requirements and slow to parse. To alleviate this, we developed a custom, reduced annotation format that can encode the variant position, reference allele, alternate allele, and a boolean indicating a non-PASS FILTER in a single 64-bit integer. This is similar to VariantKey (https://www.biorxiv.org/content/10.1101/473744v3), except that VariantKey stores the chromosome, but not the FILTER. slivar assumes that variant files will be sorted by chromosome, so we can store variants from each chromosome separately instead of including the chromosome in the encoded value. slivar stores variants with a REF + ALT allele longer than 13 bases in a separate text file as these can not be encoded into a 64-bit integer. Since the percent of variants of that size is low, the size of the text file is small and searching in the text file is only done when the query variant is also large. Whenever a long variant is found, a sentinel value with an empty reference and alternate allele are added to the encoded array indicating the presence of a long variant. Additional fields containing the values of interest, for example the AF and the number of hom-alt samples are stored in separate arrays. All arrays and chromosomes are written to a single compressed zip file. This allows us to distribute gnomAD version 3 AFs and positions for the whole-genome cohort in a 4-GB file . In order to annotate a query VCF, each query variant  is encoded to the 64-bit value and a binary search is used to find that variant. If it is found, the index of that variant in the array is used to extract the values, which are then added to the INFO field of the query variant. If a sentinel value is found, slivar searches the (sorted) array of long alleles and returns those. This setup allows us to annotate at >20K variants per second. We call this format and annotation method “gnotation.” slivar performs this gnotation step before the user expressions are applied so that the expressions can utilize population AFs. This annotation can be performed independently of the family expressions as a way to quickly annotate with AFs.As we demonstrate, annotating with population AF is critical for rare disease research. As the size of population AF resources such as gnomADSlivar includes a subtool to create these gnotation files, but we provide downloads for gnomAD for version GRCh37 and for hg38 that contain “gnomad_popmax_af,” and “gnomad_nhomalt” that are the union of exome and whole genomes. In addition, we provide a TOPMed gnotation file for hg38.In order to develop the best practices for rare disease, we utilize a cohort of 149 rare disease exome trios and a WGS cohort of 94 trios aligned to hg38. These families all have unaffected parents, making them more likely to follow recessive or de novo inheritance, however, we also evaluated autosomal dominant strategies by artificially setting the mother to “affected.” This gives an idea of the number of variants left after filtering in an analysis under each of these disease models. We also replicated the analyses in independent whole genome and exome cohorts. The additional whole-genome cohort contained 49 trios where the proband had a sarcoma phenotype and the exome cohort was 36 trios with a coronary heart disease phenotype.27 can evaluate the sensitivity by counting the number of transmitted variants—that is, the number of heterozygous variants in one (and only one) parent that are transmitted to the child. We chose to require transmitted variants to appear in the child and in either, but not both parents, so that we would penalize a caller that over-called heterozygotes. If we allowed a true positive to be any variant that appeared in both parents and the child, it would be more likely that we included variants that were false positives in all three samples.We use the number of putative de novo and transmitted variants discovered in each trio to inform viable filtering strategies. We know, for example, that there should be between 0 and 2 de novo variants in the exome. Due to alignment issues, base-calling errors, and variant calling errors, there will be many more than this without additional filtering. We can evaluate the specificity of different filters by looking at the number of putative de novo variants; likewise, we12 and evaluate slivar filters effective for that tool.We primarily rely on filtering strategies that utilize allele balance, genotype quality, and genotype that will be common to most VCFs, rather than on custom fields like fisher-strand bias or mapping-quality rank-sum, which are optional annotations from GATK. Although depth is generally used, this can vary between cohorts and does not offer improvement over allele balance and genotype quality in exomes, therefore we do not utilize it as a default. But it can be beneficial in filtering whole-genome samples. In addition, for the whole-genome cohort we use Deep Variant27 to run slivar with and without low-complexity regions for each cohort and tools. This workflow used is available at the following URL: https://github.com/brentp/slivar/blob/cf9328054a84ac6c1c2400925df604fe3e8170b2/paper/slivar.nf.For this study, we used nextflowFurther information on research design is available in the Supplementary InformationReporting Summary


Interactions between faculty and students in higher education has the potential to influence and shape many aspects of teaching, learning, curricula, student experiences and performance, yet has received little attention as an area of study. This study investigates student-faculty interactions within a physiotherapy curriculum from the perspectives of students, faculty and physiotherapy managers at a South African university. The data, produced through multiple methods, derive from students, faculty and physiotherapy managers underpinned by critical-feminist perspectives. Thematic analysis of the data produced four themes. Two dominant threads emerging from the analysis as characterising student-faculty relationships are the deeply hierarchical relations of power characterised by a lack of caring and concern for students, and the exclusion of wider constructs for interaction; deriving from a particular entrenched medical model. Ironically, while caring relationships with patients are overtly advocated and developed, they appear to be largely absent in the same physiotherapy curriculum spaces in the relationships between faculty and students. These findings raise questions about how the most foundational attribute of a health science professional, that of caring, is being produced through the curriculum in the relationship between faculty and students in the health sciences. Teaching and learning is a relational process that is influenced by the interactions between student and faculty, these relationships affecting student satisfaction and the effectiveness of learning. Health professionals pride themselves in nurturing caring in their students as part of the higher education curriculum to ensure that once students go into practice, they will transfer the caring behaviours and attributes to the relationships they develop with their patients. It is hoped that these caring behaviours and attributes become re-inscribed in settings and relationships outside the university learning environment, for example, when the authoritative role shifts to the student in practice settings. This study, therefore, explored how caring was produced in the interactions between students and faculty in the physiotherapy classroom and in clinical practice settings.The first objective of the literature review was to identify and synthesise international literature on the nature, purpose and critical elements related to student-faculty interactions by undertaking a focused review. The second was to provide an overview of the South African socio-political context, particular to higher education and healthcare that has shaped the development of interactions amongst students, faculty and patients. An environmental scan of reports, literature and regulatory processes was undertaken to describe the historical and current context of the practice of South African higher education and healthcare.An attribute of successful teaching is the strength of the interpersonal relationships that develop between students and faculty, the effectiveness of which can have implications for the success or failure thereof .Hagenauer and Volet  identifyOf the different aspects that comprise the affective dimension in teacher-student relationships, Hagenauer and Volet  highlighmodelling i.e. showing in the behaviour as teachers what it means to care; (b) dialogue is the way to model the caring ideal in communication; (c) practise, where the teacher models caring communication while the student practises it, and (d) confirmation, where the teacher identifies a better self in the student and encourages its development , and ColouredsIndividual semi-structured interviews were held with seven of the nine faculty members, who comprised one Black African, five Indians and one Coloured, which consisted of one male and six females.Two in-depth focus groups interviews together with journal entries were used to produce data from 42 physiotherapy final year students. Focus group interviews were scheduled, one before and one after the elective clinical block. An elective is a three-week clinical education block in the final year of the programme, during which students practise physiotherapy at a clinical site of their choice. Pre-elective focus group interviews were conducted at five clinical education sites, and are referred to in the analysis as A1, B1, C1, D1 and E1. Post-elective focus group interviews were conducted at three clinical education sites and are referred to as A2, D2 and E2. The distribution of participants into smaller groups is indicated in the analysis as focus group 1 (FG1) or focus group 2 (FG2).The cohort comprised 36 female students: 17 Indian, 11 Black, six White and two Coloured. Of the six male students, two were Indian and four were African. Each student was given a journal to document his/her experiences of becoming a health care professional within their undergraduate program, of which 29 were returned, with guided reflection being used to assist the journal entries.A group interview was conducted with 19 physiotherapy managers from public hospitals. There were 2 Black males, while the 17 females comprised eleven Indian, one Coloured, two Black and three White. Twelve of the participants were experienced physiotherapists who occupied management positions at urban, well–resourced public hospitals or health care centres, having had over five years of working experience. Seven participants were novice physiotherapists at small, rural, under-resourced hospitals.Data collection focused on how caring in interpersonal relationships were constructed and experienced between student physiotherapists and faculty, and observed by physiotherapy managers. Multiple data collection methods, data sources and member checks were used to assure validity, with the interviews and focus group discussions being audio-taped and transcribed. Data triangulation through consensus amongst the multiple data sources, as well as transparency and honesty relative to the context, were important to assure trustworthiness  and “caring should be the guiding principle for training physiotherapists” (Faculty B). The “identity of the profession would be lost if caring was absent” (Faculty B). (Faculty F), and “there are students who think that there are lecturers who do not care for them” (Faculty D). The absence of caring by faculty was confirmed by student reflection in the quote “it seems like no-one cares for us” (Student focus group interview: A1FG2).While a few faculty espoused how caring was constructed in their “approach to teaching as a parent” (Faculty D) and as “the nurturing mother” (Faculty G), others reported that despite physiotherapy being perceived as a caring profession, they did not demonstrate caring. They “do not give students love and care, to open and blossom” (Faculty G), “students think that we’re so far away from them, that we can’t reach them”Listening, showing empathy and nurturing, were generally not experienced by students, while several faculty conceded that these were lacking in their relationships with students. Students reported that “lecturers don’t stop to listen to you and you have a whole lot of issues.” (Student focus group interview: D1FG2). Faculty agreed with this view saying, “there is no time to get the student’s perspective. We just try to push the syllabus.” (Faculty D). Students stated that faculty were not empathetic towards their needs and that “lecturers need to improve their approach towards students that are struggling” (Student focus group interview: A1FG1).Faculty agreed that to develop caring in students as part of the professional identity, it had to be modelled during teaching in the classroom and clinical environment, and in their interactions with students. Modelling care was imparted by the educator in “role-playing on how to handle, assess and treat a patient” (Faculty B). Students, on the other hand, described their difficulty in modelling faculty because “You hardly see them [faculty] doing hands-on or showing you how to do this or that. You have nothing to fall back on or visualise or try out because you have never seen them do it” (Student focus group interview: D1FG1). Developing interpersonal relationships, collegiality and interconnectedness between students and faculty, faculty and physiotherapy managers and amongst faculty themselves featured as another dominant theme. Student physiotherapists were clear about the importance of skills for interpersonal relations as part of their professional identity, “If you can’t have an interpersonal relationship, you can’t be a physio” (Student focus group interview: E1FG1). However, these skills were not considered important and there were no explicit opportunities designed within the curriculum to develop interpersonal relationships. Communication amongst students, and between students and faculty was poor, “there is a divide between students and lecturers” (Student focus group interview: D2FG1).Students stated that “nobody takes our viewpoint into consideration” (Student focus group interview: D1FG1), while faculty described how their relationships lacked collegiality and valuing. This was evident as they did not make an effort “to meet and mix” (Faculty D), “to discuss how we teach” (Faculty E), “to share ideas” (Faculty A), and they reflected on how these behaviours were “rubbing off onto the students” (Faculty A). The state of the student-faculty relationship rested on the relationships amongst faculty themselves, the absence of cohesion and operating in isolation from each other, which was being transferred to students.Student-faculty interactions were characterised by hierarchical authoritarianism, disrespect, silencing, and ‘othering’ arising from discrimination. The students described faculty as “intimidating” (Diary No. 18) and disrespectful, particularly during clinical examination sessions where faculty “make students feel small and degrade them” (Student focus group interview: C1FG2). Authoritarianism featured in student-faculty interactions, which functioned to silence students. “Being in the physiotherapy department feels like being in school…the lecturers have some authority, some hold over you. I used to be so enthusiastic in the first year, raising my hands to answer questions, but now it’s about maintaining a low profile, obtaining my degree and leaving” (Student focus group interview: C1FG2). Authoritarianism was also observed by the physiotherapy managers, “lecturers must come down to the level of the students and they need to be open to suggestions. Most of these students are so afraid to ask questions” (Participant: Group A), and by faculty themselves, “The moment they see us, a figure of authority, they freeze.” (Faculty G).A strong theme from the perspective of faculty, that underscored student-faculty interactions, was pedagogical authority described primarily as a parent-child association. Several faculty referred to this conception in how they related to students: “To me, they are not really students. They are children. When they are at university, I stand in for their parents” (Faculty D). “I always look at them and say, ‘you’re children.’ Those that I show caring for, I can discipline very nicely because they know I care” (Faculty F).Faculty authority extended to acts of discrimination along the lines of race. Students described how “certain students are being favoured…more African students are experiencing problems than maybe Indians, Coloureds, or Whites” (Student focus group interview: C1FG2), and that there was a “lack of consistency in how people are treated” (Student focus group interview: D1FG1). Amongst students, there was “racial tension between the races and amongst the races themselves in all levels of study” (Student focus group interview: D1FG1). Faculty was aware of the lack of racial integration amongst students and consciously acted on breaking barriers during group work sessions by “…dictat[ing] the groups and make sure that they are racially interspersed so there is no discrimination of race or gender. So we learn to integrate amongst each other, learn to appreciate and respect the next person” (Faculty F).Relations of power underscored the element of caring related to collegiality and interconnectedness, which was recognised by all participants but lacking in action. Caring as human interconnectedness requires an examination of assumptions, biases and subjectivities concerning race, class, gender, culture, language and power. The students indicated that they lacked a feeling of interconnectedness and felt that they did not belong to the department (Student focus group interview: D1FG1).Students reported that “the department should do something to unite students and lecturers and build good relationships, and improve contact between students and lecturers, and between the students themselves” (Student focus group interview: D1FG1). These could be achieved by, for example, forming sports teams within the department (Diary No. 12), initiating bonding/teamwork sessions from the first year (Diary No. 8), or through talks on improving relationship dynamics (Student focus group interview: C1FG1) and the initiation of a buddy system (Student focus group interview: C1FG1).Faculty perceived that the environment contributed negatively to developing interpersonal skills between themselves and students due to the absence of a common meeting place, “If we had a common room, it would make so much difference, because we could walk in when there are students and we could have a few laughs with them…even amongst students themselves there isn’t that cohesion” (Faculty D). Physiotherapy managers also alluded to poor interaction of faculty with hospital staff and how this influenced the relevance of caring in the curriculum. Faculty were perceived as being “out-dated in relation to what’s happening in the clinical environment and they should come out more, do more hands-on and interact with the consultants” (Participant: Group C).The dominant views that emerged about interpersonal relationships in physiotherapy are characterised as being divided, with a lack of communication and interaction. Students perceived the importance of developing skills for interpersonal relationships within the curriculum for translation into patient-therapist interactions. It is evident that while students are critical, embedded in their critique are suggestions for solutions, such as more communication and engagement in extra-curricular social events to enhance the relations between themselves and faculty.The third theme, cultural and language competence, has a potential role in advancing interpersonal relations. Both students and physiotherapy managers showed awareness that language and cultural differences presented barriers to developing interpersonal relationships. Students observed how their “inability to speak and understand isiZulu was limiting during interactions with patients at the hospital” (Student focus group interview: A1FG1) yet “the physiotherapy programme offered nothing to improve one’s skills when interacting with a patient” (Student focus group interview: B1FG2). It was suggested that “It would help if we could have lectures on how to incorporate the different cultures; different races… because when there is contact between a white and black person, there are always differences” (Student focus group interview: E1FG1). Physiotherapy managers concurred with this finding stating that “Students have to know about the different Black cultures to maximise their treatment. Students must be made aware that they must learn isiZulu, especially if you’re not an isiZulu speaking person.” (Participant: Group E).The fourth theme, enacting interdisciplinary knowledge and demonstrating biopsychosocial interventions, was considered important by all participants for the patient-practitioner relationship. However, the interaction between physiotherapy students and students from other health sciences disciplines did not feature in the curriculum, this being foundational for an interdisciplinary, holistic practice. Students indicated that “there was no interaction with students from within the School” (Student focus group interview: A1FG2). Faculty resonated with this finding, indicating “we talk of interdisciplinary, holistic treatment, but we’re not even doing it in our teaching” (Faculty G). Physiotherapy managers reported the difficulties physiotherapy students experienced “interacting with other disciplines when working in a team” (Participant: Group D). This absence was evident by physiotherapy managers in the practice environment, where students experienced difficulties with the holistic management of the patient, as “holistic treatment requires exposure to all the disciplines that a patient would require as well as the integration of the different disciplines. A lot of physiotherapy graduates are going out to places and starting up departments without this knowledge” (Participant: Group F). While faculty was aware that “the role of the physiotherapist has changed, incorporating more of the psychosocial elements” (Faculty A), it was reported that the “curriculum does not address the whole person, but when we treat we encounter cultural, biological and social problems” (Faculty G) for which practitioners were underprepared.The findings with evidence from the data are presented from three perspectives of: the students; the faculty, and the observations of physiotherapy managers from the practice settings. Using a deductive analytic approach, the themes draw on Ramklass  multipleI am first and foremost one -caring and, second, enactor of specialised functions. As teacher, I am, first, one-caring”. Central to physiotherapy education and practice is the notion of caring. Interactions between student physiotherapists and patients on the one hand; and between students and physiotherapy practitioners variously teaching and supervising them on the other hand, offers a means to examine how caring is manifested (or not).Within an education context, Noddings  states, The construct of caring is expressed in different ways in student-faculty interactions. One interpretation for the relationship of care, which was constructed using the parent-child association, is the assumption that faculty display caring towards students in the same way that a parent would for their child, showing how apartheid constructions are still maintained. However, this relationship is underscored by a power differential, as the act of caring can be manipulated to exert authority as a maternal or paternal referent over the student. Through this relationship, boundaries are created that student physiotherapists, in turn, interpreted as the absence of caring by faculty. According to Noddings, many people do not understand the processes involved in bringing people into maturity and relationships of equality, with a lack of that knowledge resulting in them assuming that the process must be a dictatorial one (Belenky et al., Another interpretation for authoritarian, hierarchical relations could be in response to the biomedical model and master-apprenticeship practitioner model that the physiotherapy curriculum structures (Wellard and Edwards, Both student and faculty described how boundaries were created that decreased the space for collaboration and dialogue on both personal and professional levels between them. Faculty not only dominated but did not forge relationships with students both within the formal official curriculum spaces as well as in the informal spaces, as noted by students in the lack of participation by academic staff at social events. This was further evidenced in the absence of opportunities to engage with other healthcare professionals outside of physiotherapy on an interdisciplinary platform. Both, however, also recognised how these hierarchical relations could be mitigated by engaging in dialogue and common tasks to build mutual respect and understanding and gave examples of how this could occur. Connection with faculty helps students feel like they belong at the institution (Duberstein, promote participation in common social and intellectual activities between students from different backgrounds, and how to encourage and enable conversations between such students” (Duncan, Students and faculty socialised in racially segregated spaces, with few possibilities for creating racially diverse friendships. Little attention was given to “ Duncan, . The nee Duncan, , is not  Duncan, .A shift from one’s interest to those being cared for resonates with arguments that caring requires a capacity for empathy, and is demonstrated through a displacement of focus from self to others (Noddings, Skills for inter-personal relationships are strongly influenced by positive role-models Shapiro, , which hIn linking this analysis to the general higher education literature it may be argued that the themes discussed above are related to the affective and support dimensions as identified by Hagenauer and Volet . The anaThis study foregrounded the interactions of student, faculty and physiotherapy managers at one historically Black South African university which characterised the experiences of participants shaped by particular historical, geographical and demographic context relative to the location of the university. These experiences may be unlike those between physiotherapy or other health science faculty and students anywhere else in South Africa or globally and the findings cannot, therefore, be generalisable. Whilst this study has identified with other studies globally on generic elements of student-faculty interactions, it has expounded further on the contributing factors of the historical socio-political context on these interactions which may have little relevance to similar studies globally. The literature is limited on how caring is produced by faculty in health sciences curricula for modelling by students in the healthcare environment, particularly in educational contexts that display hierarchical relations. An important area for future research could be to compare how caring is produced during student-faculty interactions in health sciences curricula, particularly in contexts characterised by hierarchical relationships, and enacted in practice environments.The deeply hierarchical relations of power manifest between physiotherapy faculty and students, not only derived from elements of South Africa’s still present apartheid past but also a deeply entrenched positivist, biomedical model. The unsatisfactory nature of the relationships between faculty and students, according to some faculty, was influenced by the deficiencies of the physical environment and rested in the relationships amongst physiotherapy faculty themselves, the absence of cohesion and operating in isolation from each other, which was being transferred to students. Paternalistic relations were modelled in the physiotherapy curriculum, which in turn undermined the building of relationships with students as young adult learners and exacerbated the hierarchical student-academic relationship. Student-physiotherapists point to a divide or distance between themselves and faculty evidenced in the non-participation of the latter in student-related events, and in the instances of authoritarianism and disrespect that were displayed towards the student, including discriminatory practices.There were considerable efforts in addressing dissonance or disjuncture in the relationships between the patients and students as an outcome of the curriculum. Caring relationships with patients may be theoretically espoused and practically enacted in the curriculum, but appear to be absent in the same physiotherapy curriculum spaces in the relationships between faculty and students. While the relationships are largely characterised negatively, a positive aspect is that students, faculty and managers are aware and have ideas to address the challenges they articulated. In a culturally diverse society, such as South Africa, maximising student’s opportunities to successfully navigate their tertiary education needs to include more than a good curriculum, and include a caring environment that nurtures the transition from student to caring professional. There is a need for more studies on such interventions in other health sciences curricula, and on how student-faculty interactions potentially influence student performance and their development as health professionals.


In the published article, there was an error regarding the affiliation for author “Paolo M. Rossini.” He was given affiliation 4 “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)-Policlinic A. Gemelli Foundation, Institute of Neurology, Catholic University of the Sacred Heart, Rome, Italy” in error, instead his correction affiliation should read 6 “Department Neuroscience and Neurorehabilitation, IRCCS S. Raffaele-Pisana, Rome, Italy.”The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Young people transitioning from out-of-home care frequently have a history of maltreatment and multiple psychosocial challenges. ‘Survivalist self-reliance’ – thought to involve social disconnection from others, and reluctance to seek support – provides one coping strategy. However, little is known about the self-reliant young person’s own reflexive interpretations of social relationships and support during transition. This qualitative study addresses the question: In the context of transitioning from out-of-home care, what reflexive meanings do ‘avowedly’ self-reliant individuals attribute to current social support and social relationships? Participants were four avowedly self-reliant young adults in transition from care, each with a history of maltreatment and multiple adversities. In this secondary analysis, data were from semi-structured interviews utilizing Margaret Archer’s internal conversations interview framework. Data were analyzed using Interpretative Phenomenological Analysis (IPA). Three thematic contexts were identified in which social support was salient: (a) current thoughts and active memories of both the birth family and foster families; (b) the importance of socializing; and (c) perceptions of formal services. There was evidence of cognitive reappraisal (a known amenable resilience factor) and selective engagement with social support, despite the strong overall stance of self-reliance. The findings suggest a more nuanced approach to our understanding of ‘survivalist self-reliance’. Adolescents and young adults transitioning from out-of-home care are known to experience multiple psychosocial challenges. Previous history of maltreatment, removal from home, placement changes and educational disruptions may be compounded by the challenges of transition itself . Young pTransition services (including ‘extended care’) for care-leavers have gradually emerged in some jurisdictions, but there is a need for more interdisciplinary and international research into psychosocial need in order to generate evidence-based practice . A recenIn a paper from the Midwest study of young people ageing out of foster care  ‘survivaIn the UK, Although we do not know the prevalence of high self-reliance among care-leavers , these studies have identified a form of experience among some care-leavers which may have profound implications for the young people’s own futures, and has implications for the design of accessible and evidence-based services.general tendency to avoid help-seeking and perhaps to avoid the development of social relationships, but what might we discover if we take a ‘very close look’ at experiential aspects of (cognitive) re-appraisal and re-evaluation of social support and social relationships  were markedly and avowedly self-reliant (and (b) detailed accounts of the reflexive links participants made between their independent world-view and their ‘owned’ adverse histories .People’s reflexive sense of what matters – what is subjectively important to them as individuals – makes it possible to plan, participate and function in society . It foll-reliant . They deIn the primary study, we described these individuals’ avowal of high self-reliance, and their rich autobiographical ‘justifications’ for this stance, but we did not examine experiential aspects of (cognitive) re-appraisal and re-evaluation of current social support and social relationships. The present study, involving a secondary analysis of data on these four avowedly self-reliant individuals, extends the original study in two ways: (a) using Interpretative Phenomenological Analysis (IPA), we focus on the phenomenology and hermeneutics of the self-reliant young people’s reflexive descriptions of current social support and social relationships, (b) we extend our theoretical perspective, initially based on the work of Margaret Archer, to include other perspectives.Thus, the current study addresses the question: In the context of transitioning from out-of-home care, what reflexive meanings do ‘avowedly’ self-reliant individuals attribute to current social support and social relationships?Nine participants took part in the original study, of whom four defined themselves as self-reliant and survival-oriented , Danny , Don , Nailah : The study had ethical approval from the University of Essex, and the UK Social Research Ethics Committee. Further details are available in the original study paper .The semi-structured qualitative internal conversations interview followed the guidelines described by The purpose of the first section – our first interview – is to enable the young person to discuss their experience of internal conversations. The interviewer emphasizes that ‘we are all different’, and ‘there are no right answers’ – many people experience conversations with themselves, or ‘self-talk’, silently in their heads. I’d like to know whether this is so for you and if you could tell me a bit about this experience? Following any individual examples of internal conversations offered by the participant the interviewer provides ten prompts: planning, rehearsing, mulling over, deciding, re-living, prioritizing, imagining, clarifying, imaginary conversations, budgeting (see In the second section (our second interview) the researcher asks the question: ‘Which areas of your life matter most to you at the moment’? The question allows the young person to discuss ‘what matters’ or what is important in their life, entirely from their own reflexive perspective, building on internal conversations discussed in the first section. In Archer’s interview protocol there then follows a section which focuses on ‘how each subject internally deliberated about his or her own future’ .Returning to the original transcripts for this secondary analysis, an Interpretative Phenomenological Analysis (IPA) approach was used . IPA proBut meaning-making isn’t just for participants – IPA emphasizes the double hermeneutic – ‘the researcher trying to make sense of the participant trying to make sense’ , p. 3. IInitial analysis of active meaning-making  by participants led to an emerging focus on the following five aspects of the interviews: (a) what (or who) is important to the individual participant ; (b) arAfter re-familiarizing with each individual transcript in its entirety, notes were made about each reflexive discussion of social support and social relationships in each of the above five analytic contexts.Semantic patterns, across cases, were then identified .reflexive interpretation, within which there was a wide diversity of individual accounts in which social support and social relationships were highly salient.By thematic contexts we mean broad thematic areas/common areas of deliberation/of The thematic contexts were as follows: (a) current thoughts and active memories of the birth family and foster families; (b) importance of socializing; and (c) perceptions of formal services.Differences between individuals were carefully noted at each stage of the analysis and remain integral to the presentation of the findings  because participants tended to cross-reference their discussions (i.e. between birth family and foster families), and (b) to reflect extant literature on care leavers’ perceptions of family, including wider kin .My family haven’t provided me [with] moral support since even I was a young age. Not even from a young age. So I know for a fact that I can’t rely on my family.Danny seemed to be estranged from his family, certainly in the terms of his own internal conversations, which were thoughtfully angry. Talking about his birth family:He discussed the ‘side-taking’ that he currently saw in his family, and commented metaphorically: ‘we’re not in a goddam war where we have to choose which side to be on’, and explained: ‘Family are definitely not in the higher prospects of my life’.what matters to you most in your life at the moment?:At the moment, myself – myself because obviously I’ve got to think how my rent is being paid, how I’m budgeting, I’ve got to think of myself at the moment.For Charelle, answering the question at the beginning of the second interview: Well if I don’t have a roof over my head, I can’t do anything. That is obviously my main thing ‘cos I ain’t got no mum, no guardian, or anyone to look after me so if I ain’t looking after me, who is? No-one else ain’t feeding me, no-one else ain’t bathing me so it’s me, I come first.Clarifying her sense of self being of primary importance, Charelle explains:Her deep anger is evident in these words. However, anger is not all we hear during the interview. She wants to study arts, and remembers her birth mother telling her how she ‘used to get all the prizes’ for art. She felt this ability was ‘in my blood’.Charelle also had specific memories of one foster carer, who ‘taught [me] a lot’, and with whom she was in regular ongoing contact.Nailah felt very distant from her birth family and, like Danny and Charelle, expressed this with thoughtful anger. But she had found a way of ‘reframing’ her expectations, and had some significant reflexive understanding of the intergenerational impact of her parents’ own experience of abuse.you’ve mentioned your friends and going out – what about your family – where do they come in the list of important things to you? Nailah replied:Nothing. They will always be there - - - When did I stop hating them? When I was 19 - - - they’re not important, I just view them as a friend and that’s it - - - you can’t be disappointed if you view them as a friend. Soon as you start viewing them as a parent all they’re going to do is disappoint and upset you.As part of the extended discussion in the second interview about what was important to her, Nailah was asked: She discussed her memories of the original abuse she had undergone as a child, but also discussed her own realization (via discussions with other family members) that they – both her parents – had themselves been abused by their parents. She said that ‘it helped me understand’.She discussed specific and detailed memories of enjoying being with her father, earlier in her life.was one of my last foster carers and the conversations we had. I look back on it and see she was trying to help me and prepare me for things and help me avoid the situation that I’m in right now but I didn’t listen. I was just like “Ah, you’re too much in my business, go away”. I thought I was a big woman, that’s the problem - - - yeah that keeps popping upLike Charelle she had good memories of one foster carer: one active memory ‘the one that always keep coming up from before’Like my Grandmother said last time I saw her: “we don’t let down family, we don’t put down on our family, we have to come together and this needs to be done – give it time – and then it needs to be done”. So I’m trying to give space - - -Don, different from each of the three other participants, was in touch with most of his extended family, including his birth mother. He reflected in detail on his closeness to some of them, and how there was still ‘building’, ‘re-building’ and extending (i.e. meeting family members he had previously been unaware of) to do. He discussed the importance he gave to these processes via a conversation he remembered having had with his grandmother recently:In summary, for these individuals who all self-identify as especially self-reliant, there is a very wide spectrum of detailed reflexive interpretation of family and foster families, including, for some individuals, specific positive memories, reframing and/or current active involvement in relationship-building or maintenance. Three out of the four individuals expressed significant anger as they discussed family.And go out really and release my stress and socialise as that’s the thing I like doing the most (laughs)At the beginning of Interview 2, Nailah included socializing , in her account of what was currently important to her:I’m - - - a people’s person - - - I love hearing people’s points of views on stuff.And in the first interview, Nailah:I have lots of people to talk to - - - I like to listen to understand where he’s coming from - - I learn a lot from everyone else, no matter what they speak.Danny, similarly, says:makes me feel better about myself as I know that people want me to come and join them.For Danny, going out with friends to a nightclubI need to be myself, to do the stuff I want to do.Gently challenged by the interviewer about how this might suggest that social relationships might be important, Danny ‘saw the point’, and clarified:Don included socializing with a named friend, and ‘the rest of my friends’ (as well as family) in his list of most important aspects of his current life.In summary: socializing and mixing with others was important to three out of the four avowedly self-reliant individuals.They can’t help, and to be honest, they put me in most of the bad situations I’m in, so I don’t like asking them. For my housing benefit they messed up. They bribe - - - the way they see it is like we do something for you, so what are you doing for us? - - - they’re the only people I can’t control my anger - - - they play mind games.Charelle, talking about some of the services she had received:She also described the arrangements for seeing her birth mother, who lived in a different part of the country. She explained that services were ‘funny about giving me the money [for travel to see her mother]’ and ‘I kind of blame - - - services in a way because I think they could do more for us young people’. Also thinking of her birth mother, she says: ‘how could you [i.e. services] let her end up homeless when she’s our mum?’ She also felt that services had not helped her stay in touch with her siblings.However, despite not trusting services in general, Charelle identified three professionals who she trusted fully, knowing what to speak with each about.Nailah remembered the period running up to leaving care, when she felt that the ‘adult world would be horribly scary’, and that staff ‘put pressure on you to say what you wanna do’. Looking back, she says she recognizes why: ‘cos their manager is putting pressure on them’.They were just like, “Oh sorry we’ll put you on the waiting list and you can apply next year”. That’s not the point!Very recently the paperwork for an application she (Nailah) put in for a specific year-long course, for which she was highly motivated, and remembers having put a lot of preparatory work in, was lost, and the course filled up. She recalls:This administrative error, in the context of her own reflexive awareness of her lengthy history of educational disruptions and difficulties, formed a severe blow to her self-esteem. She described the mental health issues that arose from this episode, making sense of it via her careful assessment of not having much time (i.e. in months and years) to gain educational qualifications in order to obtain work.However, there is one current teacher/educator she feels close to, whose help she fully recognizes.In summary: two participants discussed detailed and thoughtfully emotional accounts of how services had been unhelpful, but also identified individual workers whom they trusted and could work closely with.‘Survivalist’ self-reliance may be understandable as a coping strategy for dealing with a social world that may have included maltreatment, removal from home and further ruptures in relationships and developmental opportunities . FurtherFor those providing help during transition from out-of-home care, this strategy / policy may seem like a ‘closed book’. It seems to cut off potential opportunities for social support. Our research question, focusing on what reflexive sense avowedly self-reliant individuals make of current social support and social relationships, seems, prima facie, to ‘go against the grain’ of the declared policies of the young people. However, the IPA-based secondary analysis brought to light ‘exceptions to the rule’, flexibilities in thinking and feeling, and selective engagement with social relationships. These congregated in three thematic contexts: (a) current thoughts and active memories of the birth family and foster families; (b) importance of socializing; and (c) perceptions of formal services.In the first thematic context, there was a very wide range of individual differences. Positive memories , positivfun of socializing was important to two of the participants. Reflexively, Danny identified aspects of personal identity which seemed to be validated by having fun in a group; Nailah identified management of stress.The Another aspect of socializing that came to light in the narratives of two participants was the experience of ‘listening to other people’s points of view’. This finding chimes with ‘post-traumatic growth’ data from Two participants discussed detailed and emotionally expressive accounts of how services had been unhelpful, but also identified current individual workers who they trusted and could work closely with. These accounts could not be characterized as ‘pot-shots’ at an agency but were deeply felt reflections on the services that had supposedly had a duty of parental care toward them. However, individual staff were identified whom they could trust. These constituted reflexive exceptions to the general rule of being personally critical of public services.Reflexive thoughts about family, and about formal services, were expressed with considerable emotion, including anger.The reflexive detail provided by participants suggested a cognitively and affectively complex process of trying to make sense of the existential meaning of family violations of trust, and of public service struggles to meet need. As indicated above, and cognitive reappraisal of, and engagement with, aspects of social support and social relationships) applied not only to the stance toward services (by two participants), but also perceptions of family, and of socializing. How might we formulate this finding?Indeed, in our study, apparent ‘inconsistency’  and social relationships in order to tap potentially rich reflexive discussions  about social context , while aThere may be a particular relevance for Local Authorities (who hold a statutory duty of care in the UK context) to continue to develop ways of ensuring the voices of care-leavers are heard by services .


With the increased policy emphasis on promoting doula care to advance birth equity in the United States, there is a vital need to identify sustainable and equitable approaches for compensation of community doulas, who serve clients experiencing the greatest barriers to optimal pregnancy-related outcomes. This case study explores two different approaches for compensating doulas (contractor versus hourly employment with benefits) utilized by SisterWeb San Francisco Community Doula Network in San Francisco, California. We conducted qualitative interviews with SisterWeb doulas in 2020 and 2021 and organizational leaders in 2020. Overall, leaders and doulas reported that the contractor approach, in which doulas were paid a flat fee per client, did not adequately compensate doulas, who regularly attend trainings and provide additional support for their clients . Additionally, this approach did not provide doulas with healthcare benefits, which was especially concerning during the COVID-19 pandemic. As hourly, benefited employees, doulas experienced a greater sense of financial security and wellbeing from receiving consistent pay, compensation for all time worked, and benefits such as health insurance and sick leave, allowing some to dedicate themselves to birth work. Our study suggests that efforts to promote community doula care must integrate structural solutions to provide appropriate compensation and benefits to doulas, simultaneously advancing birth equity and equitable labor conditions for community doulas. As health policy advocates and policymakers look toward doula care as an intervention to mitigate adverse maternal and infant health outcomes in the United States, examining the sustainability of providing this type of care has become crucial. A doula is a nonclinical birth worker who provides physical, emotional, and informational support to a pregnant person during pregnancy, childbirth, and the postpartum period . Doulas In the US, doula care is not typically covered by health insurance. A pregnant person may hire a doula privately for an average cost of 1200 USD per birth (ranging from 800 to 2500 USD per birth) . NotablyIn contrast to private doulas, community doulas are typically trusted members of the communities they serve, sharing culture and language with their clients and often providing more comprehensive services and referrals ,8. This The benefits of doula support include improved health outcomes for birthing people and their babies, increased quality of care, and potential cost savings. In a systematic review of randomized controlled trials, birthing people with continuous labor support from a staff member, doula, or person from their social network were more likely to have a spontaneous vaginal birth and shorter labor and less likely to have a cesarean or instrument-assisted delivery, use regional  or any pain medication, have a low infant Apgar score, and report negative ratings or feelings about their birthing experience compared to usual care . AdditioThe improved outcomes associated with doula support can result in reduced medical expenditures. For example, cost-effectiveness analyses indicate potential cost savings related to lower rates of cesarean deliveries and preterm births if doula services are reimbursed at an average of 986 USD per birth (ranging from 929 to 1047 USD per birth) . FurtherBirthing people of color experience poorer pregnancy-related and infant health outcomes than white birthing people in the US. Compared to white birthing people, Black birthing people have over three times the risk of maternal mortality ,18, and The causes of racial inequities in maternal and infant outcomes are multilevel, including factors manifesting at the individual , community , healthcare provider , and systemic levels  ,23,24. ADoulas may be paid as independent contractors or as employees. The independent contractor approach is typical in private-pay doula care in the US, in which a client pays a flat, out-of-pocket fee for a specific menu of services. Alternatively, doulas may be paid as hourly or salaried employees of an organization; this approach may be more common for community doulas, as care is typically provided at no or low cost to the client. Notably, doula care is not typically reimbursed by third-party payers, such as health insurers . A 2016 Four US states are implementing Medicaid reimbursement for doula services: Oregon, Minnesota, California, and Indiana ,29,30,31With the increased emphasis on promoting doula care as a means to advance birth equity, it is important to determine sustainable and equitable payment models to appropriately compensate community doulas for the care they provide to clients and communities who experience the greatest barriers to optimal pregnancy-related and birth outcomes . Bey et Founded in 2018, SisterWeb, a community-based doula organization, works to “dismantle racist healthcare systems, strengthen community resilience, and advance economic justice for birthing families and doulas in San Francisco.” SisterWeb envisions a San Francisco in which “Black, Pacific Islander, and Latina/o/x families… are centered and uplifted in their reproductive journey to welcome their children with respect, dignity, joy, and pride, leading to thriving families and communities and increased birth equity and justice” . In servSisterWeb provides doula services via three programs: Kindred Birth Companions (KBC), serving Black and African American people; M.A.N.A. Pasefika, serving Pacific Islander communities; and Semilla Sagrada, serving those identifying as Latinx. SisterWeb’s model of care includes three prenatal visits, in-person birth support (when not prohibited due to restrictions related to the COVID-19 pandemic), and four postpartum visits. Additionally, doulas communicate with clients via phone and text message between visits. SisterWeb doulas work in cohorts, consisting of two to three doulas and one doula mentor, allowing them to support one another with the goal of avoiding burnout; the cohort model also allows for the flexibility to consistently provide clients with access to support. Furthermore, SisterWeb doulas participate in regular professional development training and receive time with their mentors to develop their skills as birth workers.Since 2018, SisterWeb and university-based researchers have collaborated to design and conduct process and outcome evaluations. The aim of the process evaluation was to identify the facilitators and barriers to implementation of SisterWeb’s community doula care programs. Our approach diverged from conventional process evaluations in two important ways. First, our research team recognized the highly contextual nature of implementing community doula care programs and that solely focusing on programmatic inputs and outputs in the process evaluation would mask external barriers and facilitators to success. Second, our project drew on the principles of the Equitable Evaluation framework. This framework purports that evaluators have an obligation to contribute to equity, especially when engaged in the evaluation of programs aiming to address inequity, and it stipulates that, for evaluations to advance equity, they must be rooted in collaboration and attend to historical, structural, and cultural contexts . TherefoThe process evaluation included in-depth interviews with SisterWeb doulas, mentors, organizational leaders, clients, and key stakeholders. Because our participants were known to one another and because power imbalances existed within the sample , focus groups were not an appropriate method of data collection. Individual, in-depth interviews allowed us to gain insights into participants’ true feelings about the SisterWeb program. Additionally, we analyzed programmatic indicator data and collected survey data from two labor and delivery units in local hospitals to understand their preparation for integrating community doulas. Evaluation funding included a focus on the KBCe and M.A.N.A. Pasefika programs; therefore, data from Semilla Sagrada are not included.n = 6) and 2021 (n = 6), as well as SisterWeb leaders (n = 4). Given the small number of doulas and leaders, we aimed to interview all potential participants with experience with the two different compensation models. University-based members of the research team, including research staff and graduate students, attended a qualitative interview training led by the first and senior authors and conducted interviews. In line with our participatory approach, two members of the evaluation team presented an overview of the process evaluation to SisterWeb staff in 2019; therefore, two interviewers previously met some participants. We invited all potential interviewees to participate via email.In this analysis, we focused on data from SisterWeb doulas interviewed in 2020 . Interviews with doulas in 2020 lasted an average of 82 min. In early 2021, we invited all eight current SisterWeb doulas who saw clients in 2020 to participate in a second interview focused on doulas’ experiences working with SisterWeb, providing in-person birth support at local hospitals, and how doula work fits into their life, as well as any changes in their experiences and practices since the first interview. Interviews in 2021 lasted an average of 109 min. Lastly, in July 2020, we conducted interviews with all four members of SisterWeb’s leadership circle, which oversees program implementation and administration and acts as SisterWeb’s decision-making body. Interviews focused on SisterWeb’s organizational journey, perceptions of internal and external barriers to program implementation, lessons learned, and adaptations related to the COVID-19 pandemic. Interviews with SisterWeb leaders lasted an average of 95 min. After completing interviews, interviewers took field notes in the form of an interview summary. All interviews were conducted via phone or videoconference, audio-recorded, and professionally transcribed. The Committee for the Protection of Human Subjects at the University of California, Berkeley approved the study protocol.We conducted the analysis in two parts. First, we deployed a Rapid Assessment Process (RAP), a team-based, intensive mode of qualitative research that uses iterative analysis, additional data collection, and data triangulation in order to develop preliminary, actionable findings . RAP is Second, we utilized the results of the RAP to develop a parsimonious codebook focused on working conditions for doulas, as key findings from the RAP analysis for the process evaluation were related to the doulas’ experiences with the different compensation approaches . This coSix SisterWeb doulas in 2020 and 2021 and all four SisterWeb leaders agreed to be interviewed; three and two doulas did not respond to invitations to participate in 2020 and 2021, respectively. Five doulas were interviewed at both timepoints, while two doulas were only interviewed once. At both timepoints, we interviewed two M.A.N.A. Pasefika doulas and four KBC doulas. Doulas were between 23 and 38 years old (average age 29 years), and all but two had lived in San Francisco for most of their lives. On average, doulas had been birth workers for nearly 6 years; collectively, at the time of the first interview, they had attended over 135 births. All SisterWeb leaders were either from San Francisco or had lived in the city for over 20 years. All leaders were birth workers, including 3 doulas and a certified professional midwife; they had collectively attended over 800 births.Two of three compensation approaches utilized by SisterWeb during the evaluation period are the focus of this analysis: (1) initial payment of KBC doulas per birth as contractors and (2) then all doulas as hourly employees with benefits hired by SisterWeb . Due to Doulas discussed the benefits and barriers of each model, while leaders described these different models from an organizational perspective, including operations, logistics, and alignment with organizational goals. Both groups spoke about the sustainability of the two models. Below, we first describe experiences with each compensation approach, describing the rationale for and challenges associated with both models.In 2018, SisterWeb was tasked with developing a community doula organization from the ground up very quickly. As SisterWeb is one of the first organizations of its kind, founders had limited examples to follow in developing their programs. With 1 week’s notice to apply for seed funding, SisterWeb founders quickly mobilized to develop and submit a proposal for their community doula organization. The lack of time to engage in thorough research and lack of alternative approaches led them to adopt a compensation approach heavily based on what private doulas and a few similar organizations were offering at the time.We basically—again, with a week’s notice—pulled together a proposal. At that moment in time, we based our doula program a little bit off of what private doulas offer. Also, reading about other community programs… So, we looked at, okay, real quick, what is everybody else doing? We created a mash-up of some of the different elements of their programs and thought—again, without a long, slow process—that was what our best guess was.”“(Leader)On the basis of these existing models, SisterWeb developed an initial compensation approach for KBC doulas that consisted of hiring doulas as contractors. Under the contractor payment model, KBC doulas were paid 1600 USD per birth, an amount determined based on compensation rates from other doulas programs and private doulas. This fee was typically split between doulas in a cohort according to workload; cohorts decided for themselves how to manage the workload and compensation balance. While doulas were paid per client, the overall payment amount was intended to be inclusive of their time spent at SisterWeb meetings and professional development training, as stated in doulas’ contracts.From the beginning, SisterWeb leaders suspected that the contractor compensation model would not be conducive to their goal of providing sustainable, dignified employment for their doulas. However, due to the terms of their initial funding proposal and subsequent contract, they were obligated to use this model to begin providing services and paying their doulas.In the beginning we said, hey, this is how it’s being paid. It’s not really fair. It doesn’t even make sense for us, and we don’t have another system because we have to start working. And we are committed to changing and figuring out a different system, but in order for us to start, we have to start somewhere. If you want to get paid to do this, we have to start somewhere, and this is how we have to start. This is the only option right now.”“(Leader)Despite these concerns, SisterWeb launched its KBC program with the contractor, per-birth payment model, with plans to evolve the payment model and provide benefits as soon as it was feasible to do so.SisterWeb leaders and KBC doulas quickly confirmed that the contractor, per-birth model was not sustainable. Notably, this model was not commensurate with the amount of work doulas were doing. Some doulas noted that their workload was highly variable depending on the client; some clients needed extra support and required more contact with their doulas, while SisterWeb’s standard model of care was adequate for other clients. However, doulas would still receive the same amount of pay for every client. When asked if she felt the amount of pay was “enough, too much, or just about right”, one doula responded as follows:“It will depend on the client, because there are some that don’t require a lot of the consistent communication. There are some that know exactly what they want you for, and that’s what you’re there for. There are some that don’t know anything and call you… at 4:00 in the morning because they up with cravings and don’t know what to do, or they’re breaking down about something that they can’t control. So, it really just depends on the client.”(Doula)Another doula described the difficulty of having to balance providing her clients extra support beyond what private doulas offer with the fixed amount of pay she receives. When asked how she decides whether to provide extra support for clients or not, one doula said the following:“Honestly, if I have the time, like I’m willing to do it. It’s a lot of time and that is one of the drawbacks when you don’t get paid hourly, but like, personally, as long as like, I have availability, I’m willing to go… We kind of like, I guess, base it on urgency of [the] client in the situation. Like, if [a doula] see[s] their client’s really anxious or they’re stressed.”(Doula)Another shortcoming of the contractor, per-birth payment model was doulas’ perceived lack of payment for attending meetings and professional development trainings. Doulas’ contracts specified that their payments for providing care to clients also accounted for their time attending meetings and trainings; however, some doulas were unaware of this and felt they should be compensated more for trainings.“I would say that there should be a little more compensation for like the trainings and stuff because we don’t get compensated for that, but we do get paid for the births and the prenatals. So, I guess when you signed up for it, you kinda knew that that’s how it was gonna go, but I would say, I would like some compensation for the trainings as well. Because that’s like extra days that I’m not working at my other job, that I could be making money.”(Doula)This was especially difficult in the months when doulas did not have a birth or had a client drop out.“Say my client dropped out. I don’t have a birth this month. I still gotta go to my professional development and put two hours or eight hours, you know, six hours in a training.”(Doula)In these instances, doulas would not receive pay for attending meetings or trainings until they received a payment for their next client.Despite the challenges described with being paid as contractors, in their initial interviews, doulas felt that the amount of pay they received for births was generally fair. However, most doulas described having to work other jobs to make ends meet. For some doulas, having a second job was generally not an issue, as their other jobs were flexible enough that they could adjust their schedules to attend births as needed. One doula, who was also a childcare provider, said the following:“I’m lucky right now, because with my main job, they are very flexible. So, if I have to go to a birth, just need to give them notice. I don’t have to, and I don’t even have to give them that much notice, because the dad at work, he can work from home at any time. He always told me like from the beginning, if anything ever comes up, just call me and we could always like, I can always rearrange my schedule and work from home.”(Doula)However, another doula described difficulties balancing her work with SisterWeb and her other job.“I changed jobs toward the end of last year. When I first got, like, interviewed with the job, I was very transparent with them about…what I do on the side. I’m on call, that means, you know, I may have to leave unexpectedly. And the manager at the time was cool with it. But they did change management earlier this year, and he’s not as cool with it, so it’s kinda forcing me to look for another 9 to 5. That’s one of the biggest struggles of it, is just like, finding something where they’re comfortable with what you do on the side.”(Doula)This doula prioritized her work with SisterWeb, but she needed additional employment to ensure financial stability. Therefore, she intended to look for different employment that would be flexible enough for her doula work. Another doula mentioned the financial difficulty of getting to and from client meetings and births without a car.“I wish there was some like compensation around like travel. I think that’s my biggest thing right now… especially because Lyft’s and Uber’s like quite expensive, and they add up.”(Doula)Despite the challenges some doulas faced with the contractor compensation approach, they described being happy to receive any payment for doing doula work in their communities.“Being able to work with my community has meant everything to me. Because that was like, when I became a doula, that was what I really wanted to focus on, was like working with Black women and people in my neighborhood and stuff like that… it was just hard to be able to work with my community but also like get paid, to be able to live and stay in my community. So, [working with SisterWeb] has been kind of the best of both worlds.”(Doula)“I love this [work] so much that I would do it for free, but just like… knowing that [working with SisterWeb] can help me a little bit, like, take off the burden of that insecurity, like, that is honestly like a dream come true for me.”(Doula)For most SisterWeb doulas, being compensated for supporting birthing people in their communities was like “a dream come true”, especially given that many community doulas work for free. Being paid as a contractor allowed them to engage in work they loved, even if they had to work other jobs to make ends meet.In addition to financial challenges, SisterWeb leaders and doulas also identified administrative and ethical challenges with the contractor compensation approach. One major challenge was the multistep administrative process required by SisterWeb’s original fiscal sponsor to issue payments to doulas.“We realized that there were major flaws in the program in how doulas were invoicing and getting paid that were just not sustainable. They didn’t align with our ultimate goal of the program, which was dignified employment, to turn birth work into a career. There just wasn’t enough stability. There wasn’t enough guarantee of payment. The timing of the payments was all off.”(Leader)“The doulas ain’t been paid since December… It’s not affecting them meeting with their clients. It’s not affecting their output. But I definitely see it affecting their state, their emotional state in terms of like, ‘Hey, I put them invoices in. I’m getting emails. Hey, I’m getting the invoices in, when we gonna get paid?’”(Doula)Leaders also described ethical concerns with the contractor model in the context of the COVID-19 pandemic.“For SisterWeb, specifically [COVID-19] presented a whole bunch of questions for us around risk and… that we may be asking our doulas to assume a certain amount of risk by going into the hospital during a pandemic when we just didn’t feel comfortable with the amount of financial and healthcare support that we were able to provide them. Where it was, like, for hospital workers, nurses, doctors, midwives—they have salaries and health benefits and extra sick leave.”(Leader)These concerns led to delays in SisterWeb doulas returning to in-person birth support, even after hospitals began allowing doulas to attend births again.“One of our biggest pushes in why we weren’t ready to go back into the hospitals is because our doulas were independent contractors. We weren’t sure who had health insurance, and what people’s living situations were like, what their own health was like, their own levels of comfort and safety in working in the environment.”(Leader)Without the ability to provide sufficient financial support and health insurance, SisterWeb leadership did not feel comfortable allowing their doulas to return to in-person birth support, given the potential consequences for their doulas if they contracted COVID-19, including costly healthcare bills, loss of income, and inability to fulfill caretaking responsibilities.SisterWeb leaders were always clear about their goal of providing sustainable, dignified employment for their community doulas and, therefore, were committed to transitioning doulas to a compensation approach that better aligned with this goal.“Our ultimate goal of the program, [is] dignified employment, to turn birth work into a career.”(Leader)“We have always been very clear that our doulas get paid to get trained and get paid to do the work that they do. And they are from their own communities, serve their communities.”(Leader)“Even though this is nonprofit, for me, a for profit would be making sure that my staff would be paid and get the hours that they need and the benefits that they need and that they’re cared for, and they have the support that they need to do the work that they want to do.”(Leader)This goal, as well as the various challenges with and barriers to sustainability of the contractor compensation approach, informed SisterWeb’s decision to transition their doulas to an hourly employment model with benefit eligibility. This transition took longer than expected. First, SisterWeb needed time to raise the necessary funds required to hire doulas as hourly employees.“Seeing the numbers play out, and what [it] would cost to put doulas on as staff as employees… I was like, there’s still no way to do it, because if we do that, that shrinks down the budget… I only have a certain dollar amount, and a dollar amount is a dollar amount, and that would shrink my amount to pay our doulas.”(Leader)“The steps that we had to go through to actually change the model were pretty slow because, for one, we didn’t have the money in the bank to turn everyone into an employee. So, there was an incredible amount of fundraising that had to happen to supplement that initial funding that we got.”(Leader)Additionally, the transition to the hourly employment model coincided with SisterWeb’s transition to a new fiscal sponsor, as their initial fiscal sponsor did not provide them with needed administrative or technical support. The transition required a tremendous amount of administrative effort.“We ended up having to switch fiscal sponsors. That, also, was a huge energy and time drain on the organization, especially on the leadership… I would say hundreds of hours that we all spent filling out paperwork.”(Leader)Because the doulas would be employed through SisterWeb’s fiscal sponsor, the transition to the new fiscal sponsor had to occur first.As of July 2020, all SisterWeb doulas are paid as hourly employees, rather than contractors. Doulas are employed for up to 32 h a week at a regular wage of 25 USD per hour, a wage based on comparable city workforce development programs and doula wages in California. They are eligible for benefits, including health insurance and paid sick leave. Additionally, doulas are paid for all time spent in meetings and training.Doulas identified many positive aspects of the benefited, hourly employment model. One of the main advantages mentioned was the ability to rely on a consistent paycheck.“I know that I’m going to get paid a certain amount every two weeks. So, I like that. It’s reliable money.”(Doula)“I like the consistency of the pay now, whereas when we were doing the invoicing, it was whenever you had a birth, you submit it. And then sometimes, I feel like, when we did the invoices, they would take a long time [to process]. So, it was a hit or miss with that.” (Doula)Notably, one doula mentioned how having a consistent paycheck enabled her to have proof of income when necessary, such as when applying for housing. In addition to consistent, reliable pay, doulas described how the hourly employment model ensured they were getting compensated for all of their activities. One doula said the following:“Some clients got you working hella extra… So, I think [the hourly model is] more beneficial because you actually get compensated for what you’re doing. And it’s not this shift of you could put in 20 h with one client and get the same little 1600 USD or whatever it was. Or you could put in 5 h and get the same amount.”(Doula)Doulas also valued the benefits that came along with being SisterWeb employees compared to being paid as contractors.“We get paid time off, we get sick leave. We get health benefits, dental benefits… beforehand, we didn’t have a lot of those extra perks with being an employee, rather than being an independent contractor. So that’s really good.”(Doula)Another doula mentioned how these benefits extended to her children.“I appreciate this [health insurance] because it just has [coverage] for my kids, and emergency stuff, and all of it, just kind of included… so I was able to put them on [my insurance]. And that was a big deal.”(Doula)Notably, all doulas preferred this new hourly employee compensation approach to the models they were paid under previously. However, some doulas mentioned that this new model required more work on their part, as it involved recording their hours more closely.“It’s just tricky trying to write down exactly what you do during the day, because I have to write it down on a spreadsheet… Say you talked to your client on the phone for five minutes. And then you talked to your other client for an hour. And then you talked to your other client for seven minutes on the phone. Just trying to figure out, so how much time is that that you spent on that particular work? And then how do you translate that into the spreadsheet? And then how do you translate that into [the timekeeping system], where you log your hours?”(Doula)Importantly, one doula spoke about the difficulty some doulas experienced with transitioning from contractors to employees under the new compensation model.“This is a legit job now, going from that shift of being a contractor to then, ‘No, you’re an employee. You need to figure out how you’re getting all these hours done. If I call you during the hours that you’re working, you should be working.’ Because it was so much more free before… Doulas who we’ve hired that come straight into an employee position, they get it.But doulas who have gone through all of these changes with us, it’s a lot harder to shift.”(Doula)A few doulas also described minor issues getting onboarded as employees, including learning the new timekeeping system, and lacking knowledge on health insurance options. One doula mentioned that, while she liked the new compensation approach, it still did not address the on-call nature of doula work, which requires being available to attend a birth at any moment, and how to get compensated for this scope of work.Importantly, the hourly payment model allowed some doulas to devote themselves to birth work and quit other jobs due to the ability to work increased, consistent hours. One doula described the benefits of not having to work other jobs.“My favorite thing about working with SisterWeb is that my 9 to 5 job is birth work. It’s like, usually most people have to choose between doing reproductive justice stuff, or having a 9 to 5, where you do both and burn the candle at both ends. And I just love that I’m getting paid a wage that I can with ease afford my rent. With ease buy groceries. I’m not having to scrounge for bills, just because I’m doing birth work.”(Doula)Notably, some doulas were not aware how much time they were spending on their SisterWeb work until they began tracking their time as hourly employees.“I never realized how long I was actually sitting there, inputting all of these notes from the birth. I’m like, ‘Oh my God, this takes so much longer than I thought it takes,’ when you’re actually keeping track of it. That and other mundane tasks, like filling out a referral, or texting a client. Or we never realized how what seems like minutes is actually, when you add it all up, it’s hours.”(Doula)When asked if the amount of pay was “not enough, too much, or about right”, most doulas felt that the amount they were getting paid under the new hourly payment model was “about right” or “fair”. However, three doulas noted that, because of the work spent on program development and the cost of living in San Francisco, a higher wage would be beneficial.“[A]nother reason [it’s not enough] is just living in San Francisco. Another reason is the added work that we do for program development now. I feel like we’re building our skills. So not only are we doulas, but we’re, like, I would say, community organizers.”(Doula)This analysis highlighted the challenges that a community doula organization faced in realizing its vision of advancing birth equity in San Francisco and community doula care as a sustainable, dignified profession vis-à-vis approaches for compensating doulas. Minimal time for developing a funding proposal and for thorough program planning led SisterWeb to adopt a per-birth, contractor payment model common in private doula care. SisterWeb leaders quickly realized that paying their doulas as independent contractors did not support their goal of providing sustainable employment for their community doulas, who work in cohorts, regularly attend trainings, and often provide additional support for their clients needing more intensive services beyond the scope of fee-based, private doula care models. This is in line with a 2019 report on community doula care models that outlined the many services community doulas provide beyond private doula care, including additional home visits, referrals to social services, engagement with community, and support over a longer period in the postpartum phase . Indeed,For the community doulas interviewed in this study, there was an evolution in their feelings about compensation approaches. On one hand, in our first round of interviews, doulas generally expressed that they were paid enough and did not particularly mind being paid as contractors; an overall sense of gratitude for the opportunity to do paid birth work pervaded interviews. Notably, one survey of practicing doulas in California found that 55% of respondents provided some services for free, especially when working with clients who lacked the resources to meet their own basic needs ; this haDoula care is increasingly suggested as a “cost-effective” intervention to improve birth outcomes in the US, particularly for Black women ,47,48,49Strengths of this study include longitudinal, qualitative data collected from doulas through a long-term academic-community partnership. Through the partnership, the researchers intimately observed the evolution of the compensation approaches and organizational struggles in real-time, allowing for rich data collection that surfaced the nuances of the different payment models. With the longitudinal approach, we completed analysis of data from the leadership circle and the first round of doula interviews prior to developing the interview guide for the second round of doula interviews. As such, our analysis represented iterative data collection and confirmation and evolution of initial findings. Additionally, our sample included interviews with all leadership circle members and most doulas in the two programs included in the evaluation. Limitations of this analysis include the specificity of the geographic context , which has implications for the amount of compensation. Future research should investigate the longer-term sustainability of the hourly benefited compensation approach, both for community-based organizations and for doulas themselves.For provision of community doula care to be a health equity strategy, community doulas—who, by definition, are community members and often identify as people of color—must have equitable labor conditions. That is, health equity cannot be advanced if intervention strategies rely on community doulas from Black and Brown communities to be contingent, low-wage workers. This was especially pertinent during the COVID-19 pandemic, when providing in-person birth support required community doulas to put their own health at risk; for contractors, this risk occurs without organizational support for health insurance, paid sick leave, and other benefits. As policymakers and private funders seek to promote community doula care, sustainable and equitable compensation models must also be advanced, as doulas may leave the profession due to burnout, low-pay, or lack of full-time employment opportunities. Equitable labor conditions for community doulas may also increase the pipeline of racially and culturally concordant healthcare providers serving pregnant people of color, as doulas may seek opportunities to become midwives, nurses, and physicians. Furthermore, expanding services requires sufficient resources for baseline and ongoing training, as well as workforce development initiatives. Efforts to advance community doula care must integrate structural solutions to provide appropriate compensation to doulas for the full range of their activities to ensure that the benefits of doula care are realized for birth equity and to support equitable labor conditions for community doulas.