Recent years have seen a spirited debate over whether there is linguistic injustice in academic publishing. One way that linguistic injustice might occur is if gatekeepers  judge the scholarly quality of academic writing more harshly if the writing does not meet expectations for international academic English, even if the content is good. We tested this with a randomized control study in which scholars judged the scientific quality of several scientific abstracts. Each abstract had two versions with identical scientific content, such that the language in one version conformed to standards for international academic English, and the language in the other version did not (but was still comprehensible). While the data are preliminary and the effects statistically inconclusive, both pre-registered and exploratory analyses of the data suggest that scholars may give abstracts lower ratings of scientific quality when the writing does not conform to standards of international academic English. These results suggest that linguistic bias may occur in academic peer reviewing and motivate further study to better understand and address this phenomenon. Previous research on the difficulty of publishing in English as a second language by non-native speakers of English e.g., , pressurMore recently, however, the notion that scholars publishing in a second language face unique challenges and biases has come under question. In an influential paper, In the years since this series of papers issued this challenge to the field, several more papers have put forth conceptual arguments for or against the existence of linguistic injustice. For example, 2.While the studies in Specifically, in their proposal, Fortunately, experimental methods already exist for testing implicit biases. In the most famous example, This kind of experiment design has been applied to academic contexts as well. Additionally, vignettes, or written information in a narrative paragraph format, have been found to be a useful and cost-effective methodology to evaluate practitioner decision-making. Previous studies have used vignettes to determine how teachers perceive and make educational decisions for children with Attention Deficit/Hyperactivity Disorder , as wellWe provide here a brief overview of vignettes using an example from Thus, vignettes are an informative method that may be equally informative for understanding the reviewal of academic abstracts for conferences. Just as practitioners from these fields, reviewers for academic conferences are in the explicit role of assessing academic work and making decisions that have real-world impact. That is, reviewer decision-making helps determine what science will be presented at a scholarly meeting and will ultimately help progress the field. Therefore, it is important to examine how people who serve as reviewers for academic conferences may perceive differences between abstracts that vary along one parameter: whether or not they conform to the conventions of international academic English.3.The goal of the present study was to use the same approach to test whether peers consider scientific writing to have lower scientific quality if it is written in English that does not conform to international academic English standards.We introduced this question above by asking if two pieces of equally “good” research would be judged differently based on how “good” their English writing is. To test this, we must define what constitutes “good” research, as well as what constitutes “good” English. Research quality might refer to the methodological rigour of the study conducted, to the extent that the conclusions are justified , to the perceived novelty or impact of the work, or to any combination of these or other factors. In the present study we only asked respondents to rate the “scientific quality” of each work, without giving explicit instructions on what dimension of scientific quality they should evaluate. Further, we did not provide information on the linguistic background of abstract authors. Thus, the assumption was that respondents could focus on any combination of the above dimensions or other dimensions we have not described.What about what constitutes “good” English? Here we employ scare quotes in acknowledgement of the fact that this is a term that is not useful and is not used in discussion of English as an additional language or English for academic research publication purposes. When people colloquially refer to “good” English, they generally are referring to English that conforms to international standards of what English written by educated native speakers of a mainstream English variety  is expected to look like in terms of grammar and register. These standards include prescriptive grammar rules , as well as stylistic and register expectations about how academic writing normally looks. In our case, we wanted to test whether reviewers would change their judgment of scientific quality based only on how well the language conformed to these English standards. Of course, if the English deviated so far from these standards that the reader could not understand the procedure of the study or the claims of the authors, then this could influence their judgment of scientific quality for reasons not directly related to language bias. That is not the case we were interested in testing. Our interest was in whether reviewer judgment of scientific quality would be influenced by language mechanics even if their ability to understand the work was unimpaired. Thus, in the abstracts we used for the present study, we manipulated the adherence of the writing to prescriptive grammatical forms, rather than the adherence of the writing to register and stylistic expectations.https://osf.io/mwd6z/ .We prepared four short abstracts describing research in communication science and disorders , and edited each abstract to have one version with “international academic standard” English (hereafter referred to as “standard English” for brevity) and one with English not conforming to international academic standard English conventions (hereafter referred to as “non-standard English” for brevity). The example below shows both versions of the opening sentence of one abstract; the two versions of the abstract from which these examples were taken are included in the Appendices, and the complete set of materials is available at 1a.“standard” English:While much research has focused on first language acquisition of tone, there is little study of the development of tone in bilingual children whose dominant language is non-tonal and who are exposed to a tone language in school.1b.“non-standard” English:While much of the research focused on first language acquisition of tone, there is little study of development of the tone in bilingual child whose dominant language is non-tonal and who are exposed to tone language in school.As the example demonstrates, the scientific content was identical, and the sentence should be easy to understand in either version. The English in the second example included several patterns which are common in English academic writing by native speakers of some other languages . Our goal was for readers of each abstract to be able to understand the content equally well. While it was possible that the writing differences may still have influenced comprehension , we felt that this manipulation kept the clarity of the content as similar as possible between the two abstracts while still keeping the language differences easily noticeable.We recruited scholars in communication science and disorders to evaluate these abstracts as if they were reviewing them for a conference. We predicted that, if academic reviewers’ judgments of scientific quality were biased by their judgment of language mechanics, they would give lower ratings of scientific quality to abstracts written in “non-standard” English. This would constitute evidence for one kind of linguistic injustice.they may associate with native-like-ness/standard-ness or non-native-like-ness/non-standard-ness. We aimed to investigate biases against aspects of language, not biases against people. Hence, throughout this paper, we use the terms “standard” and “non-standard” in scare quotes, to acknowledge that not all scholars who learned English in adulthood write in “non-standard” academic English, and not all scholars who learned English from infancy as their dominant language write in “standard” academic English. If one adopts the additional assumption that scholars who learned English later in life have to work more to attain “standard” English academic writing proficiency than scholars who speak English as a first and dominant language do, then a finding of bias against “non-standard” academic English in the present study would entail greater challenges for non-native English speakers than native English speakers.Here a note about terminology is in order. When we refer to “standard” and “non-standard” patterns of usage, we are referring to how these patterns may be perceived by readers, not to where these patterns actually come from. We are under no illusions that all “native” English speakers write at what reviewers would consider an ideal standard, nor that all “non-native” speakers write below that standard. Furthermore, we are not suggesting here that all, or even most, “non-native” speakers write in the way exemplified in our “non-standard” example. We specifically edited these abstracts to have “worse” English  than that of most “non-native” English-speaking scholars we have worked with or read. Our purpose is not to claim that all “native” speakers write one way and all non-native speakers write another way; indeed, many authors have challenged the utility of the notion of native-ness when discussing English for academic purposes e.g., , and havAs the present study was a preliminary investigation, there were many aspects left open for further study. For example, it would be worthwhile to evaluate abstracts in a real context by actually submitting abstracts to a conference, rather than by sending them out in a survey. Such methods would provide additional ecological validity. We designed this study as an initial exploration into whether this approach to testing linguistic bias is worth pursuing.4.https://osf.io/bngfj.1 Any analyses that deviate from the pre-registration are reported here as exploratory.Methods for the experiment were pre-registered at Methods were approved by the Human Subjects Ethics Sub-Committee at The Hong Kong Polytechnic University (reference: HSEARS20161219001).4.1.https://osf.io/mwd6z/. We closed the survey when we had responses from 102 respondents. The first six respondents completed a version of the survey with an error which prevented the abstracts from being displayed, and thus are not analyzed. After closing the survey and viewing the data, we discovered that many participants did not complete the entire survey and did not respond to all (or even any) of the abstracts. Overall, 37 respondents completed the survey , an additional 16 respondents provided partial responses , and 43 did not evaluate any of the abstracts.We recruited participants through e-mail discussion lists and online forums for scholars involved in psycholinguistics , communication science and disorders/speech-language-hearing sciences , and the cognitive sciences (SPARK Society). Demographic information from the respondents is available at 4.2.https://osf.io/mwd6z/.Colleagues who volunteered to have their abstracts used in this project provided four real abstracts. We edited the abstracts to roughly mimic the format of the American Speech-Language-Hearing Association Convention. As such, each abstract was 200e300 words in length and divided into four sections: “Rationale”, “Method”, “Results”, and “Discussion”. The abstracts described studies about acquisition of lexical tone in bilingual children, language assessment in bilingual children, motor memory of Chinese characters in a post-stroke client, and speed of Chinese character writing. Furthermore, the authors edited each abstract to conform to international-standard academic English. To make “non-standard” versions of each abstract, one native Chinese speaker translated the abstracts into Chinese, another native Chinese speaker translated them back into English, and we further edited the abstracts to ensure that the scientific content remained identical and comprehensible across abstracts  and to make sure that the writing clearly did not conform to international-standard academic English but was still comprehensible. The full abstracts are available at 4.3.Participants completed a survey with the abstracts on Qualtrics, an online survey platform, to isolate the role of reviewer behavior, the survey did not provide information on the linguistic background  of the abstract authors. As such, participants reviewed each abstract blind to the linguistic background of all authors, thus increasing the likelihood of revealing linguistic bias. After providing informed consent, participants responded to questions in major content blocks: 1) demographics (race/ethnicity and sex); 2) language background (languages spoken and proficiency in each language); 3) professional background ; and 4) abstracts. The questions in the first three blocks were included to facilitate later exploration and were unrelated to the pre-registered analysis plan. After completing blocks 1–3, participants read the abstracts one at a time. For each of the four abstracts, they rated the scientific quality on a five-point ordinal scale  and could select zero or more areas in need of improvement . Participants also rated the clarity of the abstract on a five-point ordinal scale  and selected areas for improvement ”, “Organization”, “Writing style”, “Other” [with a text input field], and “Nothing”). Finally, participants had the option to provide further feedback . Upon completion of the last block , the participants responded to an item asking whether they are an editor or reviewer for an academic journal published in English, and indicated their exact role as a reviewer.The abstracts were meant to be arranged into two lists in a Latin square design, such that in the first list , abstracts #1 and #3 would appear in the “non-native-like English” condition and abstracts #2 and #4 would appear in the “native-like English” condition, whereas in the second list , the mapping between abstracts and conditions would be switched. The pre-registered analysis plan assumed this arrangement. Due to an error in the online survey setup, the abstracts were not presented in this way: half of participants saw the first list as planned, whereas the other half saw all four abstracts in the “standard English” condition. In other words, abstracts #1 and #3 were seen in the two different conditions (by different participants), whereas abstracts #2 and #4 were always seen in the “standard English” condition. Below we report additional exploratory analyses that take this limitation into account.4.4.The only dependent variable analyzed was the five-point rating of scientific quality. We regressed this ordinal quality rating on the language condition (“native-like” English vs. “non-native-like” English) using a cumulative link mixed effects model. The pre-registered analysis plan also included List as another fixed effect in the model, interacting with language condition; however, we could not include this interaction because of the failure to properly present the second list, as explained above. For this mixed-effect model analysis we included all ratings we received, including those from participants who did not rate all four abstracts.Below we also report several alternative, exploratory analyses, given that the data format we received differed in several ways  from what we had expected when we pre-registered the analysis plan.5.https://osf.io/mwd6z/.All data and statistical analysis code are available at 5.1.“Non-standard English” abstracts were much more likely than “standard English” abstracts to be labelled “Poor” and much less likely to be labelled “Fair”, indicating that at this relatively low quality level, abstracts perceived as having “better” English  tended to be rated more highly. “Non-standard English” abstracts were slightly more likely than “standard English” abstracts to be rated “High quality” and slightly less likely to be rated “Top level”, although these differences are quite small compared to the abovementioned differences.b = −1.34, z = −1.97, p = .048).The statistical model showed that abstracts with “non-standard English” received lower ratings than abstracts with “standard English” —with the abovementioned caveat that p-values from exploratory analyses are not very meaningful.First, we removed participants who did not rate all abstracts, and re-ran the pre-registered model on this subset of the data. The qualitative pattern was in the same direction, but not statistically significant .Second, we only examined participants who did List 1 (the list with both “standard English” and “non-standard English”), excluding participants who did the other version of the survey in which all abstracts had “standard English”. This allows us to compare ratings within the same people as a function of language condition, but the limitation is that ratings are being made across different abstracts which probably had different intrinsic levels of scientific quality. We ran a new statistical model regressing scientific quality rating on language condition.  Abstracts with “non-standard” English were given marginally lower ratings .Third, we only examined abstracts #1 and #3, which were different across the two lists, and excluded observations from the other two abstracts . This allows us to compare ratings of the same abstracts as a function of language condition, but the limitation is that ratings are being made across different people, who may have different quality thresholds they use to make their evaluations. As shown in b = 0.95, z = 1.94, p = .052) than abstracts 1 and 3 (the ones that had “non-standard English” in this list). Yet the concomitant difference between abstract types in List 2, compared to that difference in List 1, was smaller . In List 2, the difference between those abstracts was not significant  and was in the opposite direction as the difference in List 1.6.In the present study, scholars evaluated the scientific quality of abstracts that were written in English that either conformed or did not conform to international standards of academic English. We found suggestive evidence that abstracts with international academic-standard English may tend to be judged as having higher scientific quality than abstracts with identical scientific content but English that does not meet international standards of academic English. While the results are statistically inconclusive, they offer the first empirical and experiment-based demonstration (to our knowledge) that scholars may exercise linguistic bias when reviewing academic writing. These results are potential evidence for one kind of linguistic injustice that may be at play for academic publishing. They highlight the need for further research on this topic.One limitation of this study is that is used survey responses rather than real-life reviews. While the respondents were likely experienced reviewers , they were conducting the reviews in a different context than they would for real conference or journal reviewing. Therefore, even though our results suggest that linguistic bias may have occurred in this sample, we cannot rule out the possibility that reviewers may be less biased when they review for real conferences and journals. We find this unlikely, however, given that implicit biases are probably not subject to conscious control.  Furthermore, if reviewers show evidence of linguistic bias in an online survey, it would be likely that such bias may also appear in conference or journal reviews; while one might argue that reviews for real conferences and journals are done more diligently than reviews in this survey were, this point of view seems idealistic, given most scholars’ experience receiving cursory reviews . Nevertheless, future research in a more ecologically valid context would be valuable. For example, submitting abstracts for real review to an actual conference (in collaboration with the conference organizers) would yield more realistic data, and such collaborations with conference organizers have proven fruitful in the past e.g., .Another limitation has to do with the data. As described above, the sample ended up being much smaller than expected, because of high participant attrition. Furthermore, because of an error in the survey design, the study was not run in a full Latin square design as intended. Therefore, the statistical results are weak and exploratory. We opted not to attempt to re-run the study online with a proper Latin square, given the ecological validity limitation mentioned above. We felt that if this study is run again, it would be more valuable to do so with real conference reviews rather than with a survey.but which would not impair comprehensibility. However, we have not empirically tested this assumption; our survey did not include any comprehension check to confirm that readers did understand the “non-standard English” abstracts as well as the “standard English” ones. Future studies should attend to this issue .A third limitation relates to the comprehensibility of the abstracts. As discussed above, we intentionally manipulated the language in a way that we expected would make one version of the abstract clearly diverge from international standards of academic English, Finally, the present study only examines one way in which linguistic injustice could manifest during the peer review process. There are other ways that language could bias the outcomes of peer review. For example, How do the findings of this study relate to the broader question of linguistic injustice? There are really two questions at play in the recent debate over linguistic injustice: whether it exists at all, and whether it is worth researching or talking about. The present study challenges the notion that linguistic injustice does not exist at all: even though the statistical results are inconclusive, they at least suggest that linguistic bias may be occurring. That notion, however, may well have been a straw-person. While not a result of the scholars’ own deficiencies.While both of the abovementioned positions have merit, we believe linguistic injustice is a topic worthy of discussion - and, critically, action. Even if there are other injustices which have a bigger impact on academic publishing (and there certainly are; we agree with abstract_ratings_wide.csvabstract_ratings_long.csvConference+Abstract+Review+Survey_July+7%2C+2019_16.48.csvr_analysis.txt


Great changes have taken place in terms of people’s lifestyles and behavioral habits. Diabetes has become a threat to human health and is the most important noncommunicable disease. More than 60% of rural diabetic patients experience delayed diagnosis and treatment. In this study, we explore the inner experience of the delayed diagnosis and treatment of patients with diabetes in rural areas and provide a reference for targeted intervention.A qualitative research design was used to examine the cognitive behavioral intention of patients in rural areas with delayed diagnosis and treatment of diabetes. Thirteen diabetes patients with delayed diagnosis and treatment were sampled with maximum variation in rural Daqing City and Tangshan City in China. The data analysis involved several levels of analysis consistent with qualitative research.The following themes were relevant to diabetes patients in rural areas with delayed diagnosis and treatment delay: “Lacked knowledge of diabetes”, “Negative coping style”, “Dissatisfaction with the existing medical service” and “Influence of social support”.The respondents’ delayed diagnosis and treatment represent a common phenomenon. Medical personnel should provide interventions for patients and encourage them to go to the hospital on time. Diabetes mellitus, which has become a threat to human health, is the most important noncommunicable disease . In 2013Delayed diagnosis and treatment of patients with diabetes have serious impacts on the quality of life and disease prognosis. Gulam showed that mild diabetes that is not treated in time may incur complications, such as infection, sepsis and gangrene, and can increase the risk of amputation and death . Zubair Delayed diagnosis and treatment are characterized by a delay in diagnosis and a delay in treatment. A delay in diagnosis, which is called a patient delay, occurs if the time between when a patient first observes suspicious symptoms and when the patient first visits a doctor in a medical institution spans more than 3 months , 11. A dMost studies of diabetes have focused on complications and influencing factors, while few have considered delayed diagnosis and treatment. China has started to attach great importance to the prevention of diabetes, but there is a lack of prehospital targeted screening and early intervention measures, with impacts on prevention, diagnosis and treatment. This study was conducted to explore the inner experience of clinical treatment and the behavioral intention concerning delayed diagnosis and treatment of patients with diabetes and provides a reference for comprehensive intervention in rural China.In this phenomenological qualitative research, interviews and observations were used to collect data for conventional content analysis through a qualitative descriptive method conducted by the first author. Content analysis can explain and classify textual data by considering individual cultural and contextual effects on phenomena. The final products of data analysis for content analysis are classifications and themes .This research adopts the convenience sampling method, and thirteen diabetes patients with delayed diagnosis and treatment were sampled with maximum variation in rural Daqing City and Tangshan City in China. All diabetes patients with delayed diagnosis and treatment had to meet the inclusion criteria provided by the first author to participate in the study. The inclusion criteria were having diabetes, living in a rural area and having experienced delayed diagnosis and treatment. Further information gathered from the patients interviewed included demographic background, age, gender, course of the disease, delay time of diagnosis and treatment, level of education and family income per month.All of the included patients with delayed diagnosis and treatment were asked and agreed to participate in this research, and all were farmers.The data collection was carried out from April to October 2018. In the process of the in-depth interviews, all diabetes patients with delayed diagnosis and treatment were informed of the aim of the study and agreed to participate. The respondents were encouraged to express their inner thoughts concerning the behavioral intention behind their delayed diagnosis and treatment of diabetes. All interviews were conducted in a quiet and well-lit room, comprised a face-to-face conversation between the interviewee and the interviewer, and lasted from 45 to 60 min. The researcher listened carefully and recorded the audio contents of the interview with a recording pen at the same time, and the interviewees’ behaviors and expressions were also recorded in a timely manner. After the interview, we returned the transcripts to the respondents, and they were asked to check whether the transcripts were consistent with their intention in order to improve the credibility of the results.When information was repeated in the process of the interviews, the sample size was considered to have reached saturation. All diabetes patients with delayed diagnosis and treatment and living in rural areas spoke Chinese, and the researcher translated the interviews into English to obtain the results. The outline of the interview was as follows Table .Table 1There were 2 researchers,who had nursing master’s degree, involved in coding the data. The seven-step Colaizzi phenomenology was used to analyze the interview data . The quaConsent for the study was obtained from the ethics committee of Daqing campus of Harbin Medical University. Before each interview, the researcher explained the purpose and content of the study to the respondents and promised confidentiality. The participants then agreed to participate in the research and signed the informed consent. Participants had the right to refuse to participate in the research at any time without reprisal.There were thirteen participants in this study: five were male, and eight were female. All patients had type 2 diabetes. The age of the participants was between 38 and 82 years old, and the mean age was 57.53 years. The disease course was between 1 and 20 years, the mean course of the disease was 9.1 years, the delay of diagnosis and treatment was between 0.5 and 13 years, and the mean delay of diagnosis and treatment was 6.1 years. Twelve patients had diabetes complications, 4 had diabetic foot, 7 had diabetic macular edema, 9 had diabetes complications with cardiovascular symptoms, and 2 had asymptomatic symptoms. Three of the participants were illiterate, 6 had primary school education, 2 had junior high school education and 2 had senior high school education. All of the participants were married, and four had experienced the death of a spouse. Six people had a monthly family income less than 500 RMB, 5 people had a monthly family income of 500 ~ 999 RMB, 1 person had a monthly family income of 1000 ~ 1999 RMB, and 1 person had a monthly family income of more than 2000 RMB  said, “I don’t know what are symptoms of diabetes and what’s the normal blood sugar. Maybe the normal blood sugar is about 6 mmol/L.”Another participant (N05) stated, “I am a farmer; because information is underdeveloped in the countryside, I don’t know what complications diabetes has.”The third participant (N01) said, “I didn’t know about diabetes before I had this disease, I paid attention to this information after I was sick. If I had known I was a diabetes patient, I would have gone to the hospital early.”Judgment of the severity of disease can have an effect on patients’ health behavior decisions. Two respondents thought that going to the hospital sooner or later would have no effect on the treatment of the disease. Four participants thought that if the disease did not affect normal life, it did not need treatment.One participant (N08) said, “Diabetes is a chronic disease, it doesn’t matter that you go to hospital sooner or later.”Another participant (N12) stated, “Everyone says that diabetes is a cancer that you can’t die from. If you are comfortable, then you don’t need to see a doctor.”A third interviewee (N10) said, “I didn’t need to be hospitalized after the diagnosis of diabetes, I just went home and controlled it by myself. And I always thought that diabetes was ok. I was diagnosed with diabetes five years ago, and I was hospitalized for the first time because I fainted.”The patients’ effective self-health management involved a long and difficult process. Some people did not accept regular treatment, and they used folk prescriptions and delayed treatment.One participant (N02) said, “I took the medicine, I still felt that I was bad, so I didn’t continue to take the medicine.”Another participant (N07) stated, “Usually, I have time to try to walk for exercise, because it is difficult to control my diet. I feel no one can control their diet so strictly.”A third participant (N09) said, “At first, the doctor told me that I should take medicine and have a strict diet, but I could not do it. I took folk prescription drugs for nearly three months, but it was no use, and I felt it was more and more serious, then I went to the hospital.”This theme includes three subthemes: poor medical behavior, fear/anxiety and uncertainty about the future. All participants were not positive about going to the hospital for various reasons.The interviewees had a weak awareness of medical treatment in general. Two respondents said that they did not go to the hospital if diabetes mellitus had no effect on their normal life.One participant (N08) said, “We live in the countryside and are busy every day, I don’t pay attention to myself, and I never go to the hospital.”Another participant (N10) stated, “I had symptoms of diabetes early, but I didn’t want to come to the hospital; when I had an examination, my blood sugar was 23.5 mmol/L.”Two respondents said that they were in good health and did not engage in treatment by themselves. Most people did not have good habits, and they thought it was trouble and a waste of time to go to the hospital.One participant (N06) said, “I still feel very young, and the chronic disease is not going to heal, so I never want to go to the hospital; I can control the disease at home.”After some patients were diagnosed with diabetes, they were fearful and refused to discuss their diabetes with others.One participant (N11) said, “Everybody said diabetes was difficult to cure, but people couldn’t die from diabetes. So I felt fear in the face of the disease, and I didn’t want to let others know that I had diabetes and I didn’t go to the hospital.”Another participant (N04) stated, “I don’t want to be in the hospital because it’s too much trouble, I’m afraid of family trouble, and I also fear missing work.”The patients with diabetes felt too much great worry and anxiety about the care of their children and families.A married woman (N04) said, “I was worried about my child, I was afraid nobody would take care of him while I was in the hospital, and it would have an effect on his studies.”Two respondents said that the hospital environment would produce anxiety and irritability. One participant (N13) said, “When I came to the hospital, I felt depressed, bad tempered and agitated.”Most of the patients had no confidence in the treatment of diabetes. Their uncertainty about the future led to delayed treatment.A patient (N04) with badly controlled blood sugar said, “I don’t know whether I can control my blood sugar or not, sometimes I had no confidence.”Another participant (N09) stated, “My current total blood sugar is above 10, now my legs are itchy. I don’t know whether going to the hospital and spending money can cure me or not.”All participants believed that the hospital environment was of poor quality. This is the main reason most people with diabetes were reluctant to seek help.The medical environment is not comfortable, and the poor medical services provided can directly affect the patient’s medical behavior. Three respondents said they were not satisfied with the medical environment of the hospital.One participant (N02) said, “The environment of the hospital was poor and not comfortable. There were too many patients, and they did not have good rest in the hospital.”Another participant (N03) stated, “I think the hospital conditions do not meet the standard in my mind, there were not enough beds in the hospital, and extra beds were in the corridors. In particular, I didn’t want to the hospital.”A third participant (N08) said, “I think that the process of seeing a doctor was too much. The fee was paid on another floor, seeing a doctor meant running around all morning, a person can’t see the doctor.”Three respondents hoped to obtain professional knowledge to guide the treatment of their disease.One participant (N03) said, “We don’t know what diabetes is, I didn’t even know when I was sick. When I don’t feel strong enough, then I’ll go to the community hospital, but that’s no medical condition.”Another participant (N05) stated, “Information in rural areas is developed, but I don’t know where to go to understand diabetes. Even if I’m sick, I don’t know when to see a doctor.”Social support is very important for people with diabetes, and patients with diabetes who have good social support have higher levels of cognitive behavioral intention.The majority of patients with diabetes learn about the disease from family, friends and people around them. Family members’ lack of medical knowledge will lead to delayed treatment. Some respondents went to the hospital at the urging of those around them.A patient (N03) whose blood sugar was 19.8 mmol/L said, “I don’t want to be in the hospital, but my daughter always advised me to go to the hospital.”Another participant (N05) stated, “I didn’t take medicine after illness, but I heard she had to take medicine to control her blood sugar, so I just came to the hospital.”A patient (N06) whose diagnosis was delayed by one year said, “People say that diabetes is a chronic disease. I didn’t need to go to the hospital for treatment for a long time. My diet and exercise could control the blood sugar, I received these effects, and so I didn’t go to the hospital.”Three of the respondents expressed that they did not want to go to the hospital because of the heavy economic burden.One participant (N05) said, “I had to spend money when I went to the hospital. I spent thousands on an optical inspection. I can’t afford it.”Another participant (N09) stated, “Because of the high cost of the treatment of diabetes, although the national subsidy exempts some treatment. But I still can’t solve the problem of diabetes drug costs.”This is the first qualitative study specifically aimed at exploring the inner experience of the clinical treatment of diabetic patients with delayed diagnosis and treatment.Relative to urban areas, diabetes health services for the rural patients in China are poor, which could be one of the reasons for delayed diagnosis and treatment in rural areas. Because rural patients tend to have a low education level, diabetes health education resources are scarce, resulting in a lack of knowledge of diabetes.The respondents said that before they were ill, they did not take the initiative to understand diabetes, and they did not know the first symptoms of diabetes. Eventually, this led to delays in diagnosis and treatment. The respondents did not understand the importance of early treatment for diabetes and ignored self-health management. Poor blood sugar control consciousness leads to disease development and complications involving other organs. Many people’s understanding of diabetes is flawed, which results in treatment resistance. This may be due to atypical early symptoms of diabetes, which most people cannot recognize. Second, people may lack knowledge of diabetes treatment. Knowledge about diabetes has the strongest effect on health behavior, and the higher the degree of knowledge is, the better prevention and control behaviors an individual engages in . TherefoThis study found that most of the respondents did not have good habits, and they responded negatively in the face of early symptoms. They thought their condition would improve through taking their own medication or resting more. The result was that when their symptoms affected normal life, the patients were forced to seek medical treatment. Some of the respondents did not understand the state of their body and considered themselves healthy, even delaying treatment for 16 years, and when they went to the hospital for medical treatment, they had serious complications. To address these habitual negative responses, we should first change patients’ negative medical attitudes. Zhang Cang found that a negative attitude towards medical treatment is the main reason for delayed treatment . TherefoPeople with diabetes experience or whose friends work in medical-related fields engage in better medical treatment behavior and have less fear and anxiety concerning the disease. Therefore, good social support can eliminate adverse psychological reactions and promote positive treatment. Studies have shown that a good role model or a good medical treatment atmosphere can promote patient health decisions; the absence of these factors leads to delayed diagnosis and treatment . TherefoIn the interviews, when mentioning reasons for their reluctance to go to the hospital, nearly half of the respondents thought that it was troublesome to go to the hospital. We conclude that treatment involves a complicated process, there are too many patients per hospital, and the patients live far away from the hospital. The best solution to this problem is to improve community health care. At present, patients’ medical understanding and patterns are changing in China, and people attach more importance to the convenience and effectiveness of treatment. The results of the study also showed that the convenience of treatment had a significant influence on residents’ medical behavior . TherefoIn addition, this study found that people with diabetes face a heavy economic burden, which is one of the reasons for the delay of diagnosis and treatment. Research statistics reveal that hospitalized patients with diabetes (1396 cases) spend approximately 13 days in the hospital, incurring a total hospitalization expense of 6578.88 yuan, while expenses for medicine account for the greatest cost, followed by inspection, examination and treatment. The economic burden to patients with diabetes cannot be ignored. We should continue to focus on the problem, seek to perfect medical insurance for patients with diabetes and let more people enjoy treatment.Because the research object of this study covers only two provinces in rural China, it is subject to bias due to region selection and research conditions. Additionally, because cultural differences exist between native English and Chinese speakers, the translation of the interviews from Chinese to English is another limitation of the study. Further strengthening of the theme extraction is necessary. Furthermore, this study was conducted on a limited number of patients with diabetes in rural China; therefore, the results cannot necessarily be generalized to all patients with diabetes in China. Because regional differences in China are relatively large, the psychological experiences of patients with delayed diagnosis and treatment of diabetes are different.Future studies may add quantitative research and engage in more in-depth investigations of the causes of the delayed diagnosis and treatment of diabetes.The findings of the current study show that 13 patients with diabetes suffered from problems of diagnosis and treatment delayed by a minimum of 2 to 13 years, and more than 90% of the respondents had complications.People with diabetes who live in rural areas experience a serious phenomenon of delayed diagnosis, which is particularly due to poor knowledge and habits. Therefore, nurses should start with the patient’s needs and wishes, raise awareness of diabetes treatment, reduce the occurrence of delayed treatment, and improve the prevention of diabetes.


The “German Darwin” Ernst Haeckel (1834–1919) was a key figure during the first “Darwinian revolution“, a time when the foundations of the modern evolutionary theory were laid. It was Haeckel, who crucially contributed to the visualization of the Darwinian theory by designing “genealogical-trees” illustrating the evolution of various species, including humans. Although the idea of explaining human evolution by natural selection belongs to Darwin, Haeckel was the first who attempted to create a new exact anthropology based on the Darwinian method.Trying to immediately reconstruct human evolution proceeding from the description of modern populations led Haeckel to the views which, from the contemporary perspective, are definitely racist. Haeckel created racial anthropology intending to prove human origins from a lower organism, but without the intention of establishing a discriminatory racial praxis. Although hierarchical in its outcome, the Haeckelian method did not presuppose the necessity of a racial hierarchy of currently living humans. It is crucial to grasp in what sense Haeckel’s theoretical explorations in human evolution were racist, and in what sense they were not. Our argument flows as follows. One of Haeckel’s pupils was the Russian ethnographer, anthropologist and zoologist Nikolai Nikolajewitsch Miklucho-Maclay (1846–1888). Maclay and Haeckel worked closely together for several years; they traveled jointly and Maclay had enough time to learn the major methodological principles of Haeckel’s research. Yet in contrast to Haeckel, Maclay is regarded as one of the first scientific anti-racists, who came to anti-racist views using empirical field studies in Papua-New Guinea.We claim that while conducting these studies Maclay applied scientific principles to a significant extent acquired from Haeckel. The paper contributes to the view that Haeckel’s theoretical racism did not follow the Darwinian method he used. Haeckel is the worst and the most harmful of all I know”“You were the first, who, from your own experience, clearly demonstrated that humans are everywhere humans, that they are friendly, social creatures”Ernst Haeckel defended and developed the Darwinian theory with a passion and energy like nobody else on the continent , 54, 57.Moreover, his theories were encouraged and admired by Darwin himself. Ernst Haeckel is, without doubt, a crucial figure in the growth of Darwinian thought in the nineteenth century. As Robert Richards emphasized: “More people at the turn of the century learned of evolutionary theory from his pen than from any other source, including Darwin’s own writings” . HaeckelCosmos about “the unity of human race” and provided several arguments in favour of this view including the form of the skull   : “Almostreation] . Darwin eted it” .Stettiner Vortrag (Speech in the city of Stettin) in 1863 and ending with Unsere Ahnenreihe (Our ancestors) (Progonotaxis Hominis) in 1908  written at the beginning of the First World War, Haeckel in a polemic style repeated his thesis that “black-brown” Australians and Papuans represent lower human races [niedere Menschenrassen]  . He stater races .Meanwhile, as Haeckel continued to speculate about higher and lower humans, his Russian pupil Miklucho-Maclay was occupied with the thorough field studies that challenged the very foundations of Haeckel’s human phylogenetic trees. The major point of controversy were the Papuans.Pithecanthropus alalus, whereas other species are at a much more advanced stage of evolutionary development  anthropology and allied sciences. Yet Maclay was not ready to accept the idea of humanity consisting of various hierarchically structured species. His intention was not to design speculative anthropological theories as Kant and Blumenbach had done, but to apply the very empirical method, which he learned in the Jena period primarily under the guidance of Haeckel . At the As Miklucho-Maclay is little known outside of Russia, and there are just a few biographical sources available in English, we summarize here relevant biographical details Fig. .Fig. 11Otechestvennye Zapiski (Domestic Notes) a philosophical essay “Letters on the Study of Nature”, where he, among others, emphasized the importance of empirical knowledge, and even speculated about the methods of morphology [Russkoje Slovo [Russian Word] the voluminous paper “Progress in the Realm of Animals and Plants”, in which he made Darwin’s Origin accessible to a broad audience, explaining it chapter by chapter  He built his hut between two Papuans villages, on a promontory that was occupied by nobody” , Fritz Müller’s Allgemeine Ethnographie and Haeckel’s Natürliche Schöpfungsgeschichte as the sources of the “bushy-hairiness” hypothesis. “No geographic variety” of Papuans, Maclay argued, demonstrated that kind of hair  first printed in 1921 and republished altogether five times, Erwin Baur, Eugen Fischer, and Fritz Lenz appealed again to the “hair-argument” to prove the lower value of “Papua-Melanesians”; their ulotrichan hair [Kraushaarigkeit] served the authors as an indicator of Papuan retardation [Unfortunately, Maclay’s observations had little influence in the Western world, and could not prevent growing racial thinking in Europe and especially in Germany in the first half of the twentieth century. In their infamous book By contrast, Maclay’s exact observations contributed to the growing scientific anti-racism, which became a commonly accepted position nowadays .


The COVID-19 pandemic has necessarily affected the operation of Canada's Parliament and, thus, the activities of Members of Parliament (MPs) . Here, we explore how the pandemic has affected the representational activities of individual MPs. The COVID-19 pandemic has necessarily affected the operation of Canada's Parliament and, thus, the activities of Members of Parliament (MPs) Malloy, . Here, wIn doing so, we rely on the Representational Connections Framework (RCF) developed by Koop, Bastedo and Blidook  in theirWe view the COVID-19 pandemic as a new influence that could shape the representational behaviours of MPs. We conducted semistructured interviews with 11 MPs during May 2020. Questions were designed to probe MPs’ self-observed differences in their activities due to the COVID-19 pandemic, with an emphasis on connections with their constituents and how they typically spend their workdays at home and in Ottawa.First, we discuss how the pandemic has shuffled MPs’ representational priorities, shifting MPs away from some connection-building activities and toward behaviours that support service connections. Second, we explore the particularities of service representation during the pandemic. The pandemic has affected MPs’ daily work through increased constituent demands for service in an abruptly changed operating environment. MPs report increased volume of constituent inquiries and requests, a changed nature in these demands as constituents mostly seek assistance and information related to COVID-19, and significant implications of a remote workstyle for MPs’ daily activities and those of their staff.We found that COVID-19 has affected MPs’ connection-building representational activities. Most importantly, the pandemic resulted in an increased emphasis on constituents’ requests for service from MPs, which limited the diversity of representational practices normally found among MPs. While some MPs already prioritize service connections, this became the case during the pandemic for all MPs we interviewed, supplanting other types of connections. As MP Francis Scarpaleggia puts it: “We're in full service mode as opposed to, say, debate mode.”While some MPs indicated a decline in their usual policy work, others said there has been no decline, but that increased service demands have simply increased the hours of work overall and/or altered what gets prioritized. “I think the amount of legislative work we're doing has not really diminished,” argues a government MP. “It's pretty much the same except we're also doing an influx of constituency work, a volume of constituency work that's increased quite dramatically.”“I miss the face-to-face because I could be at a senior's dinner in Carbonear and there could be 150 people there. So you get to mingle and speak to a lot of them face-to-face. Most of it is a cordial greeting, or someone might have an issue that they want to talk to you about. So this doesn't get done face-to-face now.”“Politics is like many other human activities: it's a human-to-human interaction,” MP Kenny Chiu expands. “I need to have coffee with, I need to talk to, I need to shake hands … [with] constituents, stakeholders, [and] colleagues.” And MP Alexandra Mendès links the importance of face-to-face communication to characteristics of her constituency, arguing that “non-verbal communication is extremely important” for interacting with constituents in her highly diverse urban riding.The physical distancing regulations and restrictions on public gathering necessitated by COVID-19 make it difficult for MPs to build and maintain symbolic ties with their constituents by attending events and being present in the community. As MP Ken McDonald notes,In response, many MPs have adopted new techniques to keep in touch and maintain linkages with constituents. MPs talked about webinar town halls and other online forums as ways to continue communications. MP Jenica Atwin, for example, reports that 160 people had attended a recent local webinar.“… there's a lot of things about this COVID pandemic that will maybe change the way that I do the job in the future.” He expands, “… [T]o leave my home and drive to Grand Bank, it's like four hours. So if [mayors and municipal councillors] want a meeting about a particular issue, my executive assistant and I can set up a Zoom meeting…. And we can spend extra time in the meeting because now we don't have to spend eight hours driving.”While some MPs are eager for the pandemic to end so they can get back to their normal operations, others noted that some of the shifts in their representational approaches may outlast the pandemic. MP Churence Rogers, for example, suggestsWe also heard from some MPs that they are developing new representational connections with various local populations. MP Iqra Khalid, for example, reports that the pandemic has resulted in requests for assistance from local businesses, which generally have not contacted the MP's office in the past.The predominant shift in representational behaviours reported by the MPs we interviewed is in their approach to building and maintaining service connections with their constituents. We observed three main ways the daily service work of MPs has changed.First, MPs’ volume of casework increased dramatically. Regardless of whether they typically prioritize service connections, all the MPs we interviewed were experiencing surges in service needs, with many adding that their Ottawa staff are currently assigned to constituency matters. As MP Atwin explains, “Our offices have never been busier … phone calls, emails, or messages through the various platforms, so there's lots of points of contact every day … the volume has certainly increased exponentially.”My caseworkers have been inundated with casework. Normally, the majority of casework that comes is around immigration.… [N]ow, the vast majority, on top of the immigration pieces that we've been helping people with, is actually COVID-19-related questions. Either people who are trying to access the benefits that are available through the federal government or a lot of people who are falling through the cracks of those programs.Second, the substance of the service work performed by MPs and their staff has changed during the pandemic. Typically, MPs and their staff develop the knowledge and skills to help constituents with a fairly narrow set of concerns. COVID-19 quickly spawned a host of government programs and regulations, generating new service concerns from constituents and increasing the immediacy with which offices need to respond.MP Mike Lake similarly adds that other service cases have often taken a backseat: “… [T]he priority from the government side is around COVID and so the typical things that we've dealt with … are completely different in terms of timeframes. Basically, a lot of the regular stuff is on hold.” The urgency of COVID-related service needs was emphasized by many of the MPs we interviewed. “This has to get done now,” said MP Raquel Dancho of these requests. “There is no putting this off. People are suffering, people are not being heard.”Finally, COVID-19 has changed the way MPs gather and act on concerns. Normally, MPs receive service requests via email, phone calls, walk-ins to constituency offices, and unplanned or chance meetings at events or on the street. Staff or the MP then work with constituents to address these concerns. When COVID-19 resulted in the closing of riding offices, in addition to adapting to the increased volume and novelty of service requests, MPs and staff alike had to adjust.For the most part, adjusting has meant working remotely from home. This entails increased use of technology, more staff and caucus meetings, and sometimes working without a dedicated office space among the demands of family. While MPs generally reported that operational practices transitioned well from constituency offices to remote settings, the loss of foot traffic deprived MPs of in-person contact with constituents, which is a key element of some members’ representational style.While MPs’ representational styles focus to varying degrees on policy, service, symbolic and party connections, the COVID-19 pandemic has tended to shift MPs’ behaviours heavily toward service. Across parties and jurisdictions, MPs emphasized the need to provide service to aid and inform constituents on matters related to COVID-19. In this way, COVID-19 has affected the nature of representational work undertaken by MPs during the crisis. The loss of opportunity to make significant strides in non-COVID-related policy and symbolic connection building during the “crisis” portion of the pandemic was discussed most by those MPs who prioritize those types of connections, and their frustration was often evident.There is preliminary evidence that the changes we observed in Canada are also taking place in other democracies that employ single-member units of representation. In a larger study of representational practices currently underway, MPs in Australia and New Zealand told us that similar restrictions to those implemented in Canada caused a focusing of their time and energy toward direct service to constituents. Also similarly, while many saw benefits to take forward from their experiences with new media, most MPs expressed concern about a loss of in-person contact with constituents.Once in office, MPs engage in experiential learning about being a representative or learning through reflection on doing (Koop et al.,


ISCB honors a leader in the fields of computational biology and bioinformatics each year with the Accomplishments by a Senior Scientist Award. This award is the highest honor conferred by ISCB to a scientist who is recognized for significant research, education and service contributions. Bonnie Berger, Simons Professor of Mathematics and Professor of Electrical Engineering and Computer Science at the Massachusetts Institute of Technology (MIT), is the 2019 recipient of the Accomplishments by a Senior Scientist Award. She is receiving her award and presenting a keynote address at the 2019 Joint International Conference on Intelligent Systems for Molecular Biology/European Conference on Computational Biology in Basel, Switzerland on July 21–25, 2019.Bonnie Berger grew up in Miami, Florida with her parents and older brother and has early memories of being curious about mathematics. She recalled, ‘As a young child, I responded, ‘I want one too, please’, when my father slipped math problems under my brother’s door. My father would continue to challenge me with math riddles and chess puzzles. He would also engage me in science projects. Our relationship laid the foundation for my comfort with, and interest in, math and science, even though it was not so common for girls at the time’. Berger’s early interest in math and science led her to complete her AB in computer science at Brandeis University. In 1990, she completed her PhD in computer science at MIT under the mentorship of Silvio Micali. Berger’s dissertation research on randomized and parallel algorithms was recognized by the Machtey Award for a manuscript that she co-published with fellow graduate student John Rompel, as well as the George M. Sprowles Award.After graduate school, Berger remained at MIT and stumbled upon computational biology quite unexpectedly. She recounted, ‘My postdoc supervisor Daniel J. Kleitman, who has Erdos #1 and solved dynamic programming for RNA base-pairings with Ruth Nussinov, had just come back from an NSF workshop whose goal was to get mathematicians and biologists together to solve challenges at the interface between the two fields. He was so taken with Michael Levitt’s talk that he said, ‘Proteins, that’s what you should do’. Well, fortunately, he didn’t say, ‘Plastics’, as in ‘The Graduate’, or I might have ended up a material scientist’. She appreciates the freedom she had as a postdoc and took to heart the advice Kleitman gave her when he told her, ‘We are applied mathematicians looking for interesting problems to investigate’. Following her postdoc, Berger became an Assistant Professor of Mathematics at MIT, and as a PI, she has pioneered the use of computer algorithms for analyzing, interpreting and sharing diverse types of biological data.Among Berger’s scientific contributions, she developed the use of pairwise residue correlations to predict protein structure from sequence through her highly cited Paircoil/Multicoil programs. Her seminal work on the hardness of protein folding was recognized with the 2010 RECOMB Test of Time Award. Berger’s interest in genomics included development of the ARACHNE genome assembly tool, which was used by the Human Genome Consortium for whole genome assembly. She also initiated the area of comparative genomics with her cutting-edge work comparing human and mouse genomes. Berger launched the subfield of global network alignment with her Isorank/IsorankN programs and advanced protein structure alignment with her MATT program. More recently, Berger has founded the field of compressive genomics by designing algorithms that can be used for genomic analysis on compressed data in order to keep pace with data generation. She has also spearheaded efforts to improve biomedical data privacy, including the development of tools to securely crowdsource genomic and pharmacological data at scale.Berger considers her theoretical computer science background to be critical to her success in identifying and studying computational biology problems. She said, ‘I have realized that with my algorithms background and flexibility, I can easily shift between areas as the research landscape changes. As I gain knowledge across diverse research areas, I can see connections between them and techniques that can be used to address them’. Berger has also come to appreciate the many mentors that helped her bridge the gap between computer science and biology, including Peter Shor, Peter S. Kim and Jonathan King. She recalled, ‘[They] taught me biology on a need-to-know basis. It took many rounds of back-and-forth by, would you believe, fax machine with Peter Kim for me to turn my early Paircoil writeup from definitions and theorems to one accessible to a biology audience’.Berger has trained numerous graduate students and postdocs, using an approach she learned from her NSF Postdoc supervisor. She said, ‘[Kleitman] gave me a lot of freedom to pursue whatever interested me, and that’s how I mentor my students. I ask them what interests them and suggest several research problems, or I encourage them to bring entirely new research areas to us’. Many of her trainees have become leaders in the field of computational biology.Berger is also fascinated by developing methods to improve data sharing and said, ‘I am interested in individuals, labs and companies owning rights to their own data but providing provably secure algorithms so that they can for the first time share their data at scaleto enable biomedical insights across different nations and diverse data. Recently, I am interested in developing sketching algorithms that take advantage of the geometry of single-cell RNA-seq data to better share, analyze and draw insights from the data’.Berger has served the computational biology community in many capacities, including her roles as Vice President of ISCB and Head of the RECOMB Steering Committee; as well as her service on multiple editorial boards, and program and conference committees. Her scientific contributions have been recognized by numerous awards, including the NSF Career Award, Biophysical Society Dayhoff Award for Research, inaugural Technology Review Top 100 Innovators, ACM Fellow, ISCB Fellow, AMS Fellow, AIMBE Fellow, NIH Margaret Pittman Award for Outstanding Scientific Achievement & Lectureship, election to the American Academy of Arts & Sciences and an Honorary Doctorate from EPFL.Berger is extremely grateful for this recognition by ISCB, especially considering her longtime involvement with the Society. She said, ‘It’s a tremendous honor to join such a distinguished and accomplished group of scientists’.


Multicomponent workplace-based interventions aimed at reducing sitting time among office workers are becoming increasingly popular. ‘Take a Stand!’ was such an intervention, reducing sitting time by 71 min after 1 month and 48 min after 3 months. However, it is unclear how the implementation process of ‘Take a Stand!’ affected these results. The present study explored how individual factors and organizational context influenced implementation and effect in ‘Take a Stand!’Framework for Evaluating Organizational-level Interventions. Interview data were combined with questionnaire and activity data, and multilevel analysis was undertaken to assess how changes in sitting time varied depending on the assessed factors. In addition, interview data were used to underpin results from the multilevel analysis.This was a mixed-methods study, combining data from interviews, questionnaires and accelerometers. Directed content analysis was used for analysing interviews with participants, ambassadors and managers from the 10 intervention offices in the ‘Take a Stand!’ study. Categories for analysis were taken from Concurrent institutional changes were found to be a barrier for the intervention by ambassadors, while participants and managers did not find it to be an issue. Management support was consistently highlighted as very important. Participants evaluated ambassadors as being generally adequately active but also, that the role had a greater potential.The motivational and social aspects of the intervention were considered important for the effect. This was supported by regression analyses, which showed that a strong desire to change sitting time habits, strong motivation towards the project, and a high sense of collective engagement were associated to less sitting time at 3 months of about 30 min/8 h working day compared to participants with low scores. Influence from other participants (e.g. seeing others raise their tables) and the use of humour were continuously highlighted by participants as positive for implementation. Finally, the intervention was found to influence the social climate at the workplace positively.Individual motivation was related to the sitting time effect of ‘Take a Stand!’, but the organizational culture was relevant both to the implementation and effect within the office community. The organizational culture included among others to ensure general participation, to uphold management and peer-support, and maintain a positive environment during the intervention period.NCT01996176. Prospectively registered 21 November 2013.ClinicalTrials.gov,  Sitting for long periods has been associated with adverse health outcomes; e.g. all-cause mortality and cardiovascular disease , 2. The Nielsen et al.  address Nielsen & Randall  have proA review of studies from Australia, the UK and the USA on barriers to, and facilitators of reducing workplace sitting identified elements such as work pressure, and social norms around movement, as relevant to consider when implementing interventions . HoweverThe aim of this study was to explore how factors during the implementation process influenced implementation and the effect size of the ‘Take a Stand!’ sitting time intervention towards office workers. This was done using a mixed-methods approach, and included both statistical analysis of changes in sitting time and relevant factors among the 173 participants in the intervention group, and interviews with a total of 58 participants, ambassadors and managers taking part in the project.The cluster-randomized controlled trial ‘Take a Stand!’ aimed to reduce sitting time among office workers. Details on the included offices, inclusion and exclusion criteria, recruitment and randomization are reported elsewhere, together with the main results , 13. In Eligible individuals were ≥ 18 years, worked > 4 days/week and were not pregnant, sick or disabled so their ability to stand or walk was affected. All participants had sit-stand desks prior to inclusion.The main effects on accelerometer-measured sitting time was a reduction of 71 min/8 h working day after 1 month and 48 min after 3 months in the intervention group compared to the control group. Sitting was mainly replaced by standing, but the number of steps and breaks from sitting increased as well. Sitting time during leisure and time spent on physical activity did not change .www.clinicaltrials.gov (NCT01996176) and approved by The Ethics Committees of The Capital Region of Denmark (H-6-2013-005) and Committee of Research Ethics in Greenland . Procedures were designed in accordance with the Helsinki Declaration.The study was prospectively registered at Details on the ‘Take a Stand!’ intervention have been published previously , but briFidelity to the intervention was high, based on information from observations and questionnaires. For dose delivered, all five intervention-components were implemented similarly at all four workplaces. While dose received generally showed high levels for all intervention components; 86% felt management supported the project; 79% knew where to have standing meetings; 76% participated in the workshops; and 73% signed up for the weekly e-mails .To evaluate the implementation process of the intervention and uncover how the intervention worked in different groups, a framework was selected to direct the process evaluation. The framework by Nielsen & Randall considers factors from the intervention context, factors related to the initiation and implementation of the intervention, and the mental models of the participants. Based on the framework, we have assessed a number of factors, as shown in Fig. Context considers how different hindering and facilitating factors influence intervention outcome. Context is divided into omnibus and discrete context. Omnibus context considers the different characteristics of the participants, and has been analysed elsewhere . This arOrganization of the intervention includes how it is initiated and implemented. This includes participant involvement in initiating the intervention, and the role of managers and ambassadors as drivers of change.Finally, the mental models consider the social setting and interactions within the office in relation to the intervention. This level includes factors like motivation, perceived need for the intervention, and whether participants share mental models around the intervention. More specifically, this was assessed as a sense of community and mutual support between participants in relation to the project.To gain knowledge of the different factors in the model, multiple data sources are included in the article , 15: 1. Questionnaire data were web-based and collected at baseline and at 1- and 3-months follow-up. Background information was recorded at baseline, while variables included in the regression analysis were recorded at different time points as follows . Ambassadors helped recruit participants for focus groups. Focus groups lasted between 18 and 58 min. In addition, all ambassadors were interviewed either alone or together (if offices had appointed more than one ambassador) resulting in 11 interviews with a total of 15 participants. These interviews lasted between 11 and 70 min. Finally, all managers were interviewed, resulting in 9 interviews with 10 participants lasting between 12 and 45 mins.All 31 interviews and focus groups took place shortly after the last follow-up measure at 3 months. Interviews and focus groups took place during working hours and at the workplace, except for 5 manager interviews, 4 interviews with ambassadors and 2 focus groups, which, due to necessity, were conducted by telephone.The interviews followed a semi-structured interview-guide designed using questions from the framework by Nielsen & Randal , with a Activity was recorded at baseline and after 1 and 3 months, by an ActiGraph GT3X+ accelerometer worn on the front of the thigh 24 h/day for 5 days (Monday-Friday). During this period, participants kept a log of sleeping and working hours. Data were processed using Acti4 software, which is found to have high sensitivity and specificity for the thigh-mounted ActiGraph –18. ActiAll interviews were transcribed verbatim and imported into NVivo12  for analysis. Directed content analysis was used  as displAnalyses were conducted using STATA/IC-14.0 . Multilevel mixed-effects linear regression was used with sitting time at 3 months follow-up as outcome, taking baseline sitting into account. Then all factors of concern .Employees were involved in the decision of participation (coded ‘yes’ if participants described participation in the decision to join the project).Active ambassador .Focus on common goals Non-participants had negative influence on the project (coded ‘yes’ if some participants found that non-participants affected their attitude towards the project).Data integration took place in the data processing phase, as part of the interview data resulted in variables, which were included in the statistical analysis. The following themes were classified into categories (yes/no):Finally, methods were integrated in the analysis phase as interview data were used to improve understanding of statistical findings and vice versa. Inspired by the process described by Moran-Ellis  and KellOf the 173 participants, 105 (61%) were women, the mean age was 47 years old, and 76% had finished tertiary education Table . One thip = 0.171) more compared to participants from offices without concurrent changes , while participants and managers said they had no influence: “Well, management backed it in both places, so it didn’t mean anything.”  and “I don’t think it had any influence on project outcomes.” .This might be explained by the fact that many ambassadors found that the concurrent changes were influential; “It may have had a positive impact, in the sense that it added something else that we could work on collectively to get to know each other better.”  and “I think the project was good for us in our situation, with a whole new management and new departments, so we had some kind of a joint project.” . In this way the project became part of the social context at the workplace: “The parts of “Take a Stand!” that we used were the more social aspects, so there was a bit more to it than just telling each other to stand up.” .In a few departments, participants even described that ‘Take a Stand!’ had come at a good time because it gave them a common project across the new department, “The first time we were introduced to it was at a departmental meeting. Peter and Johanne said we were going to be part of something exciting. He was already very committed, and thought it was great that we’d been allowed to take part because so many were up for it.” . Additionally, some managers succeeded in appealing to everybody, making them feel they were able to participate: “Our managers aren’t naturally sporty types... so I think people felt that they started on the same level as the rest of us, so that probably made a difference. If we’d been confronted with a super-fit gym bunny, people might have felt that they were being coerced into it. [...] It was sold to us in a way that made everybody feel they could take part, nobody thought, ‘Oh God, I can’t, I have osteoarthritis’.” . On the other hand, within some offices, particularly one, participants felt imposed on by the decision to participate in ‘Take a Stand!’, and felt a lack of information and ability to influence the decision: “I kind of felt we were being forced into it, and weren’t really provided with proper information about why us and what it was for. It was just kind of, ‘Well, you have to do it’. I didn’t feel like I had any say in the matter.” .During the interviews, participants from 6 out of 10 offices  stated that they were included in the decision about participating in ‘Take a Stand!’ In the multilevel analysis, we found no association between this influence and the effects Table . Across “I said we were going to be part of a research project that would enhance well-being in the workplace, instil good habits and make us more active during the day, and that I thought it was really positive, and doing it would generate a lot of positive energy, make us more efficient, and enhance the well-being of individual members of staff.” .In addition, participants from several offices expressed that they had wanted more information about ‘Take a Stand!’ and the content from the very beginning, which is in line with managers explaining that they sold the project, not as a sitting time project per se, but more as a health or wellbeing-at-work project: “I really think that the single most important aspect has been that management and colleagues backed the project.” . This was expanded on by explaining how managers could show their support for the project and show it was important and possible by setting a good example: “So, our manager played a very active part in the project, and did a lot to make sure people followed up on the targets. At the very least, she was good at keeping us motivated and active.” .At 1 month, 120 participants (77%) felt a high/very high degree of management support towards the project. At 3 months, the number was 105 (67%). In the multilevel analysis, neither management support at 1 nor 3 months was associated with outcomes .Finally, managers could state their support physically by ensuring the right facilities: “It’s really important that management thinks it is OK to spend time on it. That they’re motivated and think it’s in our best interest, even if not necessarily theirs. That means something.” .Management support was crucial for participants to feel they were allowed to change their work routines and spend time on the project, “Well, my role is to focus on the fact that we’re part of this project. Much of what we’ve done as a department has been based on ‘Take a Stand!’ All of the departmental meetings, one-on-one meetings, etc., that I’ve been to have taken place standing up as far as possible. And then there is the constant encouragement – ‘Remember to stand up!’” . Being the good example and inviting workers to stand was also expressed by another manager, especially when making it fun: “I also used a bit of humour. Like when I stand up and shout ‘All rise!’ like in an American courtroom” .Management interviews showed that managers were very aware of this role, as they understood the need to be supportive, participating, and enthusiastic and to ensure focus on the project and the common goals, e.g.: “It requires management backing. We support it, and say that you can do it in your working hours, including spending time preparing for it and stuff like that. That’s needed, of course.” .The managers also emphasized the need for them to participate equally with the employees, and their roles in supporting both the ambassador and the employees: During the interviews, participants, ambassadors and managers from 4 out of 10 offices (representing 58 persons 43%)) described an active ambassador, mentioning different initiatives and supportive actions the ambassador had carried out during the project period. However, having an active ambassador was not related to sitting time in the multilevel analysis (Table %) descri“If the boss forgets that you could stand up, one of the ambassadors always says, ‘Shouldn’t we stand up for some of the items on the agenda?’” .In several interviews, participants described how ambassadors made fun activities and small reminders, e.g., in one department, ambassadors put up notes on toilets and coffee machines suggesting using another one down the hallway (a11). Ambassadors described their role as motivators and as setting good examples, and many took the role of reminding participants of the project: “You have to remember to do it [remind colleagues about the project], because we’re just so damn busy. It would be easy for it to be drowned out by everything else.” , and on the other hand, there was a fear of going too far and interfering with people’s privacy: “I actually think it’s been difficult sometimes. Part of me thinks that, in my department, a lot of it has just happened of its own accord. And when it didn’t, it’s been a question of not interfering too much. It’s maybe best to leave people in peace, but also make sure there’s always room for them among the rest of us if they want to join in.” .Nevertheless, other participants called for more active ambassadors, however, some ambassadors described barriers in this regard. On one hand, there were barriers such as time constraints on themselves and participants p = 0.001). Participants with a strong/very strong desire to change sitting time at 3 months reduced sitting by 31 min at 3 months compared to participants with less desire . The proportion of participants with a strong/very strong desire to change sitting increased slightly from 49% (65) at baseline to 62% (79) at 1-month follow-up, followed by a decrease to 56% (72) at 3-months. In addition, we assessed to what degree participants felt they needed a project on sitting time at baseline: 48% (63) thought this was necessary, but there was no association with outcome .Baseline measures were taken before participants were randomized to intervention or control and before they knew about ‘Take a Stand!’ During the final interviews, participants explained that the workshop and knowledge about the health consequences of sitting motivated them: “I’ve always had sit-stand desks, I’ve just never used them to stand up.” . However, many participants were positively surprised how long they could stand without being tired and how easily they were able to change their sitting habits . Some participants even described how it became more natural to stand than sit: “I’ve also noticed that when we’re sitting down in meetings, I get antsy quickly and need to stand up.” .Before ‘Take a Stand!’, participants had not considered their sit-stand desk as a means of varying their working day: p = 0.002). For motivation at 3 months follow-up the difference was − 36 min . The absolute level of motivation fell from 68% (87) with strong/very strong motivation at 1 month to 57% (73) at 3 months follow-up. As mentioned, perceived management support fell from 77% at 1 month to 67% at 3 months .In follow-up questionnaires at 1 and 3 months, intervention group participants were asked about their motivation for ‘Take a Stand!’ and this measure was strongly associated with sitting time at 3 months. Participants with strong/very strong motivation at 1-month follow-up were sitting − 34 min/8 h working day less than participants who answered they were only somewhat, little or not at all motivated for the project .Several participants explained how the workshops motivated them, but that over time this motivation had faded, and they would have liked more reminders of the health consequences of sitting during the period. However, some participants explained that something had changed in the way they worked, which they expected to continue: p = 0.011). However, sense of collective engagement at 1-month follow-up was not associated with sitting time effect at 3 months. Mutual support at the office, focus on common goals, positive atmosphere concerning the project, and whether the project created positive experiences with colleagues, all measured at 3 months follow-up, showed no relation to sitting time at 3 months . In contrast, some participants worked in private offices or with non-participants and they often found it difficult to maintain their motivation or to remember the project: “I think I’d have been reminded of it more if we’d been sitting together and I could have reminded others – if we were all sitting in a big, open-plan office, like. Or if I at least shared with somebody else, and we could have done it together – if she raised the desk, I’d do it too, I think.” . It seemed that seeing somebody else standing up was the best reminder of the project and the best cue to behavioural change.During interviews, participants described how they were influenced by seeing their colleagues raising their desks, and were thus encouraged or reminded to do the same themselves, e.g. “I could imagine somebody else adopting a different approach, but she did it in a positive and humorous way, so it was all good. It was not like she constantly told us what to do. Because that’s not the way it should be. I think.” .Humour was mentioned in most focus groups and by most ambassadors as a mean to remind colleagues of the project without being strict. One participant talked about the ambassador and her role in the project: “It’s been a matter of just walking around and saying, ‘Hello, stand up!’ and sending e-mails with fun links for exercises or something else to do.” . Other ambassadors admitted they would have liked to have provided more fun and encouraging activities.Additionally, several ambassadors explained that they tried to have a humorous take on the activities: “The sense of collective engagement around this has been the most positive thing.” .An important part of ‘Take a Stand!’ was the workplace community around the intervention. In questionnaires, 47–50% of participants answered they felt a high/very high sense of collective engagement concerning the project  when asked after 1 and 3 months, and sense of collective engagement was related to reduced sitting time after 3 months .The workplace community around ‘Take a Stand!’ was fostered by participating in the same workshops, wearing accelerometers at the same time and working towards common goals. In addition, some offices experienced secondary social effects, which enhanced the general sense of collective engagement and coherence: When you add the big professional challenges that were so important during this period, then it doesn’t happen. Then it’s only in social contexts that there’s room for it.” . The social part of ‘Take a Stand!’ was also essential in offices where work was centered on helping the public, where participants expressed satisfaction about doing something for themselves, the workplace community, and for the public.In some offices, experiencing concurrent changes and thus new ways of working meant that ‘Take a Stand!’ even became more of a social thing than a health promotion project: ““I probably didn’t get the same sense of community because I was sitting on my own. It didn’t really feel like something we were doing it together.” . This was reflected in questionnaire results in which about half of the participants reported collective engagement.However, even though it was perceived as something essential, not everyone felt this sense of collective engagement: In 3 offices, representing 43 (31%) of participants, non-participants were described as influencing the project negatively. However, there was no difference in the effect on sitting time between those who experienced negative influence of non-participants, and those who did not . Meanwhile, there were others who remained seated, and who even expressed aversion towards the project: “Somebody held a meeting where we had to stand up. Somebody else at it said, ‘Oh, is this that nonsense you’re part of?’ and those who weren’t part of the project remained firmly seated and offered no support.” .All offices had some non-participants, who, from the descriptions in the interviews, could be divided in two groups: those who just did not want to participate and those with legitimate excuses, such as being on holiday when the project started, working part-time, or having problems standing or walking (e.g. due to pregnancy). Additionally, the measurements (anthropometric measures and wearing the accelerometer) discouraged some participants. The interviews clearly indicated that how non-participants influenced the project (or did not) varied greatly. Some non-participants joined the activities such as standing meetings or raising their desk: ““It really gets to you. It would’ve been much better if everybody had been involved and thought it was fun, because we’ve been rather split. And that’s really bad for motivation.” . Managers reported that these negative non-participants created a dilemma between trying to motivate them to participate, or simply excluding them from discussions of the project.In offices where this happened, both participants and managers agreed it affected the motivation towards the project negatively because the whole office was not participating and supporting each other: During the intervention period, the implementation and the sitting time effect of ‘Take a Stand!’ were influenced by factors related to context, organization of the intervention and the mental models of the participants. Main results of each level are summarized and discussed below.Even though it was a theme for the ambassadors, participants did not find concurrent organizational changes an obstruction to the intervention; in some cases they even welcomed the intervention into a period of organizational changes. This finding is supported by the claim that organisations constitute an ever-changing environment . Thus, oRegarding the initiation of the intervention, some participants felt they were included in the decision to participate, while others felt imposed upon and unengaged. Several participants mentioned that they would have liked more information about the content of the project from the very beginning. Other studies have shown that a positive and participatory initiation of an intervention is an important driver of behavioural change , 22. FurParticipants consistently emphasized the role of the managers, which is in line with several other studies of other occupational health interventions , 23 and In addition to management support, previous studies have found workplace champions play an important role during the implementation of workplace interventions , 26–29. In general, the social element of the project played an important role - that is consistently emphasised by the literature; a supportive environment is crucial for workplace health interventions to be implemented successfully , 30 . MoOur findings on motivation are supported by other studies that highlight that a positive attitude from participants is essential for implementation . During In our study, participants and ambassadors pointed to the use of humour as an effective means during the intervention period, which is supported by other studies. However, although we did not find this in our study, it has also been suggested that such strategies are effective only during the initial stage .Several studies have emphasized that social support from other participants is essential to intervention implementation and effectiveness , 32, 34.In some offices, not all employees participated in the intervention, and some even expressed their negativity towards the project e.g. during standing meetings. In this case, non-participants may negatively influence the results of the intervention – something that has been brought up by others who suggest the need for sitting time interventions to be implemented throughout the entire workplace , 31, 32 Looking at the results across the three levels , we have identified a number of promoters and barriers that are potentially relevant for future implementation. The principle promoters identified were management support, both when initiating the project and over the course of the intervention period; the social aspects of the interventions including mutual support between participants; and the use of humour and collective engagement to create a community around the intervention. As discussed above, several promoters were identified in other studies also e.g. , 34). We. We34]).Together, the findings of the present study are in line with findings from other evaluations of sitting time interventions, and highlight the importance of an organizational perspective (e.g. ): This iTogether with findings from other process evaluations of similar interventions, findings from the present study contribute to the body of knowledge on how these interventions work, on which factors need to be enhanced, and on potential problems to be addressed when further disseminating these interventions into real-world settings .A major strength of the present study was the use of mixed methods, which made it possible to understand the success of interventions and to uncover associations between processes and effects . CombiniAnother strength was that participants, ambassadors and managers were interviewed, which contributed important perspectives on the results. Finally, the outcome measure, sitting time, was measured with accelerometers on the thigh, which is currently considered the most accurate method for measuring sitting time .A limitation of the present study was the fact the interviews were coded by a single researcher (IHD). In order to accommodate this limitation, results were verified in other ways: results were discussed thoroughly in the author-group; a group of experienced qualitative researchers gave feedback on the analysis of one of the interviews; and findings were often confirmed in several other ways such as in data from participants, ambassadors and managers or through the mixed-methods design. However, this approach might potentially have caused some bias in the results due to the tendency in mixed-methods research to follow the more interesting findings in the material . The resEven though we had a high number of participants in the trial, analysis for the present paper was restricted to the intervention group, which reduced the number of clusters and the number participants, making it harder to detect small statistical differences.In addition to the factors assessed, others have found a relationship between social-cognitive factors and intervention effect on sitting time . Thus, iManagement support was pointed out as very important, but we received mixed views on the consequences of concurrent changes during the intervention period and the role of the ambassadors. Desire to change sitting and motivation towards the project influenced the sitting time effect of ‘Take a Stand!’Finally, the social element of the project was important, as a high sense of collective engagement was related to decreased sitting time, and participants highlighted mutual support, use of humour and the social community in the office as important for the project to succeed.Altogether, when implementing sitting time interventions within the office community, the motivation of individual employees seems important, as does the organizational culture surrounding the project, ensuring general participation, management and peer support and fostering a positive atmosphere at the office during the intervention period.