Breast cancer incidence is rising among Pakistani women in the United Kingdom. However, uptake of breast screening remains low. This study aimed to improve access to breast screening for British-Pakistani women by exploring their knowledge of breast cancer and the role of primary care and community networks to support screening access amongst British-Pakistani women.We undertook a secondary qualitative analysis of 18 semi-structured interviews with British-Pakistani women from East Lancashire in the United Kingdom. Anonymized transcripts of the interviews were used for a thematic analysis.Three themes were identified in the interviewees’ responses: (i) ‘Women’s knowledge of breasts and breast cancer’, which described how a cultural taboo exists around Pakistani women’s bodies and around breast cancer; (ii) ‘Role of primary care’, which detailed how General Practitioners can support informed decisions and offer a trusted and valued information source; (iii) ‘Community engagement’, which described the potential to disseminate breast-screening information through the whole community, including primary care providers, all family members and mosques.Our analysis suggested three main targets for future interventions to improve access to breast screening for British-Pakistani women: (i) co-produced strategies to increase knowledge of breasts and breast screening; (ii) greater collaboration with local General Practitioners to support women to make informed choices about screening; and (iii) community engagement involving General Practitioners and community leaders, to inform everyone – not just screening-age women – about breast cancer and screening. Breast screening aims to detect cancer at an earlier and more treatable stage. It involves the use of an X-ray test, also known as a mammogram, to check each breast for a growth or lump too small to see or feel. In the United Kingdom (UK), the National Health Service Breast Screening Programme (NHSBSP) was established in 1988. The NHSBSP invites women aged 50 to 70, once every three years, for a free breast screening. The programme saves approximately 1300 lives per year among those invited. However, uptake of the NHSBSP is consistently low in Pakistani-dense areas in the UK.4 There are approximately 1.1 million Pakistanis in the population of England and Wales, and 49% of this population identifies as female. Approximately 9.9% of the total Pakistani population is between the ages of 50–70, making low uptake of screening a significant public health challenge.A major driver of success of the NHSBSP is uptake, with approximately 70% of eligible women attending in England.7 A study in the Greater Manchester area found no significant difference in incidence of breast cancer based on ethnicity. Ethnic differences in breast cancer risk between South Asian and Black women in comparison to White women were mostly accounted for by known risk factors such as height, age at menarche, childbearing and breastfeeding history, consumption of alcohol, and use of hormone replacement therapy. Once these risk factors were adjusted for, there were no differences in incidence by ethnic group. Asian women tend to have lower risks of breast cancer in their native countries; however, the move to a country with higher incidence results in gradually increasing levels of risk. This higher incidence is attributed to adopting new westernized lifestyle factors, such as reduced levels of physical activity, increased alcohol consumption and having fewer children, later in life.7There is a perception amongst some women of South Asian ethnicity  that they are at lower risk of developing breast cancer compared to White women, but this view is not in accordance with evidence. These include, but are not limited to, cultural differences, beliefs, suitable methods of dissemination of knowledge, language and tackling unfamiliarity due to the ‘newness’ of a concept.Given this increasing breast cancer incidence but low uptake of screening, British-Pakistani women’s access to the NHSBSP needs to be understood and addressed. Szczepura suggested that to reduce inequalities in access to a healthcare service for ethnic minority populations, intrinsic barriers to access need to be addressed.9 Saeed et al. identified individual, sociocultural and structural barriers in accessing information and screening, all of which prevent Pakistani women to seek timely diagnosis. Culturally, there is fear of social isolation as there is a belief amongst some Pakistani communities that those diagnosed with breast cancer are ‘unclean’ and should be avoided.The cultural taboo surrounding breast cancer complicates engagement with awareness programmes and informational materials – privacy and modesty are valued strongly by Pakistani women, making the breasts and the female body, overall, a taboo to expose or even talk about.Karbani et al. conducted a qualitative study involving interviewing 24 South Asian breast cancer patients, including 12 Pakistani women, in West Yorkshire to better understand cultural practices regarding breast cancer. Seven of the interviews had to be conducted outside the women’s homes because the women found it ‘restricting to talk about their illness’ inside their own houses.11Lack of engagement with breast screening and delay in help-seeking are also suggested to be interlinked to belief systems. Some Pakistani Muslim women with low awareness reportedly deem a cancer diagnosis as ‘God’s will’ and look to spiritual healers for their treatment. Evidence from diabetes management, and in help-seeking for memory problems, amongst British-South Asian communities has suggested that some members of the Pakistani community in the Greater Manchester area put greater trust in advice that comes from a General Practitioner (GP), as opposed to other information sources, such as letters or leaflets from government agencies.14 Therefore, in the breast-screening context, it is important to explore how such GP-patient relationships in the Pakistani community can be utilized to improve access to breast screening.British-Pakistanis and other ethnic minority populations lack awareness of cancer-screening programmes in the UK. Research that has attempted to understand inequalities in the uptake of breast screening mostly does so from a ‘South Asian’ perspective, and the distinct ethnicities of Indian, Pakistani, Bangladeshi, Afghani, Nepalese, Bhutanese, Maldivian and Sri Lankan women tend to be treated as one homogenous group. Similarities exist among people from the South Asian community, but lived experiences of British-Pakistani women – which impact their health-seeking behaviours – need to be considered individually, particularly given their lack of engagement with breast screening. Pakistani women navigate different barriers owing to their religious beliefs, cultural practices and the kinship networks in Pakistani communities, which impact their decisions. Moreover, there are significant socioeconomic disparities between South Asians living in the UK, with Pakistanis more likely to live in deprived areas with lower income, less education and increased racial discrimination.The literature has noted a need for studies into how different ethnic groups understand cancer and how to improve screening uptake.The current study aims to extend the existing literature by exploring in depth the role played by British-Pakistani communities’ knowledge of breast cancer and breast cancer screening, including the role of primary care.18 In the primary study, 19 semi-structured interviews with British-Pakistani women residing in East Lancashire, UK, were conducted in 2018–2019. The participants had all moved to the UK from Pakistan. Twelve women were of breast-screening age, five were under 50, and two chose not to report their age. All women of screening age reported to have attended at least one screening appointment.This study was a secondary analysis of qualitative data originally used in studies published elsewhere. of 70%. Participants were recruited via a community event organized in East Lancashire, where information and advice about breast cancer were provided. At this event, the aim of the study was also explained, and women were provided with information sheets and contact information of the research team if they were interested in participating. Recruitment was further supported by community contacts who disseminated information about the study in the area and provided the research team’s contact information to women interested in participating.East Lancashire was selected due to the presence of a dense Pakistani community in the region, and the overall uptake of screening in the entire population of Lancashire (60.6%) falling below the National Health Service targetth was not audio-recorded or transcribed. The 18 interviewees are identified below as P-1 to P-18.Of the 19 interviews conducted in the primary study, 18 transcripts were used for this analysis, as the 19th case, P-10, the interview was partly in English and partly interpreted by the participant’s daughter. Before the interviews, the interpreter met with the researcher to run through what was going to be asked and how the interview would run. The interpreters worked within strict guidelines, so during the interviews they only translated, and minimized any side conversations. The interviews followed a topic guide focused on the NHSBSP’s invitation letter, understanding of screening and the screening process, the role of the GP and community and what could be improved.One-to two-hour semi-structured interviews were conducted in either the participants’ homes or a private space in a community centre. Only participants P-1, P-3, P-4 and P-17 conducted their interviews in English. Of the other 14 interviews, in 13 cases a National Health Service-approved interpreter was appointed, who translated in Urdu and Punjabi, and in the 14This study was a secondary data analysis of a previously collected data set. The analytic techniques applied were similar to the primary analysis. The epistemology of a researcher informs the design of the research methods and the process of theorizing meaning from data.This reanalysis highlighted aspects of data that were not the focus of the primary analysis, leading to new knowledge production. Thereafter, an iterative process began, involving coding of data on NVivo12. Notes on NVivo12 were taken side-by-side to add reflexivity to the analytic process, and to keep track of coding choices.Braun and Clarke’s approach to thematic analysis was followed, beginning with reading all 18 transcripts thoroughly, to become familiar with the data.Codes were then categorized. Codes with commonalities between them were grouped together to make data sorting easier. These categories were then used to establish preliminary themes, which were then tested for coherence. Their extracts were read again to judge whether there was a pattern forming under that theme, and if the various themes were distinct from each other. This was a cyclical process, involving discussions between HMK and KAR, until the researcher was confident that distinct themes had been succinctly established. Finally, the themes were named to immediately explain what they address, and in relation to words used by participants.1. Women’s knowledge of breasts and breast cancer2. Role of primary care3. Community engagementData were grouped into three key themes:We discuss the three major themes, and their respective subthemes, below. Participants were asked why they think women hesitate about attending screening. They replied that women feel uncomfortable both with undressing from the waist up and with talking about the female body.My husband asked me first time, when I’m pregnant, how babies come out. I don’t know. I have never seen. Really, I’m telling the truth, I don’t know which way baby is coming (P-17).The participants said Pakistani women were deeply unaware of the mechanisms of their own bodies, which meant making choices for their health difficult. This lack of knowledge extended beyond breast cancer to basic biology, such as periods or pregnancy. One participant shared:Another participant expressed confusion over whether it was normal to have ‘breasts of different sizes’ (P-1) and whether breast size affects breastfeeding.Because it’s such a private matter and we don’t talk about it openly and we don’t show our private parts to anyone like that … It’s just a fear, maybe because you don’t know your body much (P-1).Modesty and privacy are valued highly within the Pakistani culture. This wish for privacy extends to discussions around the female body, making it ‘a difficult subject’ (P-14). Due to gaps in understanding, there is a fear about matters of the body. As one participant said:Breast cancer is a very scary thing … a life-threatening kind of thing. So sometimes people … don’t want to know that information about it, or the worry, or contact, or think ‘I’ve got it’ (P-12). Some participants explained that their cultural context restricts opportunities to learn about preventive lifestyles or to hear about the hopeful side of cancer, for example, that early detection leads to better outcomes. Instead, breast cancer remains a threat in the community that is not spoken of, and that fear stops women from engaging with screening. This lack of engagement also includes any conversation that could have ‘cancer’ and ‘breast’ attached to it. A participant explained:She’ll put the letter to one side … Even with her husband there are certain things she won’t discuss (P-14).The disease’s reputation makes receiving an invitation to screening stressful. Upon receiving a letter, some women described not opening it, being scared, or even feeling they could not discuss the invitation in their own homes. As a participant described, via her interpreter:, particularly by the older generation:My Mum, back home, she would not say ‘cancer’ … Maybe because the perception is that you lose your hair, you lose your breasts, or your womanhood. It’s not to be talked about (P-1).Participants described breast cancer as ‘the big killer in the community’ (P-2), a ‘silent killer’ (P-5) and something shameful for a woman. This feeling of shame was associated with the fact a diagnosis of breast cancer was perceived as a loss of womanhoodTry to keep a secret in the start. When it’s towards the end, when they know that … this is spread everywhere, then they might open up a little bit, about their disease and what’s happened to them (P-15).Several participants elaborated that shame and embarrassment affects women engaging with screening, since they fear they could have cancer as well, and then face cultural ramifications. One participant explained that for women diagnosed with breast cancer, the norm is silence: Several participants described the sense of comfort and trust they have with their GP. From their perspective, the role of a GP is honourable and important in the community, so the GP’s opinion is trusted and highly valued. As one participant said, ‘[Women] know the doctor [GP], and if the information is given to them by the doctor, that’s fine’ (P-12).However, when asked about their local GP’s role in engaging with them about breast screening, all but one participant said that there had been no such discussion. The participants felt that the way the breast-screening invitation is currently sent out – that is, a letter from the NHSBSP – feels separate from their usual health care. This made several women unsure of where the invitation had come from and potentially led to the women either ignoring the invitation or regarding it as unimportant. Indeed, one participant explained how mammographers or invitation letters are almost ‘outsiders’ (P-12), while a GP is at the heart of a community and a professional.If they receive a letter just from [the NHSBSP] … maybe they don’t put that much attention and it is just a letter … If you put through the GP, that’s a bit more important (P-16).According to participants, if their GP endorsed breast screening, this could potentially encourage more women to attend screening: Some participants said they had been offered no breast cancer literature inside their local primary care clinic and had seen no posters in their local primary care centres highlighting breast cancer. Participants believed that more posters in clinics would increase the community’s familiarization with breast cancer and screening.One participant added that the local primary care centre itself can act as a safe space. If a nurse or a GP is talking to women about breast health, this is a private conversation, making any shame or any stigma attached to the disease irrelevant since the women are within the safe walls of a clinic. It also allows women to ask questions without any embarrassment.If the doctors are playing more of a role in this, and making you aware, then obviously people tend to say, ‘Oh, that is my own doctor.’ … Then there’s more chance of people going [to the screening] ‘cause they think that the doctor is part of [the screening programme]’ (P-12).The feeling amongst the participants was that a small discussion with a nurse or a doctor, about why it is a good idea to attend screening, would be extremely beneficial:A concept reiterated in all interviews was that of the tightknit bond Pakistani communities tend to have. The community prides itself on looking after each other and rallying together, particularly in times of need: ‘Even though we’re not blood-related, we see ourselves as a family’ (P-7).There’s a lot of people who want to help this cause … who want to spread the word, because it’s a very beneficial kind of thing (P-2).Participants felt that this community spirit could be harnessed in the fight against breast cancer. One idea was having community open days, with a mix of health professionals and local women who had experienced screening and/or breast cancer community engaging with other women about breast health and screening. One participant explained:If you were to hold such an event at a school twice in the year, that information would disseminate quite quickly … Those mums then would be able to transfer that information to other mums (P-14).Another said:If you have a cut and it’s bleeding, you need to do something to stop the bleeding. God will give you the power to heal, but you need to get stitches to stop the blood (P-16).One participant suggested that some women perceive screening as running counter to their religion. They believe their faith in God to heal them supersedes all, including medical intervention, and they prefer to engage with faith-based healers. This participant went on to say if she had the chance to talk to such women, she would give them a different perspective:The participant said she would be happy to tell other women that looking after oneself through preventive measures like breast screening also aligns with their faith, as leading a healthy lifestyle is encouraged in Islam. That is because this would stop them from suffering later.Participants stressed the importance of involving all the family in community outreach. Participants noted that while breast cancer may affect women more than it does men, many men in the community are translators, caretakers or supporters, and therefore have a key role in promoting breast screening. After all, when a woman develops breast cancer, it affects the entire family. As one participant observed: ‘It’s kind of affecting everybody in a lot of ways. You’re saving your kids, your husband, your mum, your sisters’ (P-8).Get the mosques to encourage the husbands to make sure they send the women to these different venues you might be running the information at (P-14).Some participants suggested community leaders distribute leaflets and information cards in nurseries, clinics, and other locations that women frequent. Participants added that tailored outreach involving mosques and men would also prove beneficial:Many participants were determined that the future be different for their daughters. To achieve that, the community must work together: ‘We have to prepare for our next generation’ (P-16).This study offers important insights surrounding breast cancer and screening in the British-Pakistani community. This leads us to suggest three main targets for future interventions to improve access to breast screening for British-Pakistani women. Our analysis echoes those findings, with some women feeling uncomfortable with the word ‘breast’.First, there should be co-produced strategies to increase knowledge of breasts and breast screening. There is a lack of knowledge among Pakistani women (particularly older women) of the female body. Previous studies have reported that within Pakistani communities there is a hesitancy to even say the word ‘breast’ and it is at times replaced with ‘chest’, which causes misconceptions of the aetiology of the disease.21 Although this is no doubt true, improving Pakistani women’s awareness and understanding of breast screening may also need to incorporate an initial introduction to the anatomy and physiology of breasts. This could include an education campaign explaining the functions of the breasts, that different breast shapes and sizes are normal, and the need for breast screening (similar to the Scottish breast-awareness campaign led by actress Elaine C. Smith). These knowledge-building efforts could include leaflets, co-produced with British-Pakistanis, translated into multiple community languages and handed out at community events.To improve uptake of breast screening, previous studies have noted the importance of increasing knowledge of screening itself.Second, there should be greater collaboration with local GPs to support women to make informed choices about screening. GPs’ role in preventive care could be expanded, with the appropriate resources provided. This could include having informational leaflets in local health centres. Also, primary care facilities could be advised when NHSBSP invitations are sent out, so that GPs can encourage women, when they come in for regular appointments, to consider screening. The cultural taboo surrounding the illness leads women to think of a potential diagnosis as bad luck and that breast cancer is contagious. Some women reportedly do not tell their family members or close friends about the illness, preferring to carry the burden alone and using chaddars (long drapes) to cover any changes in appearance. This is all due to the fear of local gossip and possible social isolation.11 Primary care could alleviate this fear, with GPs explaining screening, the procedure of screening and its benefits, including early detection. Involving primary care to increase uptake of screening has been recommended previously. Additionally, a study based in New Zealand found that medical professionals talking Pakistani women through educational material has been effective in improving uptake of breast and cervical screening.Previous studies have discussed how some Pakistani women delay seeking help and only do so when the pain of breast cancer becomes unbearable. The participants in this study felt that the community offered an opportunity to improve understanding and access to breast screening. Community groups have been successfully used in interventions, to encourage camaraderie and provide extra support.26 Community events co-produced by health professionals and community groups can be helpful. At the events, health professionals could inform women of screening and explain how a breast cancer diagnosis is not necessarily a death sentence.Third, there should be community engagement involving GPs and community leaders, to inform everyone – not just screening-age women – about breast cancer and screening. Health-related interventions often fail because policy reform mostly focuses on individual behavioural choices rather than accounting for the social, economic and political factors that play into decisions individuals make. Knowledge in the community must be improved as a whole, which includes better-informed men and families. Traditionally, men in Pakistani culture have key roles – for some women, their husbands or fathers could even be making medical decisions on their behalf.Women who have attended screening could provide an important perspective in co-designing and taking part in awareness-related interventions. Such women could talk to those reluctant to attend a screening – taking into account their faith and culture – and discuss any concerns. Moreover, some participants insisted that outreach cannot be solely designed for women.This study has three main limitations. First, it did not include views of women who choose not to attend screening. Their insight into those aspects of NHSBSP that prevent them from attending screening is integral to inform long-lasting improvements.Second, most interviews involved translation. This meant the participants’ ability to express themselves freely was reduced through someone translating their words and possibly missing information.Third, this was a secondary analysis using existing data. This meant we were unable to probe the participants for further details on individual points.The British-Pakistani community has specific patterns and interactions, which cannot be homogenized under studies simply involving ‘South Asians’. A proportionate universalism approach is essential if we are to address inequalities in screening participation.Future research could focus on studying young British-Pakistani women’s perspectives on understanding their bodies and combatting breast cancer. Research could draw comparisons across generations, to gauge what is most likely to lead to potential improvements.The strategies outlined in this study could also be extrapolated to other minority communities within the UK, encouraging learning across different cultural groups and amplifying efforts to increase breast-screening uptake. While some barriers to breast screening are different across cultural groups, many are shared, and inclusive interventions to encourage screenings may be beneficial.


Favorable diets often include restrictive practices that have proven health benefits, even if initiated later in life. The aim of this qualitative study is to gain a comprehensive understanding of Restrictive Dietary Practices (RDPs) among a sample of middle-aged and older German adults (aged 59–78 years). We conducted 24 narrative in-depth interviews and analyzed the data using qualitative content analysis (Kuckartz). Following an inductive thematic approach, a typology was reconstructed comprising four typical RDP characteristics: I. The Holistically Restraining Type, II. The Dissonant-savoring Restraining Type, III. The Reactively Restraining Type, and IV. The Unintentionally Restraining Type. These types differed regarding the practical implementation of, e.g., restrictive food choice into everyday routines, barriers to do so, as well as with respect to attitudes and motives underlying RDPs. The major motives for adopting a RDP involved health, well-being, ethical, and ecological concerns. The most prominent barriers to a ‘successful’ adoption of RDPs were the enjoyment of food and the desire for spontaneity and freedom of (food) choice. Our study offers an in-depth understanding of the aspects that shape the widespread practice of dietary restriction among middle-aged and older adults. Lifeworld-related changes in RDPs and possible ‘type shiftings’ are discussed as well as the meaning and chances of RDPs for public health promotion. Definitions of what constitutes a healthy diet vary not only with respect to the  needs of specific populations—such as older adults —but alsoTo gain an understanding of the concept and practice of dietary restraint, a brief framing of the conceptualizations and empirical study of RDP is provided in what follows. Starting in the 1970s, dietary restraint was initially studied as a cause of eating pathologies and weight disorders from a psychological perspective . Ever siMainly originating from these models and developing them further, manifold conceptualizations and definitions of restrained eating have been proposed. Overall, dietary restraint may be defined as the “cognitive effort exerted by an individual to eat less than they would like”  or the iWays of exerting dietary restraint have been distinguished between “rigid”, on the one hand, and “flexible”, on the other, referring to an adherent, complete exclusion, or a rather mutative limitation of the consumption of certain foods  . MoreoveBuilding on the conceptual debate and the existing scientific evidence on dietary restraint and dieting, this study examines the phenomenon of RDP from a sociological–praxeological perspective , therebyTo date, studies have barely addressed (un-)consciously retrieved motives to practice dietary restraint or its practical (un-)successful implementation irrespective of particular diets and concerning different types of dietary restraint among the general population. Mostly, in Psychology and Nutrition Sciences, quantitative  studies have focused on dietary restraint as part of specific dietary patterns  ,25, or aTo the researchers’ knowledge, no  study has yet examined RDPs independent from particular diets or diseases and within specific groups of the general populations. Specific population groups—such as people transitioning into older age (middle-aged and older adults)—have specific lifeworlds, resources, and thus particular needs, which, among others, manifest in specific dietary practices involving restraint. Hence, it is critical to study such specific population groups separately and in greater depth to gain a detailed picture of their specific practices and to draw inferences for targeted public health dietary strategies. Since basic research on dietary practices in general appears scarce among middle-aged and older adults, addressing RDPs specifically (among others) in this population is of particular epistemic relevancy.Going along with the conceptually diverse definitions of RDPs, there is an ongoing controversy about the measurability and appropriate measurement of RDPs ,12,30,31To fill the outlined methodical and empirical research gaps, a comprehensive in-depth understanding of RDPs and related motives and attitudes within general, non-clinical population groups is needed. Exploring various facets related to the implementation of RDPs, this study provides a qualitative typology of Restrictive Dietary Practices among a sample of middle-aged and older German adults.As part of the German Competence Cluster NutriAct—Nutritional Intervention: Food Patterns, Behavior, and Products, a qualitative, cross-sectional study was carried out from 2016 to 2020. The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the Ethical committee of the Charité—Universitätsmedizin Berlin (EA4/151/16).Community-dwelling adults aged 50 years and older living in Germany were eligible for study participation. Recruitment was carried out by a combination of theoretical sampling  and snowAiming for theoretical saturation, participant recruitment took place gradually during the analysis process, i.e., participant enrollment continued until no new insights could be expected from further interviews. Study participation was compensated with an expense allowance of EUR 20 per interview.n = 24, semi-narrative in-depth interviews were conducted using a flexible interview guideline. Depending on the participant’s preference, the interviews took place either at the researchers’ institution, at the participant’s home, or in a public space. Prior to the interviews, participants provided written informed consent and verbally agreed to the interviews being tape-recorded. The tape-recorded data material was saved in encrypted form and transcribed verbatim. Thereafter, transcripts were anonymized, i.e., any information potentially revealing a study participant’s identity was pseudonymized. The data material was handled according to the European General Data Protection Regulation (GDPR). To obtain a picture of the participants’ biographical backgrounds, the first guiding question aimed at stimulating narratives and triggering thick descriptions of childhood memories, including recollections of daily mealtime routines. The major interview themes and sample guiding questions are summarized in The data were analyzed thematically, following the seven steps of qualitative content analysis described by Kuckartz . This apBased on the final category system, the content-analytical development of a typology was carried out. Distinct types could be defined following Kuckartz’ approach  of the tn = 15) and n = 9 interviewees were male. The mean age of the sample was 65 years (age range = 59–78 years). Participants varied with regard to their (former) professions. While some interviewees were still (partly) employed at the time of the interview (n = 6), others were retired for a varying length of time (n = 19)  inductively surfaced from the data material  practical implementation of RDP, (2) attitudes towards RDP, (3) motives for RDP, and (4) barriers towards RDP. The practical implementation (1) of RDP varied from a deliberate, intentional to a habitualized, unconscious practice. Differing manifestations regarding the extent and timeframes of restriction as well as the specific objects (food products) restrained from emerged. While the various forms of restraint mostly involved the omission of presumed unhealthy foods, dietary practices that aimed to increase the consumption of health-promoting foods played a subordinate role. Main objects of dietary restriction were either specific foods , processed foodstuffs, or those being rich in (refined) carbohydrates or fats. In particular, meat was mentioned across all interviews in this context, whereby its restrictive consumption showed to be on a spectrum from “not daily” to a vegetarian lifestyle. Regarding the timeframe, fasting or fasting-like dietary practices appeared as the strictest forms of restraint and ranged from episodic and complete food abstinence to (intermittent) fasting.Furthermore, attitudes (2) towards RDPs were diverse, especially regarding its effect on health and wellbeing, ranging from a positive perspective based on personal experience or the external attribution of advantages as a means of self-efficacy to questioning of its benefits. Some participants expressed that there are clear benefits to RDPs with the limitation that it could, practiced in a rigid form, interfere with quality of life. Closely related to such attitudes were various motives for and barriers to engage in dietary restraint: motives for RDPs (3) concerned individual as well as societal benefits. At the individual level, the maintenance and/or improvement of health and subjective wellbeing appeared to be a major motive. Among the fasting participants, for example, (intermittent) fasting was practiced on an intentional, conscious level: “Well, I always actually feel quite good when I fast. Well, actually really good.” (5W). Closely related, weight control or weight loss were goals intended to be realized with RDPs and were sought not only for positive health effects but also for aesthetic reasons. In contrast, other fasting participants had established routines of skipping single meals without any particular motives and in a rather unconscious manner, e.g., due to taste preferences. With respect to societal benefits, the conditions of food production—particularly in terms of ecology and animal welfare—were central themes that emerged across interviews . A lot of resources are wasted just to produce the meat in the first place (…).“ (M10)).In addition, barriers to initiate and/or maintain RDPs (4) surfaced with respect to an unwillingness or reluctance to engage in dietary restraint. In particular, the hedonistic enjoyment of food and following taste preferences were central counter-motives. In addition, the desire to retain everyday spontaneity and flexibility, as well as to gain freedom of choice as opposed to following set rules manifested in a reluctance to RDPs. Noteworthy, barriers were not necessarily perceived as obstacles to be overcome but were sometimes rather put forward as a deliberate decision for a limited or absent RDP. In the following, this is implicitly taken into account when referring to barriers towards RDPs.Based on the above-mentioned inductively generated dimensions of RDPs, a typology could be reconstructed that reveals four different manifestations or types of engagement with RDPs: The Holistically Restraining Type (Type I), The Dissonant-savoring Restraining Type (Type II), The Reactively Restraining Type (Type III), and The Unintentionally Restraining Type (Type IV). Each of these types showed different specifications of Restrictive dietary practices. Subsequently, each type and their characterizations are described in detail with respect to the above-mentioned four dimensions and contextual factors. An overview is presented in A central characteristic of The Holistically Restraining Type’s RDP is that these are based on internalized assumptions and convictions of an overarching, holistic health-oriented lifestyle and associated conceptualizations of a healthy diet. Those convictions render the restriction of foods considered unhealthy a necessity and require its integration into daily routines without compulsive adherence. As an example, (rigidly) refraining from ready-made or processed foods appears central to this type and necessitates relative high levels of engagement with foodwork:“I don’t want to have any pre-made stuff. I never buy any ready-made food. I buy natural produce and, where possible, I pay attention to where they come from.” (16W)Moreover, for Type I, restrictive practices show to be habitually embedded into long-term dietary routines and can be described as ascetic due to their fairly rigorous implementation. This becomes either apparent by participants referring to their practices with a vigorous choice of words, such as “I never buy” and “I don’t want to have any pre-made stuff”, or by them explicitly pointing at the duration of established restrictive habits ). Refraining from certain foods  or food components  and, following a restrictive food choice pattern  is one of three partially intertwined ways, in which dietary restraint among people of this type is practiced. Another such was regulation of the amount of energy intake, for instance, by means of “low-calorie days”:“And back then, I lost a massive amount of weight within three weeks and well, to maintain the weight, well, there was this recommendation to do a “hunger day” once a week, and that is what I have been doing already since 2005.” (3W)Here, one central motive becomes apparent, namely, weight control. The third way of RDP among Type I participants concerns the timeframes in which dietary restraint is practiced. Those timeframes varied across individuals, and the implementation of regular intervals of fasting routines showed to be one popular variant. Such a fasting routine ranged from fasting for several days per month or year to daily intermittent fasting alternating from 16 h of food abstinence to an 8 h window of potential food consumption. The following quote illustrates a typical daily fasting routine of the latter type:“Long story short, I do so-called intermittent fasting, which means, I always fast for 16 h after the last meal in the evening, which is unfortunately in my case usually fairly late. So, if I stopped eating at 8 o’clock in the evening, which I rarely manage to do, eight plus sixteen, would be 12 o’clock, so I could eat again at noon. […] And, when I sometimes eat at midnight, I have to get through this and then I do not eat anything until 4. It is surprisingly easy for me.” (M19) to the RDP. In contrast, another participant of this type practices fasting less regularly (“from time to time” (W5)), for several days in a row ), thereby stressing the ease of doing so.For this participant, who follows a clear self-imposed set of rules, dietary restriction may occasionally be challenging, but at the same time is experienced as “surprisingly” easy. The astonishment expressed in this verbalization may be rooted in a perceived divergence between a theoretically expected burden of adhering to these rules and the actual experience of their practical implementation. While his choice of words  indicates an effort he may indeed be confronted with, this seemingly does not interfere with his strict commitment Among participants of Type I, the central motives for dietary restraint—health, wellbeing, and weight control—appeared to be intrinsic as well as externally driven. On the one hand, personal experiences of or the desire for wellbeing and bodily comfort  as well as a profound knowledge on the health effects of specific restrictive diets motivates participants to practice dietary restraint. On the other hand, the initiation of such practices is also inspired by the personal social environment: “Maybe 15 years ago, a colleague of mine, who really wanted to fast, told me about it. […] She gave me a book about fasting, which I read and thought, yes, ‘you want to do it, too, yes’.” (5W)Especially regarding the maintenance and/or improvement of health and wellbeing , dietary guides are studied in-depth and encourage the adoption of specific RDPs. Hence, for the Holistically Restraining Type, the motives to practice restraint are based on a conceptualization and understanding of food choices in accordance with (popular) scientific evidence. In some cases, specific nutritional concepts and corresponding dietary styles  promulgated by experts were action-guiding:“And then I got some literature and got this book written by a mister Doctor Bruker, who also is a pioneer in vegetarian diet and, above all, in wholefood diet. And, eh, I read this book and so I knew about it in theory and I have put it into practice because it all seemed so logic to me, right?” (16W)“Prehistoric human beings did not constantly [eat] all day long [or] had breakfast every morning.“ (19M). Additionally, more overarching intentions were expressed with respect to a critical stance on ethical aspects: animal welfare, ecological responsibility in the context of food production (”[M]eat consumption causes damage to the environment and the air.” (M10)), as well as problems with the global (over-)use of natural resources (“[…] waste of very many resources” (10M)) showed to be pivotal initial motives for RDPs. Such reflections were either elicited by personal experiences (“[T]his experience at the slaughter […] made me think.“ (16W)) or subject to a basic orientation and an ongoing engagement with politics and the news. For Type I, the major barrier to the self-applied RDP depicts the enjoyment of eating that appears to be related to a relatively pronounced taste orientation. Such orientations are often perceived as being in conflict with the intended health-oriented or weight-regulating diet. Therefore, participants anticipate feelings of failure and/or guilt if foods considered unhealthy were consumed, for instance. At the same time, Type I typically strives to prevent himself/herself from succumbing and potentially “failing” by reflecting on and controlling “tempting” circumstances. As an example, individuals would avoid preparing specific foods just for themselves as they anticipate giving into the temptation and consuming abundantly in the absence of any social control. However, occasional exceptions are not considered as failure but rather justified as a necessary etiquette within social contexts. This is exemplary illustrated in the following quote of a participant who usually refrains from breakfast:Considering it “logic”, this participant is convinced of this dietary concept according to which she aligns her RDP. Similarly, another participant substantiates his episodic restrictive dietary practice against the background of a(n) evolutionary-bio-physiological logic: “Recently, I was in Mallorca with two friends of mine and there, I joined the breakfast, because it would have been uncommunicative not to do so. […] That really doesn’t set me back or so, that’s ok.” (19M)To The Dissonant-Savoring Restraining Type, a RDP is a necessary component of a healthy lifestyle and regularly practiced—not due to an inner need, but rather out of reason. The central motives for Type II were weight control and the maintenance of physical health as well as ethical  and ecological aspects. With regards to the latter, participants attribute physical health benefits to RDPs particularly in the context of primary prevention, e.g., as implied below:“I have always eaten well, and a lot of meat, of course, which I now slowly reduce, too. […] just for health reasons because I tell myself, you don’t have to eat all that meat all the time.“ (20M)Compared to Type I, individuals of Type II show a relative superficial diet-related knowledge and a moderate level of involvement in foodwork. Meal preparation, for instance, is usually based on spontaneous moods or special occasions rather than on fixed, internalized routines. Moreover, participants of this type engage in restrictive diets based on a general understanding of a healthy diet. Unlike Type I, this understanding is independent of any specific philosophy or (scientific) trend but rather loosely anchored in a general health orientation. In accordance with this orientation, Type II participants conceptualize dietary restraint as an ongoing consideration and trial to balance between the quantitative amount and qualitative value of food:“[In] my opinion, it is maybe not, so maybe […] the small amount is wrong, that is even wrong, you have to eat, but you have to eat the right things, whereby I would not claim to eat the right things, I just ty to.” (23W)(“slowly”) and try to achieve their similarly vaguely defined objectives (“little less”)):While the definition of a “right” or “wrong” practice of dietary restraint remains imprecise here, a certain hierarchization of the quality over the quantity of food becomes apparent. Moreover, instead of adhering to a clear set of rules and aiming for specific goals, the participants of this type mostly follow a rather indistinctively defined tendency of dietary restraint ] if possible […] I hate such things because I don’t manage to stick to it anyways. I can make a plan now, but I know exactly that if I-, if there is a delicious sausage crossing my way or a nice fish sandwich or something like that, I can’t say ‘no’, I just cannot say, ‘my plan doesn’t allow to eat that’.” (20M)(“I can’t”) to resist food-related temptations. Here, a lack of gustatory self-regulation and/or the unwillingness to restrain becomes apparent. While this is seemingly considered a failure, others accept their non-restrictive practice as a given, natural fact to which they ascribe major importance ). The positively connoted choice of language (“delicious sausage crossing” and “nice fish sandwich” (20M)) underlines this participant’s orientation towards enjoyment and taste. This orientation shows up even stronger in cases where dietary rules are considered a threat to the quality of life:Exemplary for Type II, this quote illustrates the desire for a flexible dietary routine involving a certain freedom of choice and a rather loose commitment to self-assigned RDPs. This participant explains his strong rejection towards the fixed rules of dietary restraint by his allegedly incapacity “I don’t take it too doggedly. […] if I am supposed to restrict myself to such an extent for a lifetime, I’d rather die early. So, this is no quality of life to me.” (8W)In this case, the enjoyment of food competes with restriction and is seen as an integral part of psychological well-being. As a result, savoring is likely to challenge or abandon an initial intent to restrain in a situation where desired foods are available. Hence, for Type II, the pleasure of eating and desire for flexibility and spontaneity are the predominant barriers to RDP. At the same time, the readiness and adherence to practice dietary restraint is increased if the foods ‘permitted’ to eat are regarded as tasty. In some cases, the correspondence between such ‘permitted’ foods and taste preferences even depicts a pre-requisite for taking the emotional constraints associated with a limited freedom of food choice:“I can torment myself if a plan tells me ‘you have to skip bread rolls, skip potatoes, skip pasta’, I can do that, but the little I [may] eat, that has to be tasty.” (23W)Participants belonging to The Reactively Restraining Type show an explicit readiness to refrain from or reduce specific foods and drinks in the face of manifest illness or risk factors. As opposed to the two types mentioned, one major motive for RDP is secondary health prevention, since RDP is regarded as an effective measure to prevent the emergence of (further) disease burdens:“I still keep away from coffee in the morning a little bit because of my hypertension.” (18W)“But when my liver enzymes were relatively bad, I even had to refrain a whole year [from] drinking , back then, 3 years ago, I did not drink a sip. And afterwards less.” (11M)(“not a single drop”). At the same time, the extent of restriction may change over time: as in this example, absolute RDP only applied to the initial episode, followed by a conversion to a moderate alcohol consumption. Mostly, the practice is implemented as a conscious, moderate reduction in specific dietary components (“a little bit” and “not every day a cutlet or goulash […]”).As seen above, RDP among Type III-individuals can take the form of an absolute restriction “drinking coffee in general is not healthy.” (15M)). Participants’ food knowledge is typically selective and mostly based on anecdotes and news headlines or sometimes on recommendations from physicians. Specific sources of information are not provided, which may hint at a rather superficial dealing with the topic of interest. Contrary to Types I and II, the engagement in foodwork is limited to occasional and quick cooking and a tendency towards the consumption of fast food. Here, a central orientation underlying these dietary practices surfaced: dietary practices, such as foodwork and food consumption, are matters of convenience rather than subject to a pronounced taste orientation. At the same time, and similar to the types mentioned, the enjoyment of food appeared as one main barrier to RDP:In contrast to Type I and partially Type II, rather than an overall health-promoting concept, merely the abstinence from single products or the reduction in calories is executed. RDP is motivated by a vague and undifferentiated understanding of (un)healthy foods, without any reference to precise health effects  particularly cheese is not so healthy, but, well, I like to eat cheese.” (15M)“unfortunately”) about his taste. In contrast, Type II participants would rather self-confidentially stand by their taste preferences and their decision to balance those with their RDP in order to achieve their set goals. Moreover, overlapping with the Holistically and Dissonant-Savoring Restraining Types, individuals of Type III also show a mental reluctance or even rejection towards set rules of restrictions that counteract their flexibility and freedom of choice—even if these rules were self-chosen. To avoid unpleasant constraints by strict obligations, some Type III participants would rather accept a health risk or abandon self-imposed goals as shown in the following:As illustrated here, Type III participants face the difficulty of dealing with the tension between RDP and individual taste preferences. This tension seems to be perceived as exhausting, but also as guilt-inducing. In this example, this may be indicated by his regret [T]hat [(dietary routine)] has been like that way for my entire life.” (6M)) that certainly involves an unintentional RDP. This especially manifests itself in a habitual adherence to a pre-reflexive established plan of food choice, in which specific foods are strictly excluded and thus avoided. For example, one individual describes having the same meal every day:Opposed to all other types, The Unintentionally Restraining Type does not refer to any conscious, intended RDP. However, this type shows a highly routinized daily eating routine , and in the evening one slice of cheese.“ (6M)Major motives for this habitual dietary practice unintentionally including RDP appeared to be individual taste preferences and practicability. Moreover, as illustrated in the following, certain self-ascribed character traits and an associated need of routinized, repetitive practices emerged as a reason for these habits:“Because, because […] I am such a boring guy, who always needs to have the same […], who always needs to have the same, yes.“ (6M)Contrary to Types I–III, Type IV shows little dealing with and knowledge of food-related topics in general and does not refer to any active acquisition of respective information. Furthermore, individuals belonging to this type seem to be marginally involved in foodwork. Food choice and shopping as well as meal preparation typically lie in the responsibility of others, mostly the partner or the gastronomy. While individuals of The Unintentionally Restraining Type do not actively engage with and tend to question the benefits of RDPs, some participants belonging to this type showed a certain degree of readiness to refrain from harmful foods—if those were declared as such by an authority:“Yes, if there was a warning published by the public health service or by the government, I would stop doing it, yes. Yes, indeed.” (7M).Yet, such a readiness was only expressed upon explicitly being asked by the interviewer—unlike the other types, where such objectives were expressed on the participants’ own initiatives. In terms of the health context, Type IV may potentially convert to Type III for the purpose of primary or secondary prevention. Above such a potential avoidance of officially harmful products, no further motives surfaced. Congruent with the limited, unintentional RDP, no barriers to the implementation of restrictive dietary practices were evident for this type.This qualitative study explored Restrictive Dietary Practices (RDPs) and related attitudes towards as well as motives for and barriers to its implementation in a sample of middle-aged and older German adults. Using qualitative content analysis , severalIndividuals assigned to the Holistically Restraining Type (Type I) were characterized by their holistic integration of RDP as part of an implemented concept of a healthy diet based on profound food knowledge and habitual engagement in foodwork. Intrinsic motives were based on a general health orientation, but also on ethical and ecological attitudes. In contrast to Type I, dietary restraint thereby did pose an emotional constraint for individuals belonging to the Dissonant-savoring Restraining Type (Type II), which indeed accepted the necessity to refrain from certain foods in order to stick to a healthy diet. However, they were not willing to renounce from certain foods since this would entail a limitation in the enjoyment food and the freedom of choice integral for their quality of life. The Reactively Restraining Type’s RDP (Type III) was characterized by a clear health-related goal in the face of manifest illness or risk factors. Moreover, this type only refrained from particular selective foods. Compared to the first three types, for the Unintentionally Restraining Type (Type IV), dietary restriction was not a conscious practice and solely referred to as an externally triggered necessity if foods were officially declared to be harmful.Although differences between dieting and restrictive eating have been proposed , our typRegardless of the description of differing characteristics in this typology, a partial overlap as well as dynamic shift between the types is possible. Such shifts are likely, since dietary practices are not only subject to various  socialization processes  and thusOur typology shows that—to differing extents—all study participants reported on practices of dietary restraint. In our sample, the modi operandi of RDPs were mainly distinguishable with respect to (a) the timeframe and (b) the targets or ‘objects’ of restriction. With respect to the former (a), the degree to which dietary restraint was practiced differed from “rigid” to “flexible”, which is congruent with the definitional differentiation that has previously been (quantitatively) derived . In thatRegarding (b) the targets of RDPs, participants restrained, on the one hand, from specific foodstuffs or nutrients, such as those rich in refined carbohydrates or fats. On the other hand, the targets of RDPs were single foods or drinks, for instance, sugar, alcohol, or meat. The restriction of meat consumption was a major theme that was raised without exception across all interviews. We found a widely ranging degree of restriction, in which specifically women referred to various practices of restricted meat consumption. There is a large body of literature on the meaning of meat in the re-constructing norms of masculinity and traditional gender roles ,44,45,46Despite those related to meat consumption and vegetarian diets, the predominant motives to engage in RDPs in our sample were health promotion and regulation as well as weight-management or control, which are typical for “restrained eaters”  as previIn the literature, dietary restraint as a cognitive construct has been differentiated as “successful” and “unsuccessful”, referring to its actual practical implementation ,17. In oIn the context of caloric restriction, previous work indicated increased appetitive hunger signals due to hormonal regulation to be a barrier to refrain from eating . This maFrom a praxeological perspective, (sub-)conscious orientations and attitudes manifest themselves in practices, such as RDP, and—to speak with Bourdieu —thereforMeat with its highly symbolized and changing social meaning is a prominent example of this ,54 and aMoreover, in our sample, social distinction also revealed with respect to the individual’s self-responsibility for a healthy life(style). As has previously been argued, the adherence to any form of dieting may demonstrate some kind of social distinction as long as the decision is not the consequence of a medical necessity —which weAs mentioned previously, most guidelines on a healthy diet involve RDPs. The recommendations published by the World Health Organization , for exaIn our study, a divergence between intention and behavior could be seen in the cases of “unsuccessful dietary restraint” occurring predominantly in the practice of some participants assigned to Type II. Moreover, certain food environments, such as those in most Western industrialized countries—where ubiquitous food offerings and advertising encourage overconsumption—constitute hampering conditions for the adherence to a healthy, and thus partly restrictive, diet . At the Irrespective of the background and depth of diet-related knowledge, the restrictive practice is aligned with general recommendations as those, for example, published by the WHO , which iEspecially in the age group of the study participants, the public discourse should be promoted, as RDP depicts to be effective even at older age. Furthermore, dietary restraint has been reflected on as a healthy self-regulation mechanism, including self-monitoring, realistic goals, and self-evaluation that promotes successful weight management ,8.This is the first study to qualitatively reconstruct different types of dietary restraint practices among a general, non-clinical sample of middle-aged and older adults. Our findings provide insights into the complex mechanism between practice, associated attitudes, and motives for as well as the reasons for a reluctance towards and so-called “unsuccessful” RDP. Therefore, we fill an important research gap and add a nuanced understanding of a central aspect of everyday dietary practices to the existing body of knowledge. Moreover, one strength of our study is the methodological approach. To date, the debate on the assessment of RDPs has focused on quantitative measures, neglecting the importance of reconstructive qualitative methods to gain a deeper understanding of the subject of interest. Previous classifications have focused on objects that were refrained from, while no previous work could be found that investigated the general implementation and degree of a RDP with a focus on this age group. In the present study, a spectrum of different manifestations could be identified, clustering the consumers’ behaviors with a broader view towards various aspects subordinating the objects of restraint. The theme of RDP emerged immanently from the data material, i.e., participants were not asked about restrictive dietary behavior or dieting. Thus, the participants’ partly implicit, partly explicit emphasis on dietary restraint underscores its relevance to their lifeworlds. This may certainly have reduced the bias of social desirability.At the same time, the recruitment procedure may have deterred potential participants due to feelings of not matching a social desirability or a lack of interest in the study’s topic. Although we could observe a wide range of engagement in adopting RDPs, it should be considered that individuals with a greater interest in and involvement with diet-related topics might have been more likely to take part in our diet-related study. Moreover, the fact that the majority of our participants was female can be regarded as a potential bias towards a higher engagement in Restrictive Dietary Practices, which is consistent with previous work . FurtherMoreover, future studies that investigate RDPs and our typology with respect to health-related parameters , disease burden, subjective wellbeing, and health-related quality of life) to measure potential (adverse) health effects of RDP are worthwhile. Only in some cases of Type III and Type I, the amelioration of objective health parameters was named as the result of a successful RDP. More generally, further investigations of RDP (among older adults) are promising with respect to individual–psychological factors, such as diet-related self-identifications and the respective social positioning  , on the Finally, the transferability of our findings needs to be discussed. Crucially, the socio-cultural context within which our study was carried out needs consideration. Since cultural norms and specific food environments, amongst others, shape dietary practices in general, the mechanisms of restrained eating also vary across ethnic groups ,69. A siWith respect to societal developments, our interviews were conducted before the COVID-19 pandemic and the worldwide significant rise in inflation rates. While the latter may certainly have an impact on household spending—particularly in lower income classes—the COVID-19 pandemic has shown to have (moderate) effects on dietary changes among older adults . Hence, We showed that Restrictive Dietary Practice (RDP) was a substantial and common topic mentioned in the interviews regarding dietary practices among middle-aged and older adults. The qualitative and quantitative extent to which dietary restriction was practiced differed on a wide scale. The central motives that were revealed by this study where health, well-being, weight control, and ecological and ethical reasons. The major barriers that were referred to were the enjoyment of foods and the willingness to maintain a spontaneity that allows the choice of food disregarding any rules of restraint. The understanding of RDPs has clinical relevance, especially in the context of health promotion. In a surrounding of an omnipresent food supply and temptations leading to a consumption of foods and amounts of energy deleterious to health, overeating is a central health, social, and economic issue of wealthy societies. Deliberate restriction, therefore, becomes an individual and societal necessity and depicts to be efficient even in populations of advanced age. In order to foster this behavior, it is necessary to understand the present implemented practices, motives, and barriers, which we investigated in our study. As our findings indicate, the levels of food-related knowledge were not only diverse, but essentially, the base for conscious choices of restriction. Apart from specific health benefits RDPs have to offer, the capacity to self-regulate and self-empowerment itself may promote individual wellbeing and may therefore contribute to encouraging behavioral changes in general. Therefore, successful and health-related RDPs are important to be considered as a foundation for the promotion of health-orientated self-efficacy and point of intervention for disease prevention and management.


Due to the scarcity of research on the benefits of theatresports for youth, this study examined the outcomes of theatresports as a means to implement positive education in youth work settings.To this end, qualitative research was conducted with 92 participants in a theatresports program. Thematic analysis was applied to analyze the participants’ experiences of the program, using the framework of positive education.Results showed that the processes and practices of the theatresports program helped the participants achieved well-being in terms of various domains namely positive emotions, positive health, positive relationships, positive engagement, positive accomplishment, and positive meaning. These capabilities and qualities acquired helped them achieve well-being, and the learning acquired from the program could even be applied to daily life situations and deal with the challenges.This shows that the theatresports program manifests the benefits of positive education. Corresponding implications were discussed. Theatresports, developed by Keith Johnstone , is a foTheatresports, characterized by competitions in improvisational games, does not focus on the "intent on winning" . InsteadTheatresports helps nurture not only performers’ various skills and qualities, such as storytelling, communication, team building, creativity, and self-confidence, but also a positive attitude and personal growth . First, Positive education is a form of education based on positive psychology , which iWhen theatresports is applied in youth settings as an educational approach, it can be implemented as a tool for positive education, in two key ways. First, given that theatresports is characterized by “spontaneity”  and “immTheatresports is consistent with the aim of positive education, which is to cultivate students’ general well-being –5. As anTo summarize, positive education is a kind of strength-based education which nurtures the well-being of individuals through "conditions and process" . The aboA total of 92 individuals took part in this study, all of whom were participants of a theatresports program implemented by a youth service agency in Hong Kong. The research was approved by the Research Ethics Committee of City University of Hong Kong. All methods were carried out in accordance with procedures and guidelines of Human Subjects Ethics Sub-Committee of City University of Hong Kong and the Social Workers Registration Board. The program is characterized by: 1) 18-h training workshops, which are taught by social workers who have received prior theatresports training. The workshops help participants learn the rules of the games as well as the related performance techniques. The social workers are supported by professional theatre practitioners and tutors/assistant coaches  in the theatresports program; 2) regular weekly practices for the theatresports games, which involve different scenarios for the participants to apply what they have learned from the training workshops; and 3) theatresports competitions, which are held for the participants to further consolidate their learning. Participants of the program have to meet the attendance requirement of 85% in the workshops and the practices in order to join the competitions. The researcher collaborated with the agency to evaluate the outcomes of the theatresports program. In order to gain a greater understanding of the program, the researcher also attended the theatresports training workshops and competitions before the research period.N = 31, 33.7%) were female. The participants’ age ranged from 12 to 27 years, in which 56.5% (N = 52) of them were aged between 14 and 17. Regarding education level, the majority of the participants were Secondary 1 to Secondary 6 students , whilst the oldest ones were attaining or had attained tertiary level of education. Their length of participation in the program ranged from 2 months  to 4.5 years ; more than half of the participants  had joined the program for 6 months to 1 year. Due to the age range of eligible youth service targets of 12–29 uring the process, the tutor not only leads us and teaches us how to collaborate with teammates, communicate with people from different circles, listen to them, and accept their opinions, but also, most importantly, helps us understand that we need to respect the results and every participant.” Similarly, P84 expressed that “the tutors/coaches encourage the participants to learn and try.… I didn’t imagine that I would be able to do it!” In addition, P25 was grateful for their social worker’s care, spiritual support, and company: “During the process, we were not united at all. However, the social worker did not blame us…. Every time we finished our practice, he gave us comments and encouragement.” To summarize, the guidance and support from the assistant coaches and the social workers helped the participants acquire intrapersonal capabilities  and interpersonal capabilities .Some participants mentioned that they had learned from their tutors/assistant coaches (N = 12). P70 expressed that “maybe we don’t have good acting skills, but theatresports emphasizes positive and hopeful messages. We used to think in negative directions; now we’ve gradually become more positive.” P1 also expressed that “I gained a lot of positive energy [from the program]; even when I face stress, I don’t think it is something very important.” This showed that by allowing alternatives and possibilities, theatresports helped participants understand that there were always hope and adaptive ways to deal with problems and adversities, which were related to psychological well-being aving experienced failures, [I’ll] make improvements,” showing a positive attitude when experiencing challenges and adversity.Although the program’s benefits for physical health were not made prominent by the participants, certain advantages in terms of psychological or mental well-being were noted. According to P13, theatresports required problem-solving. P49 recalled his experience in a competition: The building of positive relationships with others requires the acquisition of social and emotional competencies . Many ofN = 5). For instance, P3 shared that “since joining this program, I no longer stutter and I am able to speak more fluently.” As a form of theatre that required immediate, spontaneous interactions among improvisers, theatresports encouraged participants to refine their communication skills to improve their performance. Furthermore, many of the participants claimed to have enhanced their social skills (N = 21). For example, P41 shared that “as we had to prepare for the competition, we had more time to meet up…. We had more opportunities to learn how to express our own thoughts and listen to other teammates’ thoughts. We had more interactions than before.” P10 expressed that theatresports “enhances my ability to work with other people,” while P22 echoed this, saying, “I used to be a selfish, timid and bad-tempered person who tended to care little about other people’s feelings. But when we are on stage, we cannot show our emotions recklessly. Hence, I’ve learned to control my emotions and learned when to speak and act appropriately.” In addition, some participants expressed that they had learned to handle conflicts adaptively. For instance, P76 shared that “although we’ve experienced many conflicts and had different opinions, we will share [our feelings] with one another and learn to respect one another, so as to come up with a mutually agreed decision.” This showed that the program helped participants enhance various social skills, such as effective communication skills, empathy, and active listening skills, and these skills facilitated better collaboration with teammates and maintenance of good relationships with others.To begin with, a few participants noted that theatresports had nurtured their speaking skills (N = 41). As P67 stated, “Theatresports is not something that can be accomplished by just one person; it requires many people to be involved in it and to work well with one another.” The participants realized that it was more important and valuable for each member to make the best use of their strengths and to perform their roles as a team than to strive for their own personal honor. As P86 noted, “the whole team would feel satisfied and happy with the joint effort made by every member.” The participants understood that the essence of good team spirit included friendly relationships among teammates (P57), communication among teammates (P81), trust among teammates (P50), mutual respect for one another’s ideas (P62), mutual dependence and collaboration (P31), accommodating one another (P14), and camaraderie (P19). It is noted that despite the competition against the opposing teams, the participants recognized that sportsmanship was essential (N = 18). They did not act aggressively towards them; instead, they thought that the process of the competition, finding enjoyment and areas for further self-enhancement, were more important than winning . They developed good relationships not only with their teammates but also with opposing teams (P65). They understood that the essence of theatresports was not to aggressively compete for one’s own fame and self-interest; rather, the competing teams shared the same goal of producing a good show together on stage (P24). As P88 said, “The two competing teams are not really in a hostile relationship. Instead, the teams can mutually help each other and solve problems together, so that both teams can survive the competition. The two teams are actually mutually beneficial.” This demonstrated that the participants realized the true meaning of sportsmanship in improvisation  because it is interesting and funny.”As a program characterized by learning distinctive games and competitions, some participants expressed that the process was interesting (N = 15). As P72 said, “As many things [lines during storytelling and improvising] are instant and improvised on stage, you need to think fast and react fast in order to play the games.” Furthermore, P61 noted that “there is not much time for preparation, so it is important to have the ability to adapt to changes and give responses instantly, as well as to have creativity.” Given that improvisers experienced everything on stage and could not escape (P48), some participants expressed that the program had encouraged them to step out of their comfort zone (N = 16). They realized the potential for all sorts of challenges to occur on stage, forcing them to break through their limitations. As P82 said, “The most challenging aspect is that I need to do things with which I’m not familiar…like games which require speaking.” As such, the participants in the program were encouraged to make breakthroughs, overcome their fear of failure courageously, and make new attempts and learn, so as to achieve continuous self-enhancement.The participants showed significant involvement and engagement in the events that occurred in theatresports. Several claimed that theatresports required a degree of proficiency to adapt to changes (N = 1) ; 2) creativity (N = 3) ; 3) problem-solving skills (N = 5) ; and 4) multi-dimensional thinking (N = 4) (P53: “We…have to learn to think from different perspectives in order to generate more solutions [when improvising on stage]”), so as to improvise lines and develop meaningful stories on stage. Besides, engaging in theatresports activities encouraged self-reflection of the participants (N = 2). For instance, P10 expressed that “I engaged in deep self-reflection after the previous competition. Because it was my first competition, we were very nervous and invested a lot of effort in the opening. We hadn’t practiced the games much.” This suggests that participants reviewed and evaluated the process of theatresports and found ways to improve, using their “intrinsic motivation”  after taking part in theatresports groups and activities, I’ve become more confident…. I no longer fear how other people see me.” Likewise, P20 claimed that “I used to be timid and feel inferior; as I’m short, very often I experience limitations when doing things. Theatre helps elevate my self-confidence.” This shows that participants appeared to feel less vulnerable when confronted with challenges after joining the program.A number of participants noted that their self-confidence had increased  they had learned from the program as applicable to solve problems related to interpersonal conflicts in daily life , and that newly developed character could sustain their daily lives (P16). For example, P16 said that In spite of the significant positive feedback and outcomes generated by the program, a few participants expressed negative emotions and feelings, due to not being able to win the competitions:After taking part in numerous theatresports competitions, my deepest feeling is disappointment. This is because we’ve been practicing very hard in every competition, but we keep on losing each time. It’s frustrating. (P75)I feel stressed during competitions; the pressure makes me barely able to speak at that time. In the end, we lost. I felt heartbroken. (P79)“in the end, we could not achieve the expected outcomes and could not get into the final, so I was disappointed. Winning in the competition is of the utmost importance, not friendship or happiness…. [I]f someone thinks that losing in a competition is not a big deal, then this person is not suitable to join theatresports.”This reflects that although theatresports emphasizes processes  rather than outcomes  , 8, 11, “Actually I feel a bit unhappy, because I did not achieve good results to repay my teachers and tutors…also, it seems to me that the goal has gone…. I don’t know what to do next…if I had the chance, I would like to take part in the competition again.” Competitions were important as they provided opportunities for participants to develop a positive identity—of being “someone”—on stage. However, once the performance ended, feelings of loss emerged. Again, this reflects the necessity of further support to help participants deal with these feelings and to consolidate such experiences as valuable memories or assets that could enable personal growth.In these cases, the sense of disappointment for P75 might indicate a lack of successful experience that would otherwise have engendered a sense of achievement, while for P79, his feelings of stress and despair suggested that success was linked to self-worth, and thus he needed to increase his resilience in response to stress. Hence, further support was required to help participants handle distress and despair related to the competitions, and to review the meanings of “success” and “loss,” , 11, 12,The results showed that the theatresports program demonstrated the features and outcomes of positive education –5. In teAmong the results, the facet of positive relationships appeared to be the most prominent. A considerable number of participants mentioned the significance of peer relationships. Peer groups are widely recognized as having the following functions: 1) bringing about social support for youth, particularly when they face problems in life , and theOn the other hand, several participants were aggressive or excessively determined to win, exhibited negative emotions when they failed, and appeared to be overinvolved in the competitions, potentially causing them to bypass the self-reflection aspect of the program. Such issues are contrary to the program’s intended outcomes and suggest that further support is probably needed in aspects such as team building, conflict resolution, and inner self-development. The outcomes of positive education are affected by education providers’ skills, attitudes, and experiences, their understanding of underlying theoretical concepts, and their intervention approaches , 41. In Theatre is an art form that not only meets the interests of many young people but also helps develop their self-growth, capabilities, and sense of well-being , 45. TheTo date, research on theatresports is scarce. This study is significant in enriching the research in terms of how theatresports can be applied in educational settings as an alternative way to implement positive education and bring about positive outcomes for youth. Owing to the positive results, a practice implication is that the program can be launched in more tertiary educational settings and youth settings. Theatresports can be implemented in the form of interdisciplinary collaboration between theatrical practitioners, education practitioners, and helping professionals such as social workers and psychologists, combining the expertise of each profession to optimize the outcomes . A prereThis study was a cross-sectional study, which only captured participants' feelings and insights regarding the program specifically at a specific time, rather than investigating how the processes and components of the program contributed to the outcomes. Moreover, the age range of the participants was wide; this study only inquired into the outcomes of the program for the youth participants in general but not for those from different age groups.In the future, quantitative research could be conducted to reconfirm the qualitative outcomes of implementing theatresports as a form of positive education. Additionally, a longitudinal study could help to understand program participants’ involvement at different points in time and how this affects the program outcomes. Furthermore, such a study could be conducted for different age groups.


In social systems subject to indirect reciprocity, a positive reputation is key for increasing one’s likelihood of future positive interactions –13. The  Models of indirect reciprocity study the effect of reputational information on the actions of individuals in a group setting. They typically assume well mixed population structures –12, 15. While it is clear that network structure can influence reputation spread, the reverse is also true. The connections between individuals themselves can develop dynamically based on choices and incentives shaped by indirect reciprocity , 35–38. Instead of attempting to capture the full interdependence of reputational and structural effects, we propose here an intermediary step where we first identify local structural features that relate strongly to reputation spread, and then study attachment strategies for individuals interested in building cooperative relationships in the presence of indirect reciprocity. Our objective is to provide a crisper mechanistic understanding than might be possible in a co-evolving model. We aim to illuminate static network features affecting reputation spread, as well as provide a possible game theoretical justification for some of the observed (growth) properties of real networks. The two key assumptions are (i) that reputation information can spread across the local network –34, 39 anij learning about an actor i’s good deed to one of their neighbors j, as a function of the local network structure. The model has a single parameter p which represents the strength or likelihood of communication and gossip spread between individuals. We take the quantity nij to be a proxy of the strength of reputational incentives for that relationship. This motivates a strategy of attachment where individuals select for new links that increase incentives for mutually beneficial relationships. We call the resulting algorithm “trust-based attachment” (TBA). We show empirically and motivate mathematically that the simple and well-studied network formation strategy of triadic closure represents a realistic and effective heuristic for TBA in the limit of weak gossip (low p). Since triadic closure specifically generates network properties consistent with several features of real social networks , we conclude that triadic closure may both be the real mechanism used in network growth, and also that it may have developed as a heuristic for a TBA-like attachment strategy. As such, we develop a link between the dynamics of indirect reciprocity and network growth.In particular, we introduce a simple model of reputation spread that considers the expected number of individuals There is an extensive literature on models of network growth that can reproduce various statistical properties , 41 of rWhile there is evidence for scale free degree distributions in real newtorks, as well as for preferential attachment-like affinities during network growth , it shoup is taken as 1). Generative network models based on triadic closure with only few additional parameters can reproduce the characteristics of real social networks quantitatively [Triadic closure, i.e. forming a new link to a neighbor of a neighbor on the network, is an agent based, local mechanism common in realistic social settings , 25, 45.tatively –50. In ttatively –54.We provide further review of related work and the relationship to this paper in p. We assume that information can only flow between two individuals who both know the actor [i increases from 0, global structural properties of the network become increasingly important.Consider a population of individuals occupying the nodes of a graph. The edges determine mutual acquaintance, which implies possibilities of social interaction and communication . On the he actor . In S1 Fp, the probability of gossip transfer over an edge. The basic calculation that we perform is the following: for a given donor i and recipient j on the graph, what is the expected number, nij, of third party individuals that learn about the cooperative act Jwith information originating from the recipient j. The quantity nij is the expected size of the Jreputational audience of i’s action toward j. The larger the value of nij the more incentive there is—based on considerations of reputation and indirect reciprocity [i to j, both due to the threat of punishment for uncooperative behavior and the possibility of reward for cooperative behavior. In interpreting nij, we explicitly assume that there will be sufficient upcoming future interactions to make these considerations of the future relevant/dominant.For a given graph, our model has a single parameter, iprocity , 6—for aWe havek runs over all neighbors of the individual i, but omitting j. The quantity Pjk denotes the probability that gossip [j reaches k. Pjk grows with the number of paths that can carry information, but falls off with their length. Note that Pjk is the percolation probability with parameter p between node j and k on the sub-graph that is given by neighborhood of individual i. Calculating percolation on general graphs is a well-known, formidable problem, and efficient algorithms exist only for special cases [nij as a function of the local degree, clustering, and embeddedness by leveraging the reliability theory of random graphs [The index t gossip  originatal cases , 56–58. nij can vary strongly between recipients. Links to individuals who are weakly connected with or even isolated from the rest of the actor’s neighbors receive only small values of nij. By contrast, links to neighbors that are centrally located and highly connected to many other neighbors carry large values of nij. Such individuals can distribute information widely and thereby generate large effective audience sizes. (ii) The embeddedness [ij, which is the number of mutual neighbors between nodes i and j, has has a strong predictive influence on the value of nij  The value nij can be changed dramatically by modifying just a few key connections. (v) Overall, having actor and recipient be part of a large, densely interconnected community results in the largest values of nij.In ddedness , 18 of enij on four real-world social networks. These networks represent professional (“Collaboration” and “Email”) [nij towards their neighbors. On real social networks, gossip almost surely percolates throughout sufficiently large neighborhoods [In “Email”)  and pers“Email”)  relationborhoods .nij is the expected size of the audience who find out about a cooperative act from i to j. Thus, nij determines the incentive for individual i to be cooperative toward individual j based on reputational consequences. Conversely, nij also determines the trust of j that i will cooperate [For every directed edge on a social network, the parameter ooperate . While vooperate , here weIn j, attaches to individual i with a probability that is proportional to the quantity nij on the potential link. The larger nij the more incentive for i to cooperate with j and thus the more reason for j to trust that i is cooperative toward her. We assume here that the target individual for the new attachment i only accepts newcomers with a given constant probability. As this does not influence the attachment statistics , we omit this influence in the following discussion.We now use these insights to propose a mechanism for generating social networks . ConsideN total individuals with average degree k, we begin with a fully connected graph of k + 1 individuals. Then we add individuals one at a time until there are N individuals in total. Each new individual forms k/2 connections as described above. We propose to call this algorithm for generating social networks “trust based attachment” (TBA). In this algorithm, trust forms the glue of social networks.In order to generate a network of Naturally, TBA forms a simplified model that does not capture all aspects underlying the formation of real-life social networks. Therefore, we do not expect this model to reproduce all features of real social networks. For example, it does not reproduce the distinct community structures commonly found in real social networks, possibly due to a lack of modeling homophily, spatial constraints, or heterogeneity in the properties of individuals –54. It inij on local structural features, embedded in a more realistic context than in previous figures. Edges are colored by nij and nodes are colored by the value of nij averaged over all neighbors j, which we denote as ni*. While nij is specific to the relationship from i to j, ni* can be seen as a measure of “average trustworthiness” of the individual i, and its statistics have been studied extensively on real-world as well as small world and preferential attachment networks [To build some further intuition for the key quantities and network models introduced in this paper, we show in networks . Even inni*. By contrast, highly connected nodes that are part of densely clustered communities display large trustworthiness.TBA captures Ja subset of the qualitative features of real social networks well, including high clustering, small world behavior, hubs, varied degree distributions and an overall high prevalence of trust –21, 50. p ≲ 0.2. This “friend-of-friend” attachment is simple and intuitive, and can be implemented by individual agents without global knowledge of the network structure [p > 0.2, we find that TBA still generates networks with nearly the same properties as friend-of-friend attachment, except that the degree distribution for TBA departs from a power law and includes even more high-degree “hubs” Click here for additional data file.