Background: Knowledge about climate change may produce anxiety, but the concept of climate change anxiety is poorly understood. The primary aim of this study was to systematically review the qualitative literature regarding the scope of anxiety responses to climate change. The secondary aim was to investigate the sociodemographic and geographical factors which influence experiences of climate change anxiety. Methods: A systematic review of empirical qualitative studies was undertaken, examining the scope of climate change anxiety by searching five databases. Studies were critically appraised for quality. Content analysis was used to identify themes. Results: Fifteen studies met the inclusion criteria. The content analysis was organised into two overarching themes. The scope of anxiety included worry about threats to livelihood, worry for future generations, worry about apocalyptic futures, anxiety at the lack of response to climate change, and competing worries. Themes pertaining to responses to climate change anxiety included symptoms of anxiety, feeling helpless and disempowered, and ways of managing climate change anxiety. Relatively few studies were identified, with limited geographical diversity amongst the populations studied. Conclusions: The review furthers understanding of the concept of climate change anxiety and responses to it, highlighting the need for high-quality psychiatric research exploring its clinical significance and potential interventions. Climate change has been identified as one of the most pressing issues of our time, with major impacts on both physical and mental health . Beyond Climate change anxiety has been proposed as the most recognised form of eco-anxiety . It has The aim of this systematic review is to explore the empirical qualitative literature examining the scope of climate change anxiety and the spectrum of responses to it. A secondary aim is to explore the factors influencing climate change anxiety. Qualitative methodologies are most appropriate to develop an in-depth understanding of a new phenomenon, as they explore subjective experiences and narratives in an open way . Thus, tThe review was conducted according to PRISMA reporting guidelines. A search of the published literature was performed using the databases Medline, PsychINFO, ProQuest, Web of Science, and Scopus. Search terms used were ‘climate change’ OR ‘global warming’ combined with ‘anxiety’ OR ‘worry’ OR ‘fear’ OR ‘eco-anxiety’. MESH Headings were utilised where possible. The search was limited to English-language papers utilising qualitative methodology to examine the psychological/emotional experiences of, and responses to, climate change that fell within the anxiety spectrum. Only empirical research published in peer-reviewed journals from January 2000 to August 22nd, 2020, was included. Duplicate citations were removed after the initial search. The results of the database searches were initially screened by title and abstract by the first author. All articles potentially meeting the inclusion criteria (described below) were reviewed in full text. Where it was unclear whether an article met the inclusion criteria, it was discussed with the co-author until a consensus was reached. To maximise the comprehensiveness of the search, citation chaining was performed on all papers that met the inclusion criteria to identify further relevant papers. In addition, three experts in the field of climate change and mental health were contacted for further recommendations. Any studies that documented anxiety-related emotional or psychological experiences  in relation to climate change using qualitative methodology (including mixed methods) were eligible for inclusion. Papers were included regardless of whether anxiety about climate change was the primary or secondary focus of the study, or an emergent finding. Studies of climate change worry, a component of climate change anxiety, were eligible for inclusion if they examined the nature and content of anxious cognitions about climate change. Papers that examined anxiety responses to individual environmental phenomena  were excluded. Although related, they are considered to be different phenomena to anxiety in response to the knowledge of climate change, which was the focus of this study. Papers studying perceptions of climate change that did not identify anxiety responses were also excluded, as were papers reporting only quantitative data. Opinion pieces, reviews, and grey literature were excluded from the review. Each paper that met the inclusion criteria was assigned a quality rating as per the guideline checklist developed by Attree and Milton . This guEach paper was analysed and scored independently by both authors. Where assigned scores differed, there was discussion of ratings until a consensus was reached. As per Attree and Milton’s recommendations, papers with a score of D were excluded from the analysis . Data were extracted independently by both authors. The standardised form for data extraction included study details , aim, design and methodology, participants and setting, anxiety themes identified, other themes identified, factors influencing the emotional or psychological experience of climate change, and quality rating, with comments on methodological factors. A thematic analysis was conducted by the lead author. The methodology followed the six phases described by Braun and Clarke , using aThe PRISMA diagram outlines the search process and selection of papers see . A total of 15 studies met the inclusion criteria ,35,36,37Six of the papers were purely qualitative and the other nine used mixed methods see . The staFive studies scored the highest quality rating of A, five were rated B and four were rated C see . A singlThe results of the systematic review were divided into two broad areas of understanding about climate change anxiety; namely, (i) the “scope of climate change anxiety”, i.e., what was the specific reason for or focus of anxiety, and (ii) “responses to climate change anxiety”, which included emotional responses and ways of coping with anxiety . MultiplA number of key themes emerged regarding the focus of climate change anxiety, which included worry about threats to livelihood, worry for future generations, worry about apocalyptic futures, anxiety at the perceived lack of response to climate change, and competing worries. Disruptions to livelihood were a source of anxiety in many studies ,29,30,36Maybe in the future our plants can’t grow and we have to go buy them from the market”“ (p. 105)Water scarcity was a concern in a lakeside community in Canada:You need water, like you can’t survive without that so I do worry about…access to clean water”“ (p. 78)Financial worries were the most prominent for the predominantly male farmers interviewed in America:as with most, my worries generally stem from financial stress”“ (p. 91)Several studies highlighted concern about climate change-related migration. This included people who anticipate being forced to migrate:I know I’ll be leaving soon, but when news comes that Tuvalu is affected or will sink, it makes me cry. Because I was born here, I’m Tuvaluan”“ (p. 4)In contrast, in countries less immediately threatened by climate change, such as the United Kingdom, the worry related to how to accommodate incoming climate refugees . The increased frequency of extreme weather events and their links to livelihoods was a concern in Wisconsin:I’m afraid we’re really gonna start getting hit with like massive tornadoes. That’s my biggest fear”“ (p. 6)There were divergent subthemes of “opportunity” and “already adapted”. Some perceived new livelihood opportunities related to the changing climate. A respondent in the fishing village of Kodiak, Alaska, was optimistic:A disaster for some may mean prosperity for others – as polar ice melts, we might benefit as more shipping traffic comes through this area”“ (p. 292)The business opportunities presented by the challenges of climate change were emphasised by sustainability consultants in corporations in Australia:Answering the challenge and being part of the climate change solution can have a multitude of immediate and long-term benefits for business”“ Worry about future generations was a prominent theme in more developed countries ,29,34,36We are actually taking our planet on a crash course and as a grandmother, I am deeply, deeply, deeply concerned about this. I have a one-year-old granddaughter now. You know we are leaving nothing for her”“ (p. 80)A divergent subtheme regarding worry for future generations was that of hope. Future generations were seen as a source of hope and potential solutions amongst young people in South Korea:Hope may come from education”“ (p. 67)For some, climate change was a “frightening scenario”  (p. 784)Something like this will happen to humans; we cannot prevent destroying the earth…we will die”“ (p. 68)The failure of others to take action was a source of anxiety. Participants felt that climate change could only be talked about in certain groups, which increased their anxiety ,30,35, aThe first thing I associate when I hear climate change is terrified, you know. People don’t think it exists, or it’s happening, or nobody is going to do anything about it”“ (p. 5)Some participants struggled to place climate change amongst multiple other more pressing concerns in their daily life ,32,33,34There’s so much to be worried about, it’s diluted you know, what we have time to talk about”“ (p. 5)However, the awareness of competing worries was particularly true of participants in areas where resources were already scarce. Grape growers in Australia identified multiple financial and political stressors that they placed ahead of climate change:Climate change is the least of my worries”“ (p. 6)Amongst Yolgnu people in Arnhem Land, Australia, local social and ecological issues, such as mining and observed seasonal changes, were highlighted as more immediate concerns than anthropogenic climate change which, in fact, was barely mentioned . ClimateA spectrum of responses to climate change anxiety emerged, including symptoms of anxiety, the feelings of helplessness and disempowerment that climate change anxiety evoked, and finally a complex theme encompassing the ways of managing climate change anxiety. Distancing and avoidance, taking action, fostering support, adapting, and actively choosing optimism and hope were themes regarding strategies employed to manage climate change anxiety.Participants described worry about climate change in ways that were consistent with symptoms of clinical anxiety. This included feelings of suffocation , panic aSometimes I want to sleep, but I can’t because those thoughts about climate change keep popping up…thoughts about this distract me from my study”“ (p. 4)People across Europe ,36, NortI feel that you resign a little, this is too big. This makes you feel like: Help, what can you do other than trouble yourself?”“ (p. 785)Disempowerment was a strong theme amongst South Australian grape growers, where there was distrust of climate change information because:some of the information is too extreme, so if those projections happen we’re finished anyway”“ (p. 7)Five themes emerged describing strategies to manage climate change anxiety.Distancing and avoidanceA key theme which emerged as a way to manage climate change anxiety was distancing and avoidance. Some saw climate change as something geographically and temporally distant, which was protective against anxiety . Some doI do not think it [global warming] is as human-made…as it allegedly is, according to the tabloids…I do not think it is as bad as they want to describe it”“ (p. 789)Even those who engage with climate change on a daily basis in their work made conscious decisions to distance themselves from climate change anxiety. For activists, this was a key step in resolving feelings of crisis brought on by knowledge of climate change:I barely think about climate change now. It’s in the background of my life all the time, but I rarely sit and actually talk about climate change or read very much about it”“ (p. 230)Climate scientists and sustainability managers both emphasised rationality in their daily work, managing emotions by restricting or compartmentalising. However, this approach to coping related to emotions in general and not anxiety specifically:I think a lot of scientists convey the impression that they have no feelings at all about these issues”“ (p. 236)b.Taking actionA move towards action was another strategy that was used to manage worry about climate change. Young people in Sweden took actions, such as researching solutions and modifying behaviour, to cope with climate change anxiety . AmongstAction, not worry, solves the problem”“ (p. 91)This sentiment was echoed by climate activists who developed a sense of agency that allowed them to move forward:Action is the antidote to despair”“ (p. 229)c.Fostering supportActively seeking support was an important theme that emerged in young people  and in tWe build into it after the event, doing something where we talk about the emotions of how to deal with that”“ (p. 234)d.AdaptingDeveloping confidence in the ability to adapt to climate change appeared to be linked to a sense of resilience. This was seen in general community members in America:There are so many things we don’t know. We adapt. We’ve always adapted”“ (p. 291)Confidence about adaptation was particularly found in groups of farmers in the USA  and in GI see the changes and how they are affecting my farm but I am changing how I am farming in response to climate change rather than being depressed by it”“ (p. 91)e.Optimism and hopeActively choosing to be optimistic and hopeful were responses used to manage climate change anxiety ,26,35,37You have to feel hope to make things any better. If no one felt hope then you might as well give up”“ (p. 547)Focus on solutions and trust in science, policy, and environmental groups, amongst others, also helped young people cope with anxiety:Because a lot of people are working, planting new trees, dealing with the waste and exhaust fumes from cars”“ (p. 549)Hope was also harnessed by sustainability managers in their daily work in Australian corporate environments:I guess I’ve always been a bit of an optimist and you have to be in this game. I’ve got a hope in terms of human ingenuity that we all trade out of this somehow”“ Changes in landscapes and seasons were referred to with a sense of loss in Korea:Now I do not feel spring or fall weather as much now...I feel like I lost something”“ (p. 68)The emotional impact of local environmental change was strongly felt amongst Indigenous Yolgnu people in Arnhem Land, Australia, with their unique connection to the land:What we are doing to mother nature. Mother nature is now weeping”“ (p. 686)The aims of this systematic review were to qualitatively explore the scope of climate change anxiety as a concept and to investigate the spectrum of anxiety responses to climate change. A secondary aim was to explore the factors influencing climate change anxiety. This systematic review of the qualitative literature contributes to our understanding of this important, understudied topic. A qualitative approach is best suited to develop an in-depth understanding of new concepts, such as climate change anxiety ). The scope of anxiety about climate change was broad. The majority of studies explored aspects of climate change worry, a component of climate change anxiety. The review identified that “worry about threats to livelihood” was a major concern across all populations, with a breadth of focus from anxiety about access to food and water, to anxiety about finances, population movement, and natural disasters. It is surprising that no known previous study has explored the specific focus of climate change anxiety in a quantitative manner, despite numerous studies measuring the prevalence of climate change anxiety ,44,45,46The systematic review revealed patterns in the demographic characteristics of participants and climate change anxiety, addressing the secondary aim of this study. The key factors influencing emergent themes for the scope of climate change anxiety were vulnerability to climate change, socioeconomic factors, and occupation . Four ofOccupation emerged as a likely influence upon the scope of anxiety about climate change. In North America, farmers  identified financial concerns about the impact of climate change . Grape gA gender-related difference in the scope of anxiety might be expected, given that women often experience higher levels of climate change anxiety than men ,55,56. HThe second group of themes that emerged in this review were the responses to climate change anxiety, which ranged from “symptoms of anxiety”, to “feeling helpless and disempowered”, and “managing climate change anxiety: distancing and avoidance”, “taking action”, “fostering support”, “adapting”, and “optimism and hope”. The proximity to the effects of climate change corresponded with anxiety responses. “Symptoms of anxiety”, and the subsequent impact on daily function, were described by Tuvaluan citizens , who argThis review did not reveal any clear factors influencing the particular ways of managing climate change anxiety. Compared to factors influencing the scope of climate change anxiety, it is likely that responses to anxiety  are less influenced by characteristics, such as gender, location, or social group, but by individual psychological factors and ontological beliefs ,40,57. FIn this review, solastalgia and sadness emerged as key affects linked to climate change anxiety. Whilst quantitative results demonstrate that anxiety and sadness are frequently the two most common emotional responses to climate change ,27, the This review highlights the spectrum of anxiety people may experience in relation to climate change, and their responses to those anxieties. Worry, a cognitive component of climate change anxiety, was most commonly explored in these studies. Clinical presentations related to climate change anxiety have not been well elucidated, although they have been recognised in psychotherapeutic spaces  and at aAn alternative view is that climate change anxiety is not a clinical entity, but rather an existential one . The argFurther research is required to identify people who are vulnerable to experiencing climate change anxiety at a level of clinical significance and who may benefit from intervention. Validated screening tools, such as the Environmental Distress Scale  or the sNot all studies of the perceptions of climate change have identified anxiety within the spectrum of responses ,32,42. FFew of the papers explored participants’ knowledge and understanding of climate change, which may affect the reliability of results—why worry about something that you do not believe exists? In the two papers that did measure belief in climate change, it was as low as 58% in one study population , and shoThe quality of the included studies must be considered. One third of the studies were rated A (no or few flaws), one third were rated as B (containing some flaws), and four of the fifteen were rated C . More weight should be placed on the results from studies of higher quality. Reflexivity and ethics were particularly poorly addressed by the studies, perhaps because many were conducted within ethnographic rather than clinical research frameworks. Additionally, several studies were limited by inadequate sampling ,30,34,35Strengths of this review include a thorough literature search intended to capture any study that included qualitative data on climate change anxiety (including worry), even where this was not a goal of the original study. The heterogenous populations and varied aims and methodology of the included studies were well suited to an exploratory qualitative approach.Regarding limitations, the findings of this review may not be generalisable given the relatively small number of studies and the importance of location and population to understanding concepts of climate change anxiety that emerged in the analysis. The exclusion of grey literature and other unpublished papers may have limited the results through publication bias . The terClimate change anxiety is becoming recognised as one of the mental health effects of climate change. This review has identified a broad scope of worries about climate change, and a diversity of responses to this anxiety. Characteristics, such as occupation, socio-economic status, and proximity to climate change, appear to be important influences on climate change anxiety and related responses. The review furthers our understanding of the concept of climate change anxiety and highlights the need for future studies of this phenomenon to be conducted by clinical researchers. There is a pressing need to better understand the psychological and functional effects of climate change anxiety and to examine interventions to promote resilience and reduce clinically significant distress.


Domestic violence during the perinatal period (DVPP) refers to the various waysthat women’s partners or ex-partners control and coerce them during pregnancyand the 2 years postpartum. From the descriptions of 17 women with firsthandexperience of DVPP, this article reports on its manifestations and theassociated contexts. The results reveal escalating violence, diverse forms ofviolence, and exacerbated consequences over the perinatal period. The contextsthat pose additional challenges for the women include financial precariousnessand the partner’s substance abuse, and to a lesser extent the residentialsituation. Domestic violence (DV) is a recognized social and public health issue . It is dDV therefore takes different forms. However, they all involve an intimate partner whoseeks to gain or maintain power over the other . ThedifThe perinatal period is a time of vulnerability that brings changes toindividual, conjugal, and family lives, and particularly when it involves afirst child . In QuébFor some women, pregnancy acts as the starting point for the violence, whereasfor others, violent behaviors that were ongoing increase or, on the contrary,decrease . WhateveThe most predictive factor for DV during pregnancy appears to be previous violentbehavior toward the woman in a conjugal, family, or other context. For instance,60–96% of women who were victims of DV during pregnancy reported previousviolent behavior in such contexts .MoreoveThe research describes a variety of ways that violence manifests duringpregnancy, with disparities in the frequency, intensity, and severity of violentbehaviors, depending on the countries, contexts, definitions, and measurementtools . HoweverA qualitative exploration was conducted in collaboration with six co-researchers fromdifferent disciplines and universities as well as nine partners, includingprovincial community groups working with DV and perinatality. All the researchersand partners participated in the research orientation committee to develop the studydesign and recruitment strategy. As members of the committee responsible for thequalitative data drawn from the mothers’ testimonies, the co-authors activelycontributed to design the data collection and analysis tools. The research strategy,based on the tenets of constructivist epistemology, was to engage women inconversations and encourage them to tell their stories .The participants comprised 17 mothers living in the province of Québec (Canada)who were victims of DVPP. This study obtained two ethical certifications: one from a university and anotherfrom a state institution to meet the demands of the health care network. Toensure recruitment feasibility at various institutional service points in thatnetwork, four more requests for ethical suitability were submitted and approved.All participants signed a consent form.Participants were targeted according to three inclusion criteria: (a) aged 18years or more at the time of the study , (b)the biological mother of a child with whom she has had regular contact in theyear prior to the study, and (c) had experienced DVPP in the last 5 years.Purposive sampling was used to recruit participants with diverse profiles . Three administrative regions of Québec were targeted to represent therealities of women living in urban as well as rural areas.Several complementary recruitment strategies were used. A promotional video wassent to dozens of public institutions and community groups. Posters werecirculated on websites and social networking sites and distributed to communitygroups working with DV and/or parents. Health care and social work professionalswere asked to let mothers know about the study. Meetings were also held withmanagers and team leaders at health and social services centers.n = 17) from March 2018 to July 2019. Interviews weregenerally held at the university’s research facilities, and to a lesser extent,at sites chosen by the participants or via Zoom video conferencing. Allparticipants received CAD$30 as compensation and received a list of specializedresources.Of the initial sample of 26 women who were willing to participate, nine did notmeet the inclusion criteria and were not retained. Individual semi-directedinterviews averaging 120 min each were held with the final sample reported at least one DVepisode before their pregnancy, and all experienced DV during pregnancy. Exceptfor one participant whose child was 2 months old at the time of the interview,all participants experienced DV after the baby was born. The most oftenmentioned form was psychological violence, for all three parts of the referenceperiod. Women report that verbal violence was used more widely as a strategy todenigrate them during their pregnancy than it was before that pregnancy. Theyalso report an increase in coercive control after childbirth. Women report thatthey suffer more forms of violence after childbirth, except for sexual violence,which showed similar frequency before and after the perinatal period: “I feltvery pressured [. . .] I would do it with him, you know. I would say yes, but Ifelt pressured, as if I had no choice” (M6). For almost all the participants(n = 15), the different forms of violence were interwovenover the perinatal period.Almost all the participants (n = 12) had supported their partnerfinancially, and subsequently the family. They explained this in different ways:The woman held a job and her partner did not, her job was better paid, or herpartner refused to contribute equally to the expenses. For example, “He wasn’tworking! So it was stressful, because we had to start buying things for thebaby. [. . .] Honestly, there were many times when we couldn’t pay our bills,because he went out to buy pot or other drugs” (M12). However, two women werefinancially dependent on their partner:I was also going through a hard time. I was vulnerable, big time! And hetook advantage of that. He told me what I wanted to hear, and I fellright into his trap, [. . .] because I was going through a really hardtime. It was like there was no way out. I was trying my best to get by,but I felt like I was stuck. (M10)The participants described two contexts that they felt made them more vulnerableand aggravated the violence, while normalizing it. Notably, they identifiedfinancial precarity and their partner’s abuse of alcohol and drugs. About twothirds of the participants  said that the partner’s alcoholand/or drug abuse fueled his violent behavior. They described how it had begunwith the pregnancy and then increased markedly over the perinatal period:He drank a lot. When it’s just beer, that’s OK. But when he started onthe rum first thing in the morning, like what happened later after wehad the baby, at the end [. . .] I was scared. (M5)Several participants .So me, I wasn’t in the city anymore, [. . .] he was the one with the car.Me, I was all alone at home. I only got the car when I had anappointment. So, out in the middle of nowhere without a car, you don’tget around much. I was shut in. I felt [. . .] even more so in thathouse, [. . .] and it ended up being a jail. (M13)Many participants reported that these moves, sometimes one right after another,and especially from the city to a rural area, made them even more vulnerable:He was even more aggressive because I was even more isolated. [. . .] Wehad even fewer neighbors nearby, so I no longer had a circle of friends.[. . .] I didn’t do anything anymore because I was always cooped up athome. (M5)To the lack of mobility that accentuated their solitude, we may add increasinglyviolent behaviors by the partner, according to many of the participants:n = 7). Some hadimmigrated to Canada with their family when they were children, and others hadcome alone as adults. Still, others had come with their partner. Without beingdirectly questioned about it, three women identified how their migratorysituation (living in another country than the rest of their larger family) mayhave influenced the situation of DV by contributing to their furthervulnerability and isolation. One participant disclosed that the stress ofsettling and integrating into the new country could have accentuated someconflicts with her partner, but she clearly distinguished between that earliertime and the time when the DV began. She described the cultural shock they hadfaced as a couple. It is important to mention that all the immigrantparticipants had obtained regular status: They were neither in an irregularimmigration situation nor an asylum seeker. Their ties with at least twocountries meant travels that the partner could use for purposes of control.Thus, in two cases, during a trip to the home country, the partner confiscatedthe mother’s and children’s passports so he could control their movements:Me, I travelled to [country of origin] for a vacation. [. . .] On thetenth day, he told me, “[. . .] I’m going back to Canada, but you,you’re going to stay in [country of origin] and I only want my children[. . .] to return to Canada.” (M9)Several participants were born outside Canada . In two cases, the father’s insistence on choosingthe baby’s first name was the catalyst for violence.The 17 participants accounted for a total of 26 full-term or ongoing pregnanciesin relationships marked by DV in the last 5 years. Of these pregnancies, only 10were planned, whereas 16 were unplanned. The announcement of the pregnancysometimes was an opportunity for the partner to use violence in a new way, suchas casting doubt on the child’s paternity and accusing the mother of infidelity. Other partners hadthreatened to break up unless the woman had an abortion. Inversely, even thoughthey preferred an abortion, some participants realized that they had no choicebut to accept the pregnancy, or at least they needed more time to consider theiroptions. In the majority of cases, the partners used pressure, threats, physicalviolence, or economic restrictions in their attempts to prevent the women fromaccessing services: “But he told me, ‘If you get an abortion, I’m going to makeyou regret it. [. . .]. I’m going to report you’” (M10). In cases where thewomen were pressured to get pregnant or continue a pregnancy, the partners didnot seem to be involved in either the pregnancy follow-ups or childcare.Many participants reported that their partner did not do his share of routinehousehold tasks during the pregnancy. Many said that their partners were alsoinconsiderate about the pregnancy itself: “He didn’t do any shopping. [. . .] Hedidn’t come to my appointments. I went by myself. [. . .] He didn’t want to knowanything about it” (M1). This participant and others added that her partnerfound the idea of having a child repellent. Many participants had hoped that theviolence would stop when they became pregnant, or that at least it woulddecrease, and that their partner would be more interested in supporting them.However, all the participants had experienced at least one violent episodeduring their pregnancy. Many of them identified the pregnancy as a turning pointin the DV dynamic. For example, one participant said that her partner “gotmeaner,” and in addition to unfairly accusing her of being unfaithful, hedisparaged her body and her character.In some cases, new forms of violence appeared during the pregnancy: “And then,after that, it really began: serious punches, all over my body. It was rainingblows. [. . .] Every time we had a misunderstanding, he reacted by hitting me”(M10). Another participant reported that during her third pregnancy, her partnerbegan secretly recording her at home when he was out, using a concealedmicrophone, which as far as she knew was a new behavior. Other participants toldus about financial violence that targeted everything to do with the pregnancyand the preparations for the baby’s arrival: “You know, he wanted to stop mefrom putting any money aside for the baby” (M1).n = 12) felt that the violenceincreased during their pregnancy: “The violence got ten times worse. [. . .] Itwas horrible. [. . .] He became another person. [. . .] He was hateful! I wasterrified” (M1). Most participants said that the different forms of violence got worse during the pregnancy compared tobefore. Five participants felt that the situation had deterioratedprogressively, going from bad to worse with each pregnancy. Other participantssaid that the violence had subsided, but that there were still some episodes.One participant told us that her partner modified his manner of physicalviolence once her stomach got bigger:So that was when he, like [. . .] the stomach. I was showing, so maybethat was when he let up a little! But not really, either, you know,because he kept on giving me slaps, you know. [. . .] Or he did thingsthat according to him wouldn’t hurt the baby, that kind of thing, youknow! Pulling my hair, slapping me, pushing me around, but you know, notthe stomach. (M12)The majority of the participants Other participants also recalled some calm intervals during their pregnancy: “Hespent less time sulking. [. . .] He was faster to act sweet again after hisangry episodes” (M3). Other partners apologized after violent episodes: “Hebecame like, [. . .] he fell into a rage, a very black rage, and afterwards hewas nice again, like an angel. [. . .] He asked me to forgive him, said he wassorry” (M10). Nevertheless, after the honeymoon was over, the violence resurfaced:n = 16). In some cases, it was directlyrelated to the pregnancy, for example, when the partner prevented her fromresting or sleeping: “When I went to bed, he came into the bedroom, turned onthe light, and pulled off the bed covers” (M11). The psychological violenceoccurred partly in relation to the inherent changes during pregnancy, in thesense that the partner could use specific arguments that did not apply in othercircumstances. For example, he might complain that her weight gain made themother unattractive, threaten to take the newborn baby away from her, or blameher for placing the baby’s health at risk:Then my partner, after that, he started telling me all the time that if Ihad heartburn, because I was constantly throwing up, and I didn’t feelvery good, and I had a headache, and I was tired, [. . .] it wasbecause, [. . .] it was because, [. . .] I didn’t love my baby. [. . .]And, I was going to make it sick; I was going to make it handicapped.(M7)The most often reported form of violence during this part of the perinatal periodwas psychological . Many have gradually developed a certain vigilance inanticipating a new episode of violence: “It felt as if I was walking oneggshells, trying not to displease him so he wouldn’t burst” (M11).Some partners threatened to harm the fetus directly. For example, one partnerinsinuated that he could provoke a miscarriage: “If you fall asleep, well, youmight just lose something. [. . .] It might just happen that when you’re takinga walk, when you’re going down the stairs, that you’ll take a fall. One kick andit’ll be gone” (M1). A few women received personal death threats during theirpregnancy. One participant who had decided to break up with her partner wasexplicitly threatened: “Well, because he told me that he was going to kill me, Ididn’t dare go see him in person in case he carried out his threat” (M1). Twowomen found out that their partner had a gun.n = 4) recalled DVepisodes when they were in labor. The forms of violence included psychological, physical ,and verbal (insults). One participant was blamed by her partner for exaggeratingthe pain of her contractions while she waited for the taxi to take her to thehospital: “Then he yelled at me, oh, in the street, and he said, ‘Oh, you’rejust a piece of shit, you’re just this, you’re just that, [. . .] You’re alwaysseeking attention! [. . .] You’ve got a bitchy attitude!’” (M12). Anotherparticipant felt that her partner enjoyed seeing her suffer during thechildbirth. One participant described how, in the midst of her worstcontractions, her partner started to threaten her and act aggressively: “I wasin the middle of giving birth. I was having contractions, but I had to runaround the table while I was contracting because he was trying to strangle me”(M5). Two participants asked their partner, in vain, that he not be present forthe childbirth because they were afraid that it would only add to their stress.In another case, the staff had to implement security measures to prevent thepartner from entering the birthing room.According to many of their stories, the participants were also exposed to violentbehaviors during the childbirth. Thus, some (n = 14), this was a time of repeated victimization andmore frequent violent episodes that increased in severity: “That’s when hereally started attacking me, there, straight out, after my daughter was born”(M17). Another participant said that the violence and crises got worse by theday: “Every day there were mini crises, but, [. . .] I’d say that, once everytwo weeks there were major crises that ended with me being slammed up againstthe wall!” (M12). The DV continued to build up and got increasingly worse as thechildren grew up: “The violence escalated over the years” (M3). In addition,even though two participants broke up with their partner while they werepregnant, the partner continued to harass them with cyberbullying for severalmonths after the baby was born: “He would be sending me messages like ‘I knowwhere you are! [. . .] If I can’t have you, nobody will. You’ll see’” (M1).Almost all participants experienced at least one DV episode in the postnatalperiod. Only one said that the violence stopped after the birth of her baby, whowas 2 months old at the time of the interview. For the majority.When I gave birth, it was during a heat wave, [. . .] so there was no wayI could go out. So, seeing that I was always with my daughter, and whenhe wasn’t there, well, he knew that I wasn’t going out cruising orhanging out in bars, or whatever, going to see my friends. (M13)Other participants reported that their partner exercised less control over themduring the first few weeks after childbirth. Their explanation was that thepartner knew that she was at home taking care of the newborn, and therefore didnot ask her to account for herself as much:Nevertheless, after the first few weeks, the controlling behaviors reappeared andgot worse.n= 7), making the mother’s mental burden that much heavier. Manyparticipants felt that they never got a break because they were constantlyresponsible for the baby and were made to feel guilty if they took any time forthemselves: “When I took a shower, he’d be standing in the doorway holding thebaby. And then he’d make the baby cry. [. . .] He’d stand there and tell me,‘Well, hurry up!’ [. . .] I never got a break” (M8).Most of the participants felt that they were solely in charge of the childcare,and that their partners were not very or not at all invested. Nor did theirpartners do their share of the housework after the baby was born. Some fathersrefused to assume their parenting responsibilities, or even acknowledge thatthey were the father. According to one participant, “Before we separated, hisfavorite subject was that his son, [. . .] ‘the baby was not his son’” (M12).Not only were the majority of the participants solely responsible for theirchild’s well-being, but many said that their partner prevented them fromsleeping, resting, or going to their family for support. This made them evenmore tired and contributed to the violence-related stress. To this was added thefather’s lack of investment in financial and family planning Similarly, several participants reported that when they were out and the partnerwas supposed to take care of the baby, he would badger her on the phone.Sometimes, this control included checking up on who she was seeing, whichlimited her interactions and increased her feelings of isolation:And the time that it happened, me, I was lying down with the baby,breastfeeding. “Leave the baby alone now. Start cooking! The baby’s nota doll,” and that kind of stuff. “Since he came, it’s like you don’tcare anymore about [. . .].” He insulted me in front of everybody, putme down, and like that. (M10)On the contrary, many participants felt that the violence was a reaction to theattention she gave to the baby. In these cases, their partner’s behavior couldbe explained in part by his jealousy of all the attention and care she gave toher newborn or infant: “Once I had established a [. . .] closeness with thebaby. [. . .] It made him really jealous. Then, sort of defensive. Then,frustrated” (M3). Others blamed themselves for not cooking or doing thehousework as much as before, and being too involved in mothering tasks:Furthermore, besides being solely responsible for the childcare, the greatmajority of the participants continued to experience different forms ofviolence. These manifested as belittlement of her mothering role, herrelationship with the baby, and her ability to carry out herresponsibilities.Overall, the partners were not invested in fatherhood. Nevertheless, many of themused the baby’s presence to intensify their control over and violence againstthe mother. For example, four participants recounted that their partner hadtried to hit them or to punish them by restricting their access to the baby andpreventing them from holding it. Other participants had been subjected tophysical violence when they were holding the baby, or verbal violence in thebaby’s presence: “He pushed me. [. . .] Y’know, sometimes I’d be holding thebaby, like this, and we’re talking about a three-and-a-half-month-old, maybefour months, and [. . .] he’d throw me up against the wall” (M12).So then my son, at that time, he would either freeze or burst out crying,and go “Maaa!!!” He was witnessing more and more times when my ex, hewould back us into a corner, and then yell at me. (M8)Some partners threatened to harm the baby or even kill it. One participant heardher partner say, more than once, “I’m going to break his neck. [. . .] I’m goingto kill you and your damn baby” (M5). Further along in the postnatal period, theparticipants became more concerned about the consequences of exposing their babyto violence and threats:n =7): “When my child was about two, he started in fact, to . . . some violencetowards my daughter. [. . .] And she would be crying. She would say: Mommy, booboo” (M4). The violent behaviors toward children included arm twisting, faceslapping, shaking, breaking ribs, ripping up clothes, and wrecking the car seat.In such contexts, many participants feared for their child’s safety anddevelopment.Moreover, although the physical violence was usually directed toward theparticipants, sometimes the child was on the receiving end . Several report having suffered verbal and psychological violencein this regard. Others say their partner made them feel guilty whenever theywere away from home, even for a short time, sending them back to the image ofbeing a bad mother: “During the time I was away from the apartment, he would becalling me non-stop. He would put my son on the line and make him cry” (M8).Many also believe that being hit and insulted in front of their child has alsoactively contributed to reduced self-confidence and increased shame, as onemother reports as follows: “I did not have a lot of confidence in myself tobegin with and then he . . . he crushed it again . . . at its lower” (M5).The main objective of this article was to document the manifestations of DV thatoccur during pregnancy and the 2 years following childbirth. Mothers who hadexperienced DV during the perinatal period were interviewed and encouraged to sharetheir stories. Overall, the results corroborate prior findings  that preMost importantly, the narratives of the women we met highlight that violence was partof their daily lives during the perinatal period, in one form or another. Theirexperience is part of a dynamic of violence and control, which goes beyond themanifestation of a specific act of violence or the presence of a single form. It istherefore this reality of intertwined violence that our data illustrate. Thisunderstanding of the co-occurrence of forms of violence is important to document andmeasure, as it reveals a context of severe victimization, as depicted in otherqualitative studies focusing on violence and the perinatal period . This reAnother result worthy of attention is the high number of unplanned pregnancies. Ofthe 26 pregnancies covered in this study, more than half were unplanned. This is aworrisome issue that merits greater attention, particularly given the consequencesfor the health, well-being, and socioprofessional and academic trajectories of womenwho are obliged to continue a pregnancy when they would prefer to terminate it,2018. FHowever, while case identification during pregnancy is important for providingappropriate support and interventions for pregnant women who are victims of violenceby their intimate partner , ourresThe novelty of our study lies in the consideration of violence during childbirth.Although reported by only a few participants, the presence of violence during laborand childbirth is alarming. The women who were affected did not give birth in idealconditions, among other reasons because they were under considerable stress and didnot have access to a supportive birthing companion. The literature clearly showsthat continuous support during childbirth is a key factor for optimal physiologicalbirth without intervention . In lighOne of the significant findings of this study concerns the partner’s lack ofinvestment in parenting and the over-responsibilization of women. Many of theparticipants recalled that they had to take care of the baby and the household tasksby themselves. This heavy responsibility and the associated mental burden, combinedwith contexts of vulnerability , made it harder for them to fully exercise their parenting role andto derive enjoyment and satisfaction from it. Such contexts also impede childrenfrom developing and bonding with their parents .This study includes certain limitations that limit the transferability andinterpretation of the results. First, the women recounted their experiences ofvictimization by responding to semi-directed interview questions and dependingon whether they were ready to share their stories. Consequently, the itemizationand classification  of the fMany potential research avenues emerge from this study. First, it would beinformative to obtain longitudinal qualitative data on DV, particularly coveringthe perinatal period and the child’s first years of life. This would involve,for example, following a cohort of women by interviewing them every 6 monthsover a 5-year period regarding the presence of DVPP and their experience ofparenthood . This would enable a moresubstantial understanding of the life trajectory in terms of the violenceexperienced during parenthood. Of course, the goal would not be to compare onegroup of women receiving support for IPV with another group not receiving it. Ateach data collection period, individuals would receive a brochure featuringvarious DV services. The use or not of these services would be a component ofthe study. Furthermore, it would be useful to ensure that all relevant voicesare heard to broaden our understanding of the experiences. For instance, ourresults indicate that the domestic situation and the immigration context canpose specific challenges. Future studies are needed to give women in thesecircumstances opportunities to speak. In addition, we need to hear from womenwho were pressured to terminate their pregnancy and women whose pregnancies wereunplanned. Sexual and reproductive health, including childbirth andbreastfeeding, have been underrepresented in studies on DV and motherhood,despite their central place in women’s lives. In the future, research designsand methods could also integrate intersectional perspectives to better documentthe experiences of more marginalized women and enrich our comprehension of thedifferent ways that oppression influences the victimization experience in DVPPcontexts.


Children learn to understand gender categories and roles typical for women and men from the earliest stages of their life. Toys, by which they are surrounded in everyday routine, may have a significant role in their knowledge of cultural norms and societal expectations, but also might have a great impact on children’s health in the context of psychosocial development. Parental attitudes can also be an important moderator of the choice of gender-stereotyped toys. The aim of the study was to investigate parents’ perspectives on toys’ appropriateness for children according to gender, and to analyze parents’ knowledge about the labeling of toys in shops. In total, 526 parents from big cities participated in the study; to assess parental knowledge and perspectives on toys’ categorization, The World of Toys questionnaire was used. The results indicated that most parents from big cities observe that toys are arranged according to the child’s age and sex and the toys’ functionality. Moreover, in parents’ opinion, the compliance with the role of a woman or man affects categorization the most. Furthermore, both parents tended to attribute toys to both sexes more often than they believe the stores do. To conclude, despite the still visible division of toys in shops, Polish parents from big cities are more liberal and egalitarian than shops are when it comes to the perception of toys’ appropriateness, allowing children to play with most toys regardless of their sex. The moment they are born, children come into a world with a pre-existing structure and imposed social norms. Gender-normative behaviors are dominant in our culture, including in media and advertisements . Gender Basic gender attitudes are not inherited—children begin to understand gender categories and their constant placement inside them during development . AdditioToys designed for girls and boys are clearly different, and many studies have examined how they vary between genders. Blakemore and Centers  examinedAlthough Blakemore and Centers did not focus on this aspect , it was ®: LEGO® City®, which is marketed to boys, and LEGO® Friends®, which is marketed to girls. The thematic analysis acknowledged that both of the LEGO® categories set gendered narratives, particularly through the stereotypical roles of the LEGO® characters. First of all, the sets of thematic patterns that emerged from the data showed that male characters had professional roles, whereas the recreational activities and domestic tasks of the female characters were emphasized. Furthermore, the LEGO® City® characters were associated with dangerous actions and saving people—firefighters, for example—while the LEGO® Friends® characters were associated with socializing and caring for each other—for example, a focus on interaction with other Friends® characters. The final thematic pattern was that the narratives of female characters were often associated with beauty and attractiveness. These gendered narratives illustrate how girls’ and boys’ play patterns can vary enormously [These characteristics of gender-typed toys were examined more widely in a further study carried out by Reich, Black, and Foliaki . The autormously .®, no matter which category, can be very educationally beneficial [It should be noted that this study did not involve children, so it could not show whether these gendered narratives are perceived by children. In addition, one must recall that LEGOneficial . HoweverThe presented studies illustrate that from the beginning of their development, children are exposed to subtle gender-related messages . AlreadyThus, from very early in their development, children are taught about associations related to gender and the dichotomy between males and females present in many aspects of life . Toys caKnowing the moderators of children’s choice of gender-stereotyped toys may make it easier to understand what can be done to minimize the consequences of gender-typed play patterns and the stereotypical division between the sexes. In spite of the decrease in social gender restrictions, gendered play patterns still exist . The mosDue to the positive reinforcement associated with seeing that doing something is rewarded , parentaThis shows that parental attitude can be an important moderator of the choice of gender-stereotyped toys. However, contrary to what Kollmayer et al.  indicateOne way that parents and children identify gender-appropriate toys is through labels defining them as “for girls” or “for boys” in shops, rather than “for children” in general . MoreoveAs indicated, shops are the main suppliers of toys, and parents are most often the ones that provide them directly to children. Therefore, the aim of the study was to investigate parents’ perspectives on toys’ appropriateness for children according to gender, and also to analyze parents’ knowledge about the labeling of toys in shops. In spite of much evidence about the gender narratives presented by toys and parental attitude as a moderator of play objects, there is still no clear link between parents’ point of view regarding toys’ appropriateness according to children’s gender and the labels provided by shops.Furthermore, in recent years, the involvement of fathers in children’s upbringing has greatly increased , so it iWhat is parents’ awareness of the labeling of toys in shops?How do parents perceive toys’ appropriateness according to children’s gender? Does parents’ gender differentiate their perspective?Does parents’ awareness of the labeling of toys in shops differ from their own perspective on toys’ appropriateness according to children’s gender?Thus, we created three research questions:N = 526, comprising 376 mothers and 150 fathers. The average age of the mothers was M = 36.01 (SD = 6.13), and of the fathers, M = 40.78 (SD = 6.99). Furthermore, information about parental education levels  and the number of children  was collected. Among all parents, 31.4% had only daughters, 29.5% only had sons, and 39.2% had children of both sexes.Participants were selected through selective sampling. Only parents with Polish nationality from Tricity were invited to the study. Tricity is a metropolis in northern Poland that consists of three cities: Gdańsk, Gdynia, and Sopot. Considering its population structure according to demographic and economic criteria, Tricity might be recognized as a good example of a large city in Poland . Due to For the purpose of this study, a questionnaire entitled “The World of Toys” was developed by Lipowska and Łada-Maśko see . The aimStatistical analyses were carried out using the Statistical Package for the Social Sciences (SPSS) version 26 . The chi-squared statistic tests were used in order to analyze differences between studied variables.In order to answer the first research question regarding parents’ awareness of the labeling of toys in shops, parents’ responses to questions number 6 (“Did you notice that toys in stores are arranged according to some criteria?”), 7 , and 9  in The World of Toys questionnaire were analyzed.Overall, 90.7% of parents declared that they noticed that toys in stores were arranged according to some criteria, while 9.3% of parents did not notice that at all. Furthermore, in parents’ opinions, toys are arranged according to certain categories, as shown in Mothers’ and fathers’ differences were statistically significant in their estimates of arranging the toys according to functionality, the child’s sex, and the company. In all three cases, the mother’s mentioned the category more often than the fathers see . HoweverThe results also suggested that parents’ differences were not statistically significant in their estimates of characteristic of toys affecting their categorization for girls or for boys . HoweverSubsequently, in order to answer the second research question, parents’ answers to question number 10  from The World of Toys questionnaire were analyzed. Here, parents rated toys as typical for girls, typical for boys, or the same for both sexes see .The results indicated that most of the toys assessed by mothers and fathers were intended for both sexes; however, mothers were more likely than fathers to judge toys as intended for children of both sexes—especially those toys culturally assigned to the female role; e.g., cooker or baby dolls, or the male role; e.g., vehicles or military toys—than as toys typical for girls or as typical for boys.The results also showed that mothers and fathers significantly differed from each other in their assessment of the toys’ appropriateness according to children’s gender—only creative toys were assessed similarly by both mothers and fathers. Furthermore, the greatest effect sizes of the above differences were observed in the cases of cooker, baby dolls, tools, and vehicles—average effect size see , which aLastly, in order to answer the third research question, parents’ answers to questions number 8  and 10  from The World of Toys questionnaire were analyzed. Parents rated the toys as typical for girls, typical for boys, or the same for both sexes, and also assessed the labeling of them by shops in the parents’ opinion. The results indicated that both mothers and fathers tended to attribute toys to both sexes more often than they believed stores do, which was particularly evident in the case of toys stereotypically attributed to male or female roles, such as baby dolls, cooker, vehicles, and military toys see . Again, In this study, we investigated parental awareness of the categorization of toys in shops, especially in regard to children’s gender, parents’ own perspectives on toys’ appropriateness according to children’s gender, and the difference between those two.Our results revealed that Polish parents living in big cities are aware of the labeling of toys in shops, and that the overarching categorization criterion is the compliance with gender roles. In Poland, those roles of men and women are greatly emphasized . This geHowever, it is noteworthy that although parents are aware of the gender-normative labeling of toys in shops, our research revealed that their own attitudes do not always comply, especially in the case of mothers. Both parents judged most toys as appropriate for both sexes, but mothers’ views were even more egalitarian in regard to those toys that are culturally assigned to one of the sexes. Despite the growing recognition of the positive effects of equal distribution of household labor, women are still the ones who undertake most activities regarding children’s care —for inst® Corporation has a collection with pink bricks to match girls’ preferences and identification [Additionally, mothers chose the color of the toy as the most influencing trait of categorization according to gender appropriateness. This confirms that toys are not only labeled verbally, but also through implicit gender-typed color labels—pink and blue . Moreovefication .Interestingly, our results suggest that children’s sex did not influence parents’ perception of toys’ appropriateness, as toys stereotypically assigned to one sex, such as a toy cooker or tools, were also perceived as such by both parents, especially by fathers, whose views were less egalitarian than those of mothers. Therefore, although a child’s sex can often moderate various parental attitudes , it is nThe main conclusion of our study is that despite the still-visible division of toys in shops according to children’s sex, the majority of Polish parents from big cities are more liberal and egalitarian than shops are when it comes to perceptions of toys’ appropriateness, allowing their children to play with most play objects, regardless of their sex. This is especially true for mothers, which is an uplifting finding, as mothers are still often the primary caretakers of children , and theSeveral limitations of the current study need to be addressed while considering the results. One of the main limitations of our research was its explorative character, which did not allow for deriving conclusions about cause–effect associations. Moreover, the declarative nature of the collected data was another important limitation, which should be addressed in future studies by directly investigating parents’ behaviors in real-life situations—for instance, in toy shops. The results must also be interpreted carefully because of the lack of inclusion of the age of the children and family factors  in the study. Further research including an inter-relationship analysis between different familial factors and their influence on parental attitudes regarding toys’ appropriateness is required. It would be also interesting to investigate how psychological factors  might influence parental attitudes. Moreover, in this study, only Polish parents from big cities were examined, thus limiting the generalizability of the results. In future research, it would be extremely valuable to involve parents from different places of residence, especially villages and small cities, as well as other countries, to represent divergent cultures.


Background: For patients with coronary artery disease (CAD), smoking is an important risk factor for the recurrence of a cardiovascular event. Motivational interviewing (MI) may increase the motivation of the smokers to stop smoking. Data on MI for smoking cessation in patients with CAD are limited, and the active ingredients and working mechanisms of MI in smoking cessation are largely unknown. Therefore, this study was designed to explore active ingredients and working mechanisms of MI for smoking cessation in smokers with CAD, shortly after a cardiovascular event.Methods: We conducted a qualitative multiple case study of 24 patients with CAD who participated in a randomized trial on lifestyle change. One hundred and nine audio-recorded MI sessions were coded with a combination of the sequential code for observing process exchanges (SCOPE) and the motivational interviewing skill code (MISC). The analysis of the cases consisted of three phases: single case analysis, cross-case analysis, and cross-case synthesis. In a quantitative sequential analysis, we calculated the transition probabilities between the use of MI techniques by the coaches and the subsequent patient statements concerning smoking cessation.Results: In 12 cases, we observed ingredients that appeared to activate the mechanisms of change. Active ingredients were compositions of behaviors of the coaches  and patient reactions , interacting over large parts of an MI session. The composition of active ingredients differed among cases, as the patient process and the MI-coaching strategy differed. Particularly, change talk and self-efficacy appeared to stimulate the mechanisms of change “arguing oneself into change” and “increasing self-efficacy/confidence.”Conclusion: Harnessing active ingredients that target the mechanisms of change “increasing self-efficacy” and “arguing oneself into change” is a good MI strategy for smoking cessation, because it addresses the ambivalence of a patient toward his/her ability to quit, while, after the actual cessation, maintaining the feeling of urgency to persist in not smoking in the patient. About 40% of smokers successfully quit smoking immediately after experiencing an acute coronary syndrome (ACS)   trial) .>4 on this 7-point scale as an indication of a trusting relationship. To assess the fidelity and the quality of the delivered MI   received MISC training at the MI-coding lab of the Center for Alcohol and Addiction Studies, Brown University, USA. He trained three coders  for coding in the present study (37 h training each). The coders coded the transcript in two passes. First, the coders listened uninterruptedly to the complete session and assigned the global ratings. Second, the coders again listened to the complete audio recording but could pause and listen again to fragments of the conversation to code each parse in one of the coding categories . In weekAll audio-recorded conversations and the coded transcripts of the included patients formed the cases in the multiple case study. Through the multiple case analysis, the analyst (JD) kept a log with detailed information on the research process, the findings, and the decisions. Additionally, to analyze the case and to systematically gather data on how MI coaches applied the main MI components in their coaching, the analyst used worksheets with targets of MI consistency  MI sessions. Of the 24 patients, 16 patients completed all 7 MI sessions of the intervention, while 8 patients did not complete the intervention. In seven cases, all sessions were recorded. There are five cases missing one recorded session, four cases missing two recorded sessions, three cases missing three recorded sessions, and five cases missing four recorded sessions. Five patients used NRT, seven used varenicline (Champix®), and twelve patients, mainly the patients who had already reduced their smoking, did not use either of these therapies . At the whether these factors and mechanisms occur in the MI sessions. The next part of the “Results” section is about how the MI coach applies these factors to stimulate active ingredients and mechanisms of change. Hereto, we first describe the use of MI-conversational techniques and then the MI strategy of the coaches in the four MI processes . Finally, we will relate the occurrence of active ingredients to delivered MI quality.In the sections below, we will first discuss the occurrence of clinician factors and client factors in the MI sessions. These clinician factors and client factors may interact such that they become active ingredients and trigger a mechanism of change (these mechanisms may explain how patients decide to quit smoking) Nock, . Second,>4 on the 7-point global rating for the level of patient self-exploration. The empathy of the coach was a crucial factor in establishing this relationship. In line with MI theory, the clinician factor “eliciting change talk” was used most frequently. After this, “supporting self-efficacy” and “discussing ambivalence or barriers” were the most frequently applied clinician factors. This is consistent with our finding that the ambivalence that most patients experienced was about the ability to stop smoking . Seventeen times, we observed clues for “arguing oneself into change” see . MechaniBox 1Case 22, fragments of session 2(…)Patient: “Smoking can cause a lot of damage, like yesterday on television, there was a man with something on his heart valves. And he was… it affects me, it makes you think this could also have happened you know.”Coach: “Yes, what could have happened?”Patient: “He smokes too and things like that. It affected me, makes me think…”Coach: “What could have happened…”Patient: “Yes, what could have happened. Like the phone, his phone was downstairs and not beside his bed, so he had to go downstairs, but shortage of breath and things like that, well you know. It scared me, made me shed a tear.”Coach: “It could have been me.”Patient. “Yes, I didn't experience this, but if you're upstairs and your telephone is downstairs, what can happen in between? And no breath.”Coach: “What made it so emotional for you?”Patient: “That something like this may happen, abruptly. Well it makes me sympathize with him, I kind of experienced that. Not exactly like him, a little different.”Coach: “The vulnerability.”Patient: “Yes, so…”Coach: “It's a bit like what happened to you.”Patient: “No, that's why, you have to make decisions like to continue living your old life or start living a new life. Like this is not allowed, and that is not allowed, no, yes, no more smoking for me, but let's say I'll have to stay a bit away from food and tasty things. So, living a healthier life.”Coach: “It's worth a lot to you actually, it is important for you to stay around.”Patient: “Yes, I think so, 47, and then… no, please not yet, I still want to live for a while, so…”Coach: “You're making all sorts of adjustments.”Patient: “You must, can't go on like this, like I used to do. Or, in a few years, you won't be around anymore.”(…)Coach: “So your confidence in not having a cigarette is higher than last time. (…) How did that happen?”Patient: “How, because I don't need it at all, though sometimes I think about a smoke, but if someone would stand in front of me offering me a cigarette? No, I would not take one.”Coach: “So when you think about smoking, you're able to handle this quite well, which makes you trust you won't relapse.”Patient: “No I won't fall back. Well, I'm not 100% sure, but I'm 99% sure that I will not have a cigarette, I won't fall back.”In 12 cases, we did not observe clues for a mechanism of change. In nine of these cases, not all sessions were audiotaped, and there may have been clues for the mechanisms of change in these missing sessions. In the three cases with audio recordings of all sessions, the coaching was prematurely finished before the intervention had been completed.We describe two levels of the applications of the active ingredients of the coaches. The first level is the level of “which conversational techniques do evoke change talk on smoking cessation?” On the second level, we elaborate on the MI strategies of the coaches to trigger the mechanisms of change.a reflection directed at smoking cessation behavior or intentions (Reflection+), was 76%, and there was a 66% chance of change talk following a question directed at the smoking cessation behavior or intentions (Question+). The chance of “sustain talk” was the highest after questions and reflections directed at persisting in smoking  session The coach starts the session by asking how things are going, and the patient answers, “I'm doing fine, actually,” and continues talking about her holidays. The coach takes the subject back to smoking:Coach: “You're doing fine, but last time you said: ‘It's going very well.’ Is that a coincidence, or is it something…?”Patient: “No, it has not really changed specifically.”Coach: “No, how would you describe more precisely how things are going now?”Patient: “Well, if you take it specifically back to not smoking, I may be not as entirely motivated as I was at the start. Very occasionally, I took a cigarette puff. Incidentally, really incidentally, but I did. But since last week, I think, I have not smoked anymore, it doesn't bother me.”Coach: “The motivation dips a bit.”Patient: “Well not really, yes the motivation, there may have been moments, and I can't say why, that I longed for a cigarette, and eventually, I had a puff. But I don't think it takes a lot of effort not to. So, I say no, it's not an effort not to.”Coach: “Is it also an intention not to, or has it become an intention to ‘rather not, but if I long for it, I'll have a puff’?”Patient: “No, I quit. Definitely quit. Actually, that time I smoked a bit, it didn't really do something for me, give me something. So, I mean, right now I've stopped. I feel I've stopped.”(…)The conversation continues why these puffs may have happened. The coach asks the patient to indicate how she perceives the importance of not smoking as a mark on a ruler from 1 to 10.Patient: “Definitely a high number, (…) a 7, 8, or 9? I don't know.”Coach: “In the first session it was a 9.”Patient: “Okay, I see. Well you wrote it down and I don't remember. And that's okay, I know. But yes, the motivation is there, and like I said, I feel I have stopped.”Coach: “That's why you're less concerned with the why of smoking cessation.”Patient: “I also put on some weight, my weight shows that I stopped smoking.”Coach: “You're not smoking. (…) Coming back to your motivation, what are the main reasons for a high number? Regardless of the exact number. What are the things that you think ‘yes, that is why I stopped smoking.’?”Another result of the engagement process is the information on the sense making of smoking by the patient. An example is a patient who, after her myocardial infarction, stopped smoking, but, every now and then, she needed to take a puff of a cigarette. She called the cigarette a “pal,” helping her with stress, to sit apart and enjoy the cigarette. The myocardial infarction abruptly ended this relationship, without a proper goodbye (Case 14). This kind of knowledge of the sense making of the patient allowed the coach to choose clinician factors that connected with the cognitions of the patient, and these clinician factors might influence the way of thinking of the patient about smoking. The clinician factors, chosen by the coach based on the sense making of the patient, might also allow the coach to relate smoking with the life goals and values of the patient Coach: “Are there other things, apart from you saying ‘I can smell much better’?”Patient: “The taste, and less-at long last-less stress and things like that.”Coach: “You sense that you've calmed…”Patient: “Yes, like an inner peace. Sometimes I see smoking people, a quick smoke at the door, it doesn't look relaxed, and then I think I don't have that anymore, I'm done with it, finished.”Coach: “No complicated maneuverings for a quick smoke.”Patient: “All just for a quick smoke, yes. A few times, when I went for diner with my colleagues, I could remain sitting easily, smoking is no issue anymore. Before, it kept me kind of occupied: when will I stand up and smoke, what is the best moment, things like that. That's over now.”Coach: “It sort of distracted you, maybe keeping an eye on people, when are they going outside?”Patient: “Yes.”Coach: “It is kind of funny that you experience that, isn't it, many people feel that smoking makes them relax, but you say actually it is much more relaxed not to smoke.”Patient: “Yes. Always, I used to think smoking helps to relax, but that is not true at all, it's the opposite.”(…)Coach: Actually, you say, it is pleasant no longer needing to smoke. That is, you kind of started saying like it also has benefits.”Patient: “Yes, many benefits actually.”Coach: “Yes, are there other things you…?”Patient: “Yes, at home, with kids growing up, they also might do this kind of thing. Now, that is much less of a problem, because they know why I've stopped, and they've seen how hard it has been for me. There is less need to try, you know.”Coach: “Yes, you feel you're a much better role model, the whole picture fits better.”Patient: “Yes.”Coach: “Great, good for you!”_________________________________________________________________________________4bWeak evocationCase 2, session 3(…)Coach: “Do you still know why you stopped? Why is it so important?”Patient: “Yes, yes, my health.”Coach: “Huh? Your health.”Patient: “Yes.”Coach: “Especially your heart.”Patient: “Yes.”Most patients related their desire to quit smoking to an important value, namely their health. Sometimes a family member was mentioned as an important value: “I want to stop for my children.” In a few occasions, the coach elaborated on these values and supported the patient to engage in a more in-depth exploration of the relationship between these values and smoking (client factors “in-depth self-exploration” and “experiencing discrepancy”). But often, in situations where the health of the patient was discussed, the coaches tended to give information on the physical effects of smoking, leaving the chance of activating these client factors unused.Providing the patient with information played an important role in the sessions. Well-timed- and well-provided information can evoke client factors concerning the sense making of, resolving ambivalence of, and change talk of the patient. In MI, it is important to provide only these pieces of information the patient wants and needs. This went well when the coach only provided information if the patient explicitly or implicitly permitted the coach to give this information, after which the coach provided the information in clear language and in small amounts. After providing the information, the coach should inquire after the understanding and interpretation of the information by the patient. The absence of this inquiry about the interpretation by the patient was the most common shortcoming in the information exchange, followed by providing too much information at once and providing unsolicited information. These shortcomings impeded activation of relevant client factors and limited the absorption of the essence of the information by the patient.For all smoking patients, the patient and the coach determined a stop date for smoking, and they planned the prior preparations, including obtaining NRT or varenicline, and, if applicable, the coach provided user instructions for NRT or varenicline. Also, in many sessions, the coaches enquired after difficult  smoking situations, explored these situations, and discussed possible coping strategies. However, in none of the cases, an explicit activity or coping plan was made.post hoc to calculate the risk ratio of smoking cessation of patients who had exhibited a mechanism of change and found the risk ratio to be 3.6 (95% CI 0.99–12.22). This can be an indication that the MI quality may be related to the application of active ingredients and, thus, mechanisms of change.In this small sample, we found an association between the observed clues for the mechanisms of change and the smoking status of the patient at 12 months , with thAs shown in the columns of the summary scores . Based oWe observed many clues for mechanisms of change, clinician factors, and client factors in two of the three cases in which the summary scores indicate insufficient MI quality  and subsequent clues for mechanisms of change. In all the sessions, the coaches used eight out of nine clinician factors. None of the coaches employed the ninth clinician factor “creating a change plan,” while this factor is intended to target the self-efficacy of the patient. Notably, the (preparations for the) actual smoking cessation, and the coping with difficult smoking situations afterward, often were conversational topics in anticipation of these situations. These discussions, however, were restricted to general activity and coping strategies, and they never reached the status of a concrete plan with goals, actions, resources, and concrete coping strategies for potential barriers to remain non-smoking.“Proportion change talk” was the highest prevalent client factor, which was mostly elicited through reflections and open questions directed at smoking cessation behavior or intentions. We observed clues for three out of the four different mechanisms of change, where the mechanism of “changing self-perception” was not observed in this sample. It seems plausible, however, that changing self-perceptions from being “a smoker” to considering oneself as “a non-smoker” is also a mechanism of change for smoking cessation in patients with CAD [see also Miller and Rollnick, Though the clinician factors almost always activated one or more client factors, the interactions between these factors that turn them into active ingredients require a more extensive and more comprehensive strategy, and is more complex, than the mere application of a clinician factor followed by a client factor. For instance, the conversation in Our findings on the mechanisms of change are in accordance with the results of the mediation analysis by Magill et al. , who tesOne of the goals for this study was to explore whether MI quality depends on the use of active ingredients by the coaches. The summary scores of the MISC and the SCOPE  and the presence of observed clues of the mechanisms of change. However, the sample size of this qualitative study is very small, and the study was not designed to detect such a relationship. Therefore, we regard this finding as a stimulus for further investigation only.This study attempts to open the “black box” of MI counseling for smoking cessation in patients with CAD. We obtained rich qualitative data on both patient and coach processes to strengthen motivation and commitment for smoking cessation, and we identified two important mechanisms of change in MI for smoking cessation in patients with CAD. This study also addresses an important problem for complex behavioral interventions, namely uncertainty of the exact content of the intervention delivered. Using both quantitative and qualitative research methods, we analyzed in detail both the content and the process of the MI sessions. This made it possible to study the complex interaction between clinician and client factors and the activation of the mechanisms of change. This kind of knowledge is important to understand and enhance the application of MI.Further, our findings add to the debate on what characterizes “good MI.” We identified some shortcomings of the summary scores as a stand-alone criterion for “good MI,” and argue that the presence of active ingredients should be considered as an appropriate addition to the current criteria.immediately following the statements of the coach (lag = 1). However, it is likely that the effects of many statements of the coach will last longer.An important limitation is that 27.8% of the sessions were not audiotaped; thus they were not available for analysis. The reasons for not audiotaping these sessions were not recorded. There was no documented refusal of permission to record the session. The Luchtsignaal coaches function in a community-based lifestyle program. In their daily practice, they coach many people on smoking cessation, among whom were the trial patients. Recording these sessions is not part of their routine, and some coaches mentioned that they forgot to record some of the sessions. A likely explanation for the unrecorded sessions is, therefore, that the coaches forgot to record the sessions. This limitation forces us to be prudent in interpreting the data of the incomplete cases, especially concerning the presence or absence of active ingredients and mechanisms of change in some of these cases, the transition probabilities, and the overall MI quality delivered. In addition, the analysis of the transition probabilities using GSEQ 5.1 combines all patient statements in one pool, and all coach statements in another pool, while, in fact, these statements are clustered in 24 coach–patient relations. Furthermore, in this analysis, we calculated only the probability of patient change talk and sustain talk Another limitation is that we did not study the relation between active ingredients, mechanism of change, and the actual smoking status at 12 months. This means that we only took a small step by showing the actual presence of active ingredients and mechanisms of change. For causality, many other steps have to be taken Hill, : the rigMost active ingredients were observed when the coach adapted his/her MI strategy to the individual patient process of change. This created the possibility of several clinician and client factors to interact in such a way that they form an active ingredient and activate a mechanism of change. The combination of targeting the mechanisms of change “increasing self-efficacy” and “arguing oneself into change” seems a good MI strategy in coaching patients with CAD for smoking cessation. This helps patients to solve their ambivalence about their ability to quit smoking and also strengthen the willingness of the patient to quit.There is more to good quality MI than a trusting relationship and the application of MI-consistent conversational techniques. Although these certainly are prerequisites for effective MI, in quality assessments, the presence or absence of active ingredients should also be taken into account.https://doi.org/10.21943/auas.10265054.v1. Parts of the datasets generated and analyzed during the current study are not publicly available due to identifying patient information. Data may be available from the corresponding author upon request, but restrictions apply on the availability of these data in accordance with the ethical rules of the Medical Ethical Committee of the Amsterdam UMC.Parts of the dataset generated and analyzed for this study can be found in the Figshare repository: The studies involving human participants were reviewed and approved by the Medical Ethics Committee of the Amsterdam UMC, Amsterdam. The patients/participants provided their written informed consent to participate in this study.JD, MS, CL, RP, GR, WS, LH, and BM contributed to the study design and participated in writing the manuscript. JD and MS performed the data acquisition. JD, MS, and GR performed the data analysis. JD, GR, RP, and WS interpreted the data. MS, CL, and BM checked the data interpretation. All authors approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.