Forty people over 60 years of age took part in longitudinal research over the course of a year on the impact of the HIV epidemic in southern Uganda. In this paper we focus mainly on the data from 26 of the 40 who were HIV-positive. While we observed that feelings of depression were frequently experienced by many of the people in our study, the state of ‘being depressed’ was not constant. Participants regularly expressed economic frustration (because of a lack of money to buy food and other commodities including sugar and soap); medical problems (including those related to HIV) as well as old age, the burden of dependents (including concerns about school fees for grandchildren), feelings of sadness and isolation, and a lack of support from others, as well as stigma, whether real or perceived. However, while worries, sorrow and despondent thoughts were reported in many of the interviews across the study, moods fluctuated moving from happiness and hope, to sadness and despair, from month to month. Concerns regarding the psychological wellbeing amongst older people, including those living with HIV and older carers in Uganda deserve greater attention. Grace (aged 72 years) was in despair, her eyesight was now so poor she was having problems lighting her small lamp—she asked her 14 year old granddaughter to help her but, Grace said, ‘she scornfully laughed at me for my failure to light the lamp’. Later in the interview Grace brought out a photograph of the girl’s father, her dead son, the picture showed him laughing, enjoying a big meal. Grace looked at the picture for a long time and then said that this son ‘will never get off my mind.’Grace lives in rural southern Uganda, not far from one of the main towns but her home is very isolated down a long bumpy mud road. She lives with her 90 year old husband who is deaf, blind and incontinent and her orphaned granddaughter. Grace does everything in the home, including cultivating the land and raising animals for their food. They get no material help from anyone. She talks often about making arrangements for the death of herself and her husband. She appreciates the monthly visits of the interviewer for our study to her home, because it gives her someone to talk to and share her worries with.et al.Research from a range of different countries suggests that symptoms of depression are common in older people  Uganda . Less inet al.et al.Leserman  argues tThis study was conducted in 2009–2010 in one peri-urban and one rural area in southern Uganda. The rural site was in Kalungu District, where in 1989 the Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) established a general population cohort to study the epidemiology of HIV. Annual demographic and serological surveys have been conducted with this population for the past 22 years, resulting in a wealth of data on approximately 20,000 people in 5000 households. People living in the study area are largely subsistence farmers who produce small amounts of cash crops such as beans, bananas and coffee. The majority (70 %) of the population is ethnically Baganda, and there is a large representation of immigrants from Rwanda (15 %). About 4 % of the population is made up of immigrants from Tanzania; a mixture of other tribes makes up the remainder. The main local language is Luganda, which is spoken and understood by all the tribes. The community is predominantly Roman Catholic (60 %) with 17 % Protestant and 23 % Muslim. Just over 50 % of the population is under 15 years old. Most households have less than five acres of land but relatively few households are landless. The peri-urban site was in Wakiso, the district that includes Entebbe, where the MRC/UVRI headquarters is based. The MRC/UVRI has conducted a number of studies in Entebbe and the surrounding areas over the past 20 years. This study drew on people involved in some of the earlier research: for example, a study on strategies to reduce the burden of opportunistic infections. Some participants came from The AIDS Support Organisation (TASO) in Entebbe. The ‘peri-urban’ label refers to the site of service provision, not place of residence. Many participants lived in rural areas around Entebbe and were not, therefore, residents of the town. The population in Wakiso district is more mixed than at the rural research site in Kalungu, because people from many different tribes have settled near Entebbe. While there is a strong Roman Catholic presence in the district many other Christian denominations as well as Muslim groups are also represented. Many people in rural areas near the town still practice cultivation as their main form of livelihood, but there are also people engaged in fishing and various forms of trade, as well as formal employment in teaching, health care, and cleaning services.et al.The sample for the quantitative survey consisted of people aged 50 years and over. Five groups were selected, each with 100 participants of whom half were living in a rural area  and half in a peri-urban area (Wakiso). The groups were older people who: have an adult child who died of AIDS; have an adult child who is living with HIV and on antiretroviral therapy (ART); have no child with HIV/AIDS and are not infected with HIV (comparison group); is HIV infected and on ART for at least 1 year; and is HIV infected and not on ART or on ART less than 3 months. In total 510 people were interviewed in the quantitative component: 256 in the rural and 254 in the peri-urban area, 61 % women and 39 % men. The mean age overall was 65 years, but for the HIV-positive groups the mean age was 59. The findings of this study are reported elsewhere  were selected from the quantitative study sample. These participants were aged 60 years and over, in order to focus on people who may be more likely to face the challenges of failing health. Twenty six of these people were HIV-positive and the data from these people forms the main focus of this paper. The 20 rural participants were chosen to faithfully mirror the sample from the quantitative survey sample comprising of the five different groups. However, while eight HIV-positive people should have been included in this sample, the number was only 6 (3 of whom were on ART) because an attempt to get a representative cross-section by age and gender, as well as replacements, slightly skewed the final sample. These 6 HIV-positive people received free care from the MRC/UVRI clinic. There was a larger number of people aged over 60 who were HIV-positive in the peri-urban setting, so the decision was taken to focus on this group in that sampling. Therefore, all 20 peri-urban participants  were HIV positive and receiving free care from The AIDS Support Organisation (TASO) in Entebbe. Fourteen had been on antiretroviral therapy (ART) for at least 1 year, while the remaining 6 were not on ART but were taking cotrimoxazole. A number of these participants had also taken care of children or other relatives who had been sick with AIDS-related illnesses. The 14 HIV-negative participants from the rural area provide for some comparison with the total of 26 HIV-positive participants, 20 of whom were on ART.Many of the participants in both locations had lost supportive children and grandchildren or were worried about losing their children as a result of the HIV epidemic. A few were reliant on care and support provided by grandchildren for whom they were responsible, resulting in different levels of mutual responsibility, support and care. Some of the older people received support from their own children, now adults, and some were reliant upon neighbours to help them get food and water, although this kind of support was not guaranteed. Invariably, the participants had to do as best as they could to support themselves and, for those with a heavy care-giving burden, their grandchildren.Of the 40 participants, 17 were aged 60–69 years, 19 were aged 70–79 years; 4 of them were aged above 80 years. Eleven were married, of whom only 1 was a woman; 21 were widowed. Ten participants (6 men and 4 women) lived alone while others lived with their grandchildren or other relatives. Twenty-five of the participants were ethnic Baganda while 10 were of Rwandese or Burundian origin. The remainder were from other tribes.Seven experienced interviewers  made monthly visits to the 40 participants over a period of 1 year. The interviewers collected a monthly oral diary of each person’s life focussing specifically on the week prior to each interview. This 7-day recall period provided detail for a period that was still relatively fresh in each participant’s memory. An additional interview was conducted specifically to focus on documenting each respondent’s life history.The method of interviewing, a semi-structured extended conversation, was designed to provide qualitative insights into changing family situations and relations, older people’s tasks and responsibilities, visitors and visits, diet and food availability, and their feelings about their health and wellbeing and growing older. The interviews also addressed participants’ hopes, concerns, perceptions, expectations and experiences. The resulting oral diaries provided data on the impact of early life experiences, gender differences and perceptions of support systems; as well as a valuable understanding of the relationship between perceived support and participants’ physical and mental health. The diaries were written up from notes by interviewers (tape recorders were not used due to concerns from some participants about recordings) immediately after each interview. The interviews were conducted in Luganda or, in one case Swahili, known to both participant and interviewer and translated and transcribed into English.In our analysis we are able to cross-reference the qualitative data with data gathered in the quantitative survey because the qualitative sample was drawn from the quantitative sample.The Science and Ethics Committee of the Uganda Virus Research Institute provided ethical approval for this research, and the Uganda National Council for Science and Technology provided overall clearance. Participants found sick at the time of interviews were referred to MRC/UVRI study clinic.While this paper focuses on the findings from the qualitative research, a starting point for discussion on depression and wellbeing is provided by the quantitative data collected from the participants. The quantitative study identified cases of depression according to two methods: a single question, and a series of questions. Firstly, the participants were asked whether or not they had ever been diagnosed with depression. Twenty-two people (4.3 %) in the larger study reported that they had indeed been previously diagnosed with depression MRC/UVRI . HoweverSecondly, participants were asked a series of questions about how they felt during the 12 months prior to the survey, to assess the prevalence of depression that had not been formally diagnosed. Questions included: “Have you had a period when you felt sad, empty or depressed?” and “Have you felt that your energy levels have decreased?” The subjective answers to these questions allowed for screening for depression. It was ascertained that a total of 23 % of the 510 participants  had experienced an episode of depression during the previous year—a significantly higher number than the 4.3 % who reported that they had previously been diagnosed with depression.Of the 23 % of participants who had experienced an episode of depression during the previous year, the quantitative study identified a large gender difference, with depression being far more common among women (28 %) than men (16 %) MRC/UVRI . The stuAs stated above, the quantitative study assessed the prevalence of depression that had not been formally diagnosed by asking a series of direct questions about how the participants had felt during the 12 months prior to the survey . Meanwhile, the qualitative research team took a different approach and were concerned with general circumstances and experiences throughout the year of the qualitative study.While the quantitative study revealed a significant difference between formal diagnosis and actual subjective experiences of depression (4.3 % and 23 % respectively), recounted through a reflection on the previous year, it found no cases of depression amongst the 17 HIV-positive Wakiso participants included in the qualitative study and for whom quantitative data on depression were available. In the rural area, among the 20 qualitative study participants, 9 cases of depression were identified (45 %). These included three men (33 %) and six women (67 %). All these cases were HIV negative and 6 (67 %) were aged above 70 years.Since the research was primarily interested in the direct and indirect effects of HIV/AIDS and anti-retroviral treatment (ART) on the health and wellbeing of older people, and this paper is, more specifically, concerned with the question of despondency and psychological wellbeing, we now examine the possibility of a link between physical health problems and despondency.The examples used in this section are of HIV-positive participants from both the rural and peri-urban sites. They show despondency and feelings of unhappiness attributed to physical health problems (related to ageing as well as HIV) as well as other factors such as financial problems, isolation, loneliness and lack of support. Significantly, experiences and perceptions of all these factors influenced participants’ subjective explanations of the causes of unhappiness, frustration, despondency and even depression. Self-reported health is one example.The quantitative study MRC/UVRI : 19–20 rWe found that self-reporting of health conditions, as well as financial and livelihood hardships, were filtered through specific age- and culturally-related dispositions, with individuals often making pragmatic comments that seem incongruous when considering health complaints expressed in the same interview. As such, it is important to consider the distinction between actual or diagnosed health problems, and self-reported health. There were often significant differences between how a single participant might experience and perceive their health, report their current health condition, and then ‘rate’ their health in a way comparable to the types of responses captured by the quantitative study. For example, 63-year-old Patricia, who had been treated for tuberculosis years earlier, was receiving cancer treatment as well as ART, and also had eye problems. She walked with crutches and had experienced persistent thigh pain since falling down from the steps at her home in January 2008 but had not reported this to the hospital due to fear that treatment would be expensive and that her property would be stolen by her co-wife’s son in her absence . Despite all of these health problems, when asked how she is feeling within the 7-day period before 5 of the monthly interviews, Patricia said that she rated her health quite highly: commenting that she had not experienced any “serious illnesses” or had no “serious sickness”. She said that ART and cancer treatment had caused a great change in her life and she no longer falls sick frequently, and that she was not affected by her age.Shifting perceptions and ratings of health were influenced by the general mood  of the respondent, which had in turn been influenced by a wide variety of factors: food availability and problems or successes with agricultural work; feeling particularly abandoned by a relative; instances of increased support from others; the number of recent funerals attended or the death of a close relative. An example of the shifting perceptions of health is given by the case of Linda, a 70-year-old HIV-positive participant who lived alone and did not have wider family responsibilities. During her first monthly interview she complained of general weakness, fever, poor appetite and diarrhoea. Then, during the subsequent 4 months she reported a pain in her right leg, “painful muscles without fever”, a cough and flu, and yet she said there was “nothing disturbing” her, that she was doing well with her treatments and had “no serious health problems”. She said that ART had greatly improved her health to the extent that she did not feel that health issues affected her wellbeing.Other cases contrasted sharply with hers, and illustrate greater levels of despondency and unhappiness attributed to physical health problems by other participants. A 60-year-old woman in Wakiso, named Joyce, who was not yet on ART because her CD4 count was still above the threshold for treatment, had been prescribed cotrimoxazole. This participant reported feeling weak and experiencing physical pains “constantly attacking” her, preventing enjoyment of life and causing insomnia. She thought a great deal about the “deadly disease, which is never going to cure” and she was worried that she may die at any time.Such feelings did not only occur among women, David, another Wakiso respondent, aged between 60 and 70 years reported that his health deteriorated significantly over the period of the monthly interviews, despite being on ART. During the first interview, he said he was active and had no health problems, but later he reported that bad physical health affected his wellbeing, made him feel unhappy, prevented a “sound mind” and made him “lose peace”.For many participants, deteriorating health was not necessarily complained about as intrinsically problematic, but as instrumentally problematic, affecting many participants’ ability to do agricultural work, provide enough food for themselves and their households, which in turn emphasised to them their isolation when external support was not available. For example, Joyce, the 60-year-old woman described above, said that weakness and physical pain made her conscious that she was approaching a time when she would be unable to do anything for herself. Although ART might sustain Joyce’s health, if in future she received this treatment, she described her most troubling problem as the daily struggle to “upgrade” her life, and her biggest hope was for more money.In contrast with the case of Linda (described above), Joyce was the head of a household which usually included up to six people including her daughter (aged 22), grandchildren, nephews and nieces (aged between 3 and 18 years), and Joyce had many associated responsibilities. When a nephew grew old enough to support himself, she was brought another 3 year-old grandchild to look after. Sometimes Joyce received no visitors and no assistance. Although she did report receiving occasional support  from her son and daughter. She said she could not demand anything more than what they gave voluntarily. The support this grandmother received was invariably offset by obligations and the demands of the household, even at the expense of her own wellbeing. One month she reported being unable to spare money for her own health treatment because she had to pay school fees for a nephew. Financial worries and an unsatisfactory diet led Joyce to think a lot about how she would “get rich”.Joyce worked as a school cook to make an income but had difficulty getting paid; she was also busy with private agricultural activities, but she said that she forced herself to work despite either constant or intermittent sickness or physical pains. A major worry was a lack of a well-established income-generating activity, and these problems, as well as an unsatisfactory diet, were intensifying and created what she described as “mental stress”. While physical health problems affected her ability to maintain agricultural activities, physical health was one of a range of factors that affected her psychological wellbeing.Significantly, Joyce spent a month in prison in 2008, apparently because she severely punished one of the children she was caring for when the child would not do as she was told. This incident might be an indication of the pressure she felt to maintain the household despite the lack of sufficient financial, practical and emotional support, and her inability to cope with her responsibilities. She said, “I suffered in prison”; the interviewer noted that the incident had “left a scar on her heart”.David, the 60-year-old Wakiso participant on ART (introduced above), whose physical health affected his wellbeing and made him feel unhappy, explained that he had to force himself to do agricultural work each day despite bad health in order to earn money and to eat. Sometimes he only had strength to work for an hour, or not at all. Financial problems and loneliness, specifically the need to be financially better off in order to find a wife to look after him, were recurring topics of conversation and a cause of insomnia. David was frustrated because people took advantage of him and did not pay him enough, which, the interviewer noted, is “bringing sorrow to his heart”. This participant consistently fretted about how he lacked money to “get a woman who would make him happy”.namuginga—a pest that eats a sugar cane from the inside while the cane continues to appear intact outside—David seemed very uncomfortable with the awareness that both his poverty and HIV status were obvious to others. This awareness affected his confidence and self-esteem.David lived alone with no family and said that living alone reduced his happiness, and loneliness affected his health, especially when his landlady was away. The landlady, who lived in an adjacent dwelling and neighbours provided some assistance when David was sick, but not when he was well. He said, “There is no one who I can refer to for help”. He said he was less lonely when people visited and chatted with him for a little while, but many villagers greeted him and continued without stopping for a conversation. Describing his own circumstances by using the metaphor of being eaten by A number of participants hoped that ART would transform their lives for the better. For example, the case of Vincent, a 65-year-old fishmonger who was also busy with private agricultural activities. In his first monthly interview, Vincent reported that he experienced backache despite medicine from TASO . However, backache was not mentioned again in any subsequent interview. In the second month he reported that his condition was okay, he had gained weight and his leg pain had reduced. In the third month Vincent reported swollen legs, pain from his knees down to his feet, and general weakness preventing him from doing as much work as he would like. He said this was affecting his wellbeing. Other reported health problems included small, itching and painful spots on the skin, high blood pressure and “terrible flu”. Vincent relied on a walking stick and felt bad when friends were moving at high speed but he could not; he said he had “taken all kinds of drugs” for leg pain, but to no avail, and wished the doctors could put him on ART because “maybe my legs would improve”.Vincent moved between two homes and two wives who looked after him ; some children lived in both homes. Compared with other male participants who lived alone and regularly said that they wanted to find a wife to look after them and to reduce their loneliness, Vincent was not lonely and isolated. However, deteriorating health made his responsibility for two families a considerable burden. Vincent’s wellbeing was affected by physical health problems indirectly, in that health problems were an obstacle to work, which in turn compromised his income and created frustration. However, Vincent did seem to be faring better economically than many other HIV-positive participants. He made two seemingly contradictory statements in one interview: on the one hand, he said that there were “no marked problems” and he “hardly gets any hardships” because he had money and a good life. On the other hand, he said he was depressed because of business problems and because workers had stolen money. Vincent’s “depression” seems to have been a symptom of frustration about his financial situation. He has made many preparations in the hope that his family will survive economically in the event of his death, but believed that his money “will never be enough”. He said he was afraid of dying and leaving his two wives, children and relatives. Vincent said that all his complaints were “pointing to poverty” and that HIV was “becoming a stumbling block”.“[T]he most important thing that pains me and disturbs my mind most is the diet, because if I had a diet which was good I would feel healthier than I do now. […] This continues from day to day with no hope of having somebody to ensure that I feed better”.Some participants did not seem to suffer from unhappiness and despondency as a direct result of their physical health problems. Rather than attributing diet and financial problems to poor health, they attributed poor health to economic and livelihood circumstances. For example, throughout the interview period, a 73-year-old participant named Moses experienced “more or less continuous backache” as well as acute pain or numbness all over his body, including his knee and elbow joints, feet, headaches, and “a sharp pain on the left hand near the armpit”. The only exceptions were in month 2, when he said he was generally feeling well because of cotrimoxazole, and in month 7, when he described his physical health as good despite reporting heaviness in his back and the problems of living with HIV. Moses considered food to be a primary medicine, as hunger may have been causing him pain. Lack of food reduced his strength and the effectiveness of medicines, he said:waragi , so people were always coming and going, preventing any kind of routine. He shared his home with a friend who stole his waragi and became abusive to him and also the neighbours.Moses was owed money, an on-going problem with no resolution in sight, and which caused a great deal of worry and frustration, and contributed to insomnia. He said that he hoped he would feel very happy when he was paid his money. He tried to support himself through his rental property and vegetable cultivation but said his life pattern and lack of money were not at all conducive to good health and wellbeing. He did not have regular meals due to a scarcity of money and because he sold Although Moses did not drink heavily and had tried to avoid drinking, he said he drank in moderation because it allowed him to socialise with others, prevented loneliness, and helped him sleep. Sometimes he experienced insomnia; at other times, bad dreams troubled his mind. The dreams included money-related scenarios. It would appear that financial circumstances were a greater source of anxiety and uncertainty than his physical health problems.For a 73-year-old HIV-positive participant named Agatha, isolation and anxiety over a lack of practical and emotional support were the main causes of unhappiness and despondency. In terms of health, Agatha experienced headaches as well as leg and feet pains, a cough, palpitations, ulcers, epistaxis, toothache, severe neck pain, and an unspecified blood pressure issue. Throughout the research period, she fluctuated between feeling fine for a few days and feeling sick for a few days (expressed on a separate occasion as: “one week she is fine and the other she is sick”). However, Agatha seemed to belittle her health problems, rather than feeling unhappy. She said she does not get sick often, that her life was fairly good, her condition is good, and she felt strong enough to care for herself.Although Agatha sometimes complained of difficulties with household activities due to old age, leg and foot pains, at other times she was able to walk as far as 6 km and was able to work in her garden. She seemed to lament her changing health and increased difficulty with household activities with a degree of pragmatism (“I have to face the present situation and adjust my life”) and described herself as a very strong woman who stands whatever comes her way.In this way, the daily difficulties of living with health problems did not seem to be the cause of any despondency, especially compared to the insights provided by discussions on other topics. Agatha did experience psychological problems—apparently she is “always worried and is in thought” regarding her last days and years, although this anxiety was about loneliness, isolation and lack of support, rather than being directly associated with her health.Agatha seemed quite isolated and did not receive visitors. Passers-by always “branch off to greet her” but did not stay long. She described herself as a very social person, and indicated good relations with the community, but she felt out of place at social gatherings because she thought of her condition “every now and then”. She said she did not associate much with village members because they gossiped a lot; however, she described herself as a ‘consultant’ for all those who want to know about HIV/AIDS in the village.In some cases, the depiction of the causes of despondency and unhappiness was more mixed, even contradictory. Judith, a 67-year-old HIV-positive participant in Kalungu, had been married twice but had no children and lived alone with nobody to assist her. At the start of her participation in this study, Judith received visitors that came to buy alcohol and cigarettes most days; however, after a while she stopped selling alcohol and cigarettes because customers failed to pay her. Also, Judith experienced violence: for example, a drunk male customer assaulted her, leaving her to crawl to her room while others laughed at her; the assault resulted in a back injury and on-going back pain which caused her to lose weight and bend while walking. The interviewer noted that Judith looked “as if she wanted to cry”.When diagnosed as HIV-positive, Judith believed that it was her “time to die”, despite being prescribed ART, because there was no actual cure. She said she had no trusted friend to share the test results with, and that she feared people would “back bite” her when they come to know her status. Similar to David (described above), who seemed very uncomfortable with the awareness that both his poverty and HIV status were conspicuous, Judith said that most of the time her clothes were clean, despite difficulties, but that she was “fearing a rumour to ‘snick’ about her [if] found with dirty clothes”. However, on another occasion, she said that she did not fear even when the community knows that she is HIV-positive as long as she receives treatment.“It was very bad for me not to have a child; otherwise the child could assist me and take care of me. There came a certain time when I wanted drinking water and nobody was around; it took time for me to get out of bed, I crawled, which showed me that I was almost at a point of death and needed help!”Despite her poverty, Judith had a pragmatic faith and seemed to draw much strength and hope from both religion and her health carers. She said that when she was diagnosed as HIV-positive, she “promised to stick to God”; she expressed happiness that she was treated after diagnosis, and that ART had improved her life. She said she was ready for death, which is unavoidable for all human beings whether rich or poor, old or young—“even the Pope in Rome”. She added that she felt no fear of becoming old and prayed to stay for 40 more years. However, there was another side to Judith’s moods and sense of wellbeing. Once, on the verge of tears, she said:Judith used a walking stick to move even from her room to the kitchen to prepare meals. She said that her life had “become weak” and that she had “stopped agriculture activities long ago”. On one occasion, Judith reported having spent a whole day crying because she had no food or even tea. Yet, showing how circumstances can change, in month 12, she said she faced no food-related hardship because friends supported her; only the ‘sauce’ (vegetable or meat to go with a starch) was her problem, as she had no money to buy fish or meat. The interviewer noted: “She almost cried while saying that”.Worries over food affected everyone at some point during the study. Most of the older people depended on one meal a day; others survived on one meal for two or more days. Sometimes when participants said they eat one meal a day, they also ate leftovers for supper or breakfast but the quantities were small and they did not consider this to be a meal. There were also seasonal variations: poorer people experienced exacerbated food shortages for 1 or 2 months each year during the dry season. However, during the study period, the dry spell lasted 3-4 months. Fatuma, a 73-year-old Kalungu participant who lived alone and was HIV positive, said that food was a constant problem. She was entirely dependent on the little that was available from her garden, and only managed to have one meal each day (supper) plus maize porridge for breakfast and lunch. She faced particular hardships in getting food during the dry season, and she said that digging cassava from the dry soil pained her very much. Eighty-year-old Isaac who worked as a cobbler at a trading centre, said he used his meagre earnings to buy meals from a local hotel and, therefore, ate only one meal each day. He liked to go to the trading centre to find people to talk to, and sometimes people around the trading centre fed him when he had no money, which he appreciated.Although some participants regularly complained about health matters, caused by old age as well as HIV, the main factors that negatively affected wellbeing and caused despondency were interrelated problems and worries relating to finances, work, diet, other resource constraints, lack of assistance and support, loneliness, isolation and separation from important relatives. These same factors affected participants who were not HIV-positive. Madina, for example, an 80 year old participant from Kalungu, lived alone in a poorly thatched mud house, and struggled to get enough food to eat. Her daughter had died of AIDS-related illnesses, leaving her to the mercies of her grandson, who, she complained, failed to help her and was waiting for her to die.Of the 40 participants, 26 of them said that their health problems had become an obstacle to their livelihoods, food availability and in turn their wellbeing in general. The transcripts of interviews with 11 participants indicate that their health did not have a significant impact on livelihoods and food availability. The differences between the 26 and 11 participants did not appear to be due to bad or good health, gender, or HIV-status, but were often determined by regular family support, whether or not the participants lived in large households or alone, whether or not they were solely responsible for an extended family of children. It was clear that without family support, many of those 11 participants would find that their health severely hindered their ability to grow food or earn even a small cash income.The quantitative study identified factors significantly associated with depression, including socio-demographic factors , medical illnesses , biological markers (grip strength), and psychosocial factors . However, the qualitative study found that the psychological wellbeing of many participants, who apparently were not depressed according to the quantitative study, seemed to be adversely affected by some of these socio-demographic, medical, and psychosocial factors. Many of the participants regularly expressed economic frustration (because of a lack of money to buy food and other commodities including sugar and soap); medical problems (including those due to HIV) as well as old age, such as severe and ongoing backache, and decreased energy levels resulting in an inability to produce enough food; the burden of dependents including concerns about school fees for grandchildren, feelings of sadness and isolation, and a lack of support from others, as well as stigma, whether real or perceived. However, while worries, sorrow and despondent thoughts were reported in many of the interviews across the year of the study, moods fluctuated with happiness and unhappiness intermingled in many narratives often when older people reflected on the challenges they faced and then, later, recounted the visitors or help that they had been given.et al.Social isolation has been identified as a risk factor for depression in older people in other studies Gutzmann . This ismultidimensional dynamic life force characterised by a confident yet uncertain expectation of achieving a future good which, to the hoping person, is realistically possible and personally significant” . The participants seemed to look to the future, to be able to cling on to hope, even when their circumstances seemed dire. For example, the loss of Grace’s only son and the bad behaviour of her granddaughter drove her to despair but at another time Grace confided that she hoped her granddaughter would change and be more helpful when she grew up. She also hoped, ironically, that her elderly husband would be found to be HIV-positive (he had not been tested) because this would give her access to free medical care for him.Hope is an important concept in our study. Dufault and Martocchio  define het al.et al.For many participants who were on ART and went to clinics for regular check-ups and had contact with a counsellor, their feelings of social isolation seemed to be moderated by this social contact. ART has been shown to have a dramatic effect on the health and well-being of people living with HIV, literally restoring their hope of life (Russell Not surprisingly, the interviewers came to play a part in the participants lives, serving for some as a much needed visitor who was prepared to give them time to talk and reminisce; perhaps helping to alleviate feelings of despondency and isolation. The required social support that lifted the mood of older people in this study population was very often ‘someone to stop and chat’, getting enough to eat and someone to sympathetically treat their many ailments.Attention to the mental health of older people needs to take account of what Schatz and Gilbert  have rec


Members of animal societies compete over resources and reproduction, but the extent to which such conflicts of interest are resolved peacefully (without recourse to costly or wasteful acts of aggression) varies widely. Here, we describe two theoretical mechanisms that can help to understand variation in the incidence of overt behavioural conflict: (i) destruction competition and (ii) the use of threats. The two mechanisms make different assumptions about the degree to which competitors are socially sensitive . In each case, we discuss how the model assumptions relate to biological reality and highlight the genetic, ecological and informational factors that are likely to promote peaceful conflict resolution, drawing on empirical examples. We suggest that, relative to males, reproductive conflict among females may be more frequently resolved peacefully through threats of punishment, rather than overt acts of punishment, because (i) offspring are more costly to produce for females and (ii) reproduction is more difficult to conceal. The main need now is for empirical work to test whether the mechanisms described here can indeed explain how social conflict can be resolved without overt aggression. Understanding how females compete over reproduction in social groups, and why the outcome of female–female competition varies within and between species, have been major themes of research on inclusive fitness and cooperative breeding for the last three decades –5. The fA number of formal theoretical models have been developed to examine how natural selection acts on strategies of reproductive competition in animal societies ,2,23–25.In this paper, we discuss the possible evolutionary causes of these different mechanisms of reproductive control, and review recent theory which helps to understand how female–female competition is manifested in social species. We are particularly concerned to identify conditions and mechanisms which permit reproductive conflict to be settled peacefully, that is, without recourse to destructive or costly acts of harassment, attack, infanticide or forcible eviction. These behaviours can be grouped together as forms of ‘overt aggression’, but may have very different underlying causes. We identify two distinct mechanisms which reduce selection for costly investment in aggression or other acts of violence: (i) destruction competition and (ii) the use of threats. Both these mechanisms are particularly (but not exclusively) relevant to conflict among females, and we focus our empirical attention throughout on female–female conflict. Reproductive conflict models suggest that intrasexual competition among females will have different consequences for selection on morphology and life history compared to males. Our main empirical focus is on social mammals and birds because these are the systems where, for reasons explained below, female reproductive competition seems most likely to be settled without overt aggression.2.N identical players, for reasons of tractability [Models of reproductive conflict examine conflict over limited resources between members of a social group. The term ‘group’ is here used in a loose sense to refer to systems in which there is local resource competition among offspring ,48. We wtability . Here, w(a)et al. [What do we mean by conflict resolution? We define a conflict to be resolved when each competitor behaves in a manner that maximizes its inclusive fitness, given the behaviour of its opponents. That is, we adopt a game theoretical definition  rather et al. , p. 584,(b)V. The direct fitness of player i is denoted iW and is an increasing, diminishing returns function of that player's share ip of the resource (where p ranges from 0 to 1). If the two players are unrelated and have no other ‘stake’ or interest in each other's fitness, then the optimal share for each competitor is simply all of the available resource (a). If the two players are genetic relatives, then the optimal share of the resource for each player may be less than 1 (b). In the latter case, the zone of evolutionary conflict (or ‘battleground’) between the two players is reduced. The width of the zone of conflict gives a simple measure of the ‘scope’ or potential for conflict, that is, the degree to which the interests of the two players diverge. In addition to genetic relatedness, factors such as reciprocity, strong intergroup competition and other forms of mutual ‘interdependency’ [To illustrate the potential for evolutionary conflict between social animals, consider two members of a group, player 1 and player 2, who compete for a share of a resource of value resource a. If thes than 1 b. In theendency’ , can draHowever, the width of the battleground does not necessarily predict the intensity or frequency of overt acts of aggression. What matters is the inclusive fitness returns of effort invested in aggression, which in turn depends on how aggression is assumed to ‘work’. Do animals use aggression directly to extract or appropriate resources from rivals? Does aggression function as a signal to deter rivals from challenging for control of a resource? Is aggression observed only when more subtle forms of social control have failed? To make testable predictions about patterns of social aggression, it is necessary to make an explicit assumption about its precise function, and how players respond to each other's aggressive acts.(c)A fundamental distinction between different conflict resolution modelling approaches is whether they examine the coevolution of ‘fixed’ genetic strategies of conflict, or whether they allow for a degree of real-time behavioural responsiveness or ‘negotiation’ –55. The At their heart, these two types of modelling approaches examine two different ways that natural selection can act on conflict behaviour, but they are not necessarily alternatives. The level of aggression of a particular individual animal may be due in part to selection acting on a baseline ‘fixed’ genetic component, which determines average level of aggression irrespective of the particular social partner with which she is paired; and selection for behavioural responsiveness, which determines how that baseline level is adjusted according to the particular reactions or phenotypic features of that partner. Sealed bid models may therefore be particularly useful to understand the evolution of aggressive or non-aggressive ‘personalities’ and developmental commitment to weaponry, badges of status or other morphological traits that are important in conflict, such as body size. On top of this , negotiation models provide a way to understand social ‘sensitivity’, and the varied forms of dominance interactions, rituals and signals that are widely observed in animal societies, but remain quite poorly understood.We first describe a sealed bid approach to our two player model of social competition, and then outline a sequential (or ‘threat’) model which incorporates behavioural responsiveness into the framework in a simple way. For both the sealed bid and sequential cases, we focus on the conditions where conflict can be resolved with little or no sign of overt conflict. The models make testable predictions about the genetic and ecological conditions that can lead to peaceful conflict resolution. In the discussion, we compare these predictions with empirical data and suggest ways in which the main shortfalls in current knowledge can be addressed.3.x in costly competitive acts to shift the resolution of conflict towards its own optimum. Player 2 can invest effort y to do likewise. In evolutionary (and economic [F. The relative success of player 1 is F1 and that of player 2 is F2 (where F1 + F2 = 1).In this model, we assume that player 1 can invest effort economic –58) modeV is a declining function of effort levels x and y. In the simplest case, we assume that there are no other personal fitness costs of conflict; including these costs does not in any case qualitatively affect the results on which we focus [As we are interested in social competition, we assume that effort invested in conflict decreases the value of a shared resource, or the productivity of a group. Thus, the value of the resource we focus . With thF? Almost all models of evolutionary conflict assume that this function takes the form of a ratio, with a focal individual's effort as the numerator and the mean or the summed efforts of all competitors as the denominator [et al.'s [et al.'s model, player 1's relative success is given by the ratio x/(x + by), where b (<1) allows for an asymmetry between players 1 and 2 in ‘strength’ or the efficiency with which effort invested in conflict converts into reproductive success. In Frank's [N-player model, the relative success of player i is i depends on their effort relative to the mean effort of all players.How is effort invested in conflict likely to convert into success? In other words, what form should we assume for the contest success function ominator . These cominator ,59. For et al.'s  tug-of-wet al.'s  model of Frank's  N-playerx = 0, y = 0 are infinite, and so a situation of mutual peace is unstable. A situation of one-sided peace, where one player invests zero and the other invests positive effort, is also not a stable equilibrium outcome in ratio form models [One of the most important features of ratio form models is that no evolutionarily stable (ES) equilibrium exists where both players invest zero effort. In other words, ‘peaceful’ outcomes of evolutionary conflict are not predicted in this type of model. To see why, imagine a two-player ratio form model in which both players invest zero effort. This cannot be an ES equilibrium because any mutant player who invested an infinitesimally small level of effort would win all the resource. The marginal gains of investment at m models . The con(a)per se. However, destruction competition may apply well to strategies of intersexual conflict such as mate guarding, harassment or the production of seminal toxins [Some types of biological competition, however, do not fit the assumption of ratio form models. Cant  argued tl toxins ,63,64.iF is an increasing function of the effort of player i; and that F1 + F2 = 1). Thus, in mathematical as well as biological terms, contest success functions divide naturally into these two forms.How can we model destruction competition? Conveniently, we can capture the main characteristics of destruction competition using a simple alternative form for the contest success function, in which relative success depends on the difference between the players’ conflict efforts, rather than the ratio of their efforts. In a difference form model, zero investment in conflict does not necessarily bring zero payoff, the distinctive feature of destruction competition that we want our model to possess. In fact, the economist Skaperdas  has showCant  analysedd ranges from zero to infinity and is called ‘decisiveness’; it scales the marginal gains of superior effort invested in conflict. The shape of this function for three values of the decisiveness parameter d is shown in It is easy to see from the denominator that what matters here is the difference in the players' efforts. The parameter dcrit, the outcome is zero conflict effort, despite much potential for conflict. For the model shown in Thus, the model predicts that high relatedness and low decisiveness allow evolutionary conflict to be resolved without any costly or wasteful acts of conflict, for the simple reason that in these circumstances conflict effort does not pay. In biological terms, we can interpret decisiveness in a number of ways. Decisiveness is high in contests of endurance , since 4.x* and y*, respectively. There is no other individual variation in underlying quality or strength, so there is no need for players to observe and be responsive to changes in each other's behaviour [The sealed bid approach described above assumes that, at the ES equilibrium, the population consists of pairs of identical player 1 ‘types’ and player 2 ‘types’ who invest ES efforts ehaviour ,67,68. Tehaviour . Naturalehaviour .p of the resource, which is observed by player 1 before she decides on her response. This sequential structure opens the door to the use of threats to influence behaviour. Thus, player 1 may threaten to inflict a cost on player 2, if player 2 claims more than a threshold share of the resource pcrit. For simplicity, we will assume in this model that only player 1 has the power to exercise a threat, so in this respect she can be thought of as socially dominant to player 2. We further assume, for simplicity, that player 2's claim on the resource is cost free, unlike the sealed bid model above in which the share  of player 2 depends on how much she and her opponent invest in costly conflict. The assumption of cost-free claims is not critical to our arguments: Cant & Johnstone [x and y, but both players can respond by exercising a threat to break up the group if their share of the resource drops below a threshold level.The simplest way to incorporate responsiveness of this type is to move away from the assumption of simultaneous sealed bids, and instead assume that the interaction consists of a sequence of two steps: player 2 claims a share ohnstone  show howpcrit if player 2 ‘believes’ that player 1 will in fact carry through on this threat, i.e. if the threat is credible (a). Credibility is a key issue here because exercising a threat  may involve some cost u to player 1, so the question arises as to why player 1 would act in a way that involves an immediate cost to her fitness. There are a number of biological mechanisms that can render a threat credible, despite a cost u. First, even in a one-shot interaction, player 1 could be selected to carry out the costly punishment if player 2's claim on the resources is so far over pcrit that the costs of allowing the claim are greater than u. Second, in repeated interactions the cost u may be repaid later because carrying out the threat trains player 2 to exercise more restraint in subsequent rounds of the interaction. Third, if the threat is an ‘exit threat’, such as threatening to leave or evict the other player, the threat can be credible if it allows player 1 to avoid further exploitation and assort with a more cooperative partner in future (i.e. one that claims less than pcrit) [u is repaid, so all of the threatened actions are forms of ‘self-serving’ punishment [et al. [u (i.e. mechanism 2 above); and to refer to punitive acts as ‘sanctions’ when the cost u is repaid in other ways (e.g. mechanisms 1 and 3 above).Player 1's threat can deter player 2 from claiming more than credible a. Credibn pcrit) . Note thnishment . Raihani [et al.  prefer tWhen behaviour is shaped by threats, the degree to which competition is manifested as overt aggression or acts of conflict depends on the effectiveness of the threat at inducing pre-emptive restraint or cooperation in a social partner. Where a threat is effective it rarely needs to be carried out, so effective threats can resolve conflict with little or no overt sign of aggression. Two examples help to illustrate this point. First, some coral-dwelling fish form regular size hierarchies with a more or less constant size difference between ranks ,30–32. E(a)pcrit and no more, and the threat will never be exercised. This provides one explanation for how conflict can be resolved without any observable aggression. A more interesting  situation arises if the players have incomplete information about key aspects of the competition. Two types of uncertainty can be expected to affect the degree to which conflict is manifested as aggression: (i) uncertainty about the location of threat thresholds and (ii) uncertainty about the target of punishment. The latter form of uncertainty is particularly important for threats of policing or infanticide, and for threats directed against multiple recipients.Where there is complete information on both sides, player 2 will claim up to pcrit. In a repeated interaction, this information could be gained from trial-and-error learning, that is, player 2 could make a given claim p′, and, depending on whether the threat is triggered, raise or lower this claim in an attempt to approach the threshold pcrit. This kind of trial-and-error learning is more likely to occur where the impact to player 2 of triggering player 1's threat is small . For example, in insect societies, the impact to a reproductive worker of losing an egg is very small, so threats of egg destruction are unlikely to deter workers from breeding. Indeed, in some social wasps and bees, a proportion of workers produce eggs even when these are almost certain to be destroyed [Considering the first type of uncertainty, player 1's threat can only be effective if player 2 knows where the threat threshold lies, i.e. the value of estroyed . By contestroyed  or goby estroyed ,29 approAn alternative means to reach a behavioural settlement without triggering the threat is for both parties to communicate, to establish the location of the threat threshold. However, since player 1 has an incentive to exaggerate her willingness to exercise a threat, signals by player 1 conveying information about the location of the threshold may need to be costly to ensure their honesty . For exapcrit has been exceeded. For example, suppose that the punishment involves killing player 2's offspring rather than attacking player 2 herself. Cant et al. [s player 1 kills the offspring of player 2, with probability (1 – s) she kills her own offspring. If both females breed and raise two offspring, each player obtains a fitness payoff of 1 − k (where k < 1) to reflect competition among the offspring. Cant et al. [k + ic < s < 1 − bc, where ci is the cost to player 1 of carrying out infanticide, and bc is the cost to player 2 of producing an offspring. If s lies below the lower bound, the threat of infanticide is not credible: player 2 will certainly breed and player 1 will refrain from infanticide because her ability to distinguish the maternity of offspring is too poor. If s lies above the upper bound, the threat of infanticide is sufficient to deter player 2 from reproducing in the first place, so again no infanticide will occur. Note that as offspring become more costly (i.e. as bc increases), as the cost of competition diminishes (i.e. as k decreases) and as the cost of infanticide grows (i.e. as ic increases), the zone of infanticide shrinks. The model predicts that variation within and across species in the costs of cobreeding (k) and the costs of producing offspring (bc) determine the extent to which threats can be effective at suppressing reproduction among subordinates and the ease with which subordinates can escape from suppression . Becaternity .The ability to target threats accurately plays a similar role in determining the effectiveness of threats in groups greater than size 2. In a pairwise interaction , in bioOf the two modelling approaches described above, which model or combination of models applies best to a given biological system depends on the degree to which it pays to be socially sensitive. At one end of a continuum, we can imagine situations where there is no selection for behavioural responsiveness because the consequences of claiming a resource, or producing offspring, are highly predictable. For example, in colonies of naked mole rats, subordinate females never reproduce in the presence of the dominant female (or ‘queen’). Let us hypothesize that this is because a subordinate that reproduces is guaranteed to suffer a net fitness cost from breeding, owing to the dominant's capacity to kill her young. In these circumstances, negotiation is not required for the subordinate to make an adaptive decision to exercise reproductive restraint, and so there would be no selection for fine-scale behavioural tuning of reproductive behaviour in response to the credibility of the threat of infanticide. As subordinate females may simply be hard-wired to inhibit ovarian function in the presence of the queen, we could in principle use a sealed bid model to try to understand why the outcome of reproductive conflict is a complete lack of subordinate reproduction and the consequent monopolization of resource by the dominant. Our destruction competition model suggests that this is an example of one-sided peace, as only the dominant invests any effort into maintaining her monopoly , and tha(a)As we demonstrate above, where dominants are sufficiently capable of disrupting or punishing subordinate reproduction, selection may favour the evolution of pre-emptive reproductive restraint among subordinates given the threat of such action ,45,79–84(b)per se (prior to reproduction) and disrupting or punishing it instead [In order for dominants to induce reproductive restraint using threats, they must first be able to detect subordinate reproduction or the fertility that underpins it . In scen instead . Where s instead : (i) theThe impact of a threatened action may be insufficiently high to induce restraint either because of inherent limitations of the action itself  or bDominants may also suffer constraints on the accuracy with which they can target either reproductive transgressors or their young, potentially due in part to selection for counterstrategies among subordinates ,102. As pcrit above) may markedly impact whether threats induce restraint [pcrit = 0 (i.e. the dominant takes action whenever a subordinate breeds) this may greatly facilitate the evolution of restraint, as simple fixed-response rules could conceivably evolve whereby subordinates invariably exercise restraint without a need for behavioural negotiation . Given the high incidence of cooperative societies with complete reproductive skew, scenarios where pcrit ≈ 0 and threats are effective (so simple rules for restraint have evolved) might frequently account for the peace that characterizes such societies [Finally, the information available to both the dominant and subordinate about the scale of the threat and, most importantly, the threshold level of reproduction that will trigger it . As. Aspcrit produce b. Given ocieties ,84,87,90pcrit > 0 the situation becomes markedly more complicated mechanistically, as breeding without triggering punishment would now demand the ability to both establish pcrit and tailor reproductive output accordingly. Where reproduction is achieved via frequent small investments, as is often the case for egg laying in social insects, for example, this might conceivably be achieved as envisaged in the negotiation model above, with workers incrementally adding eggs to the queen's brood until threatening signals are received (indicating that pcrit is being approached and that egg laying should cease). Similarly, the incremental nature of growth may have facilitated the evolution of growth restraint in response to threats in fish size hierarchies [pcrit before they have already exceeded it. Even where pcrit is sufficiently large that one subordinate could breed, where multiple subordinates are present selection may favour a lack of restraint by many [pcrit varies over time. For example, dominant female meerkats evict subordinates and kill their young when pregnant themselves (pcrit = 0), but tolerate subordinate reproduction when not pregnant (pcrit > 0) [pcrit = 0) or not (pcrit > 0) by the time the subordinate gives birth. Such inescapable uncertainty regarding the future value of pcrit  but subordinates cannot incrementally add offspring to the dominant's brood or guarantee breeding asynchronously, the informational challenges entailed in determining pcrit (or in some cases predicting it) may frequently preclude the peaceful resolution of conflict via threats.By contrast, when rarchies ,29. Howerit > 0) ,96,110. rit > 0) , but thepregnant ,96,110. (c)While theoretical models of reproductive sharing have typically considered it a product solely of conflict between dominants and subordinates ,4,88, emAppreciating that any threat of action by the dominant will act in concert with such non-punitive mechanisms to devalue a subordinate's expected payoff from breeding, is central to understanding when threats will be sufficiently effective to yield reproductive restraint. This is because when such non-punitive mechanisms strongly devalue a subordinate's expected payoff from breeding, even weak threats of action may be sufficiently effective to induce restraint. Specifically, the threshold levels of threat impact, accuracy and perception (see above) that are required to induce reproductive restraint will be markedly reduced. Placing this in the context of restraint models  their impact, accuracy and perception and (ii) the extent to which reproductive payoffs are also devalued by non-punitive mechanisms, may allow one to predict differences between taxa or classes of individual in their propensity to resolve conflict peacefully. For example, we echo Young et al.  in suggeet al. ,86,96, ret al. ,120,121.et al. ,121–123.et al. .per se (rather than non-punitive mechanisms) in generating such peaceful reproductive outcomes. In the many peaceful societies where subordinates never attempt to breed, or where natural instances of subordinate reproduction might conceivably have been ‘permitted’ by the dominant (e.g. due to a transient rise in pcrit), the punitive actions of dominants that may routinely enforce restraint might never be observed under natural conditions. Attempts to test a role for threats by then removing the dominant may rarely provide conclusive support, as the expected reproductive upregulation among subordinates [e.g. per se. Ultimately, the only compelling way to test a role for threats in generating reproductive skew is to experimentally force subordinates to breed at super-normal levels with a view to eliciting the predicted contingent responses of dominants (see [Despite the potential importance of threats for the peaceful resolution of reproductive conflict, there remains little direct evidence to date that reproductive skew is indeed enforced by threats ,80,84,85tes e.g. ,126 mightes e.g. ,127,128,nts (see  for justnts (see ,80.


There are large amounts of unstructured, free-text information about quality of health care available on the Internet in blogs, social networks, and on physician rating websites that are not captured in a systematic way. New analytical techniques, such as sentiment analysis, may allow us to understand and use this information more effectively to improve the quality of health care.We attempted to use machine learning to understand patients’ unstructured comments about their care. We used sentiment analysis techniques to categorize online free-text comments by patients as either positive or negative descriptions of their health care. We tried to automatically predict whether a patient would recommend a hospital, whether the hospital was clean, and whether they were treated with dignity from their free-text description, compared to the patient’s own quantitative rating of their care.We applied machine learning techniques to all 6412 online comments about hospitals on the English National Health Service website in 2010 using Weka data-mining software. We also compared the results obtained from sentiment analysis with the paper-based national inpatient survey results at the hospital level using Spearman rank correlation for all 161 acute adult hospital trusts in England.P<.001 for all). We observed mild to moderate associations between our machine learning predictions and responses to the large patient survey for the three categories examined .There was 81%, 84%, and 89% agreement between quantitative ratings of care and those derived from free-text comments using sentiment analysis for cleanliness, being treated with dignity, and overall recommendation of hospital respectively (kappa scores: .40–.74, The prediction accuracy that we have achieved using this machine learning process suggests that we are able to predict, from free-text, a reasonably accurate assessment of patients’ opinion about different performance aspects of a hospital and that these machine learning predictions are associated with results of more conventional surveys. Understanding patients’ experience of health care is central to the process of providing care and is a fundamental pillar of health care quality ,2. TradiOutside health care, natural language processing of large datasets, including sentiment analysis and opinion mining, has been critical to understanding consumer attributes and behaviors, for example, in election forecasting ,8. SentiThe Information Strategy for the National Health Service (NHS) in England states that sentiment analysis of data could be a novel source of information  that wouWe applied data processing techniques to all the online free-text comments about hospitals on the NHS Choices website in 2010. Our purpose was to test whether we could automatically predict patients’ views on a number of topics from their free-text responses. A machine learning classification approach was chosen in which an algorithm “learns” to classify comments into categories from a given set of examples, using open-source Weka data mining software. This software has been extensively used in previous research and provides accurate classification results, including in health care -15. To tThe machine learning approach had two components: (1) pre-processing, in which data from patient comments are split into manageable units to build a representation of the data , and (2)P<.001.In the “bag-of-words” approach, the total body of words analyzed (known as the corpora) is represented as a simplified, unordered collection of words . For thiA technique called “information gain” was used to reduce the size of the bag-of-words by identifying those words with the lowest certainty of belonging to a given class, and then removing them—this is an approach to feature selection . This imF measure , the Receiver Operating Characteristic (ROC), and the time taken to complete the task were calculated. To reduce computing processing time of the classification, we limited the words in the learning process to the top 10,000 words by frequency. All text was converted to lower case, and we removed all punctuation. Typographical errors and misspellings were not corrected.A number of different technical approaches can be taken to classification in machine learning. We applied four different methods, to see which gave the quickest and most accurate results: (1) naïve Bayes multinomials (NBM) , (2) decTo obtain a score to predict sentiment analysis against, patient ratings left on the NHS Choices website on a Likert scale were converted into simple categories, either positive or negative about cleanliness and dignity, to simplify the prediction task. The website presents patients with five options to rate the cleanliness of a hospital: “exceptionally clean”, “very clean”, “clean”, “not very clean”, “dirty”, and “does not apply”. In this analysis, the first three options were grouped into a “clean” class and the “not very clean” and “dirty” into a “dirty” class. The website also asks patients to rate whether they were treated with dignity and respect by the hospital staff, with the options being “all of the time”, “most of the time”, “some of the time”, “rarely”, and “not at all”. Again, the first three options were grouped, in this case into a “more dignity” class and the “rarely” and “not at all” into a “less dignity” class. Finally, the NHS Choices website asks all patients whether they would recommend the hospital or not.Having calculated the accuracy of our prediction algorithm, the results of the sentiment analysis were then compared with the national inpatient survey results for 2010. This is an annual national survey of randomly selected patients admitted to NHS hospitals in England, similar to the HCAHPS survey in the United States. The 2010 survey covered all 161 acute hospitals with adult services in England, involving 60,000 respondents nationally (response rate 50%). Patients were contacted via post between September 2010 and January 2011 if they had received overnight care in hospital in 2010 . This suThere was agreement between the patients’ own quantitative rating of whether they would recommend their hospital and our prediction from sentiment analysis between 80.8% and 88.6% of the time . Of note, all algorithms tended to be worse at predicting cleanliness and SVM in particular. This may represent the limited language around cleanliness compared to the other opinions examined, or the more skewed results, with higher number of negative ratings.P<.001 for all). We found significant, weak to moderate associations between machine learning predictions using NBM and quantitative responses from the national inpatient survey for the three categories examined: cleanliness, dignity, and overall recommendation   see . Rank coOur results reinforce earlier findings that sentiment analysis of patients’ online comments is possible with a reasonable degree of accuracy  and thatSentiment analysis via a machine learning approach is only as good as the learning set that is used to inform it. By taking advantage of a complete national rating system over several years, we have been able to use many more ratings in this learning set than in other studies. Indeed, our learning set was more than 10 times larger than earlier work . MoreoveOnline comments left without solicitation on a website are likely to have a natural selection bias towards examples of both good and bad care. It is likely that these online reviews are contributed more by those in particular demographic groups including younger and more affluent people . FurtherFurther research is needed to improve the performance of sentiment analysis tools, extending the process to other forms of free-text information on the Internet and exploring the relationships between views expressed by patients online and clinical health care quality. For example, several technical components might be added to improve the process, including the consideration of higher number n-grams (longer phrases) and refining contextual polarity (understanding what a word or phrase means given its context in a sentence). It would also be useful to compare the relatively simple techniques used in this analysis against other platforms and tools used for the sentiment analysis and opinion mining process, for example WordNet Affect  and SentLarge amounts of data about the use of services are collected in digital form. An important strand of this is consumer opinion and experience. Today, many people express their views and share their experience of goods and services via the Internet and social media. Such data, converted to information, are essential in improving services, facilitating consumer choice and, in some sectors, exploring public accountability and value in the use of taxpayers’ money.By its nature, the information is highly personalized, idiosyncratic, and idiomatic. However, if it is to be useful, it must be analyzed in ways that are not solely reliant on someone reading individual contributions  nor on pre-structured responses necessary to allow aggregation. A solution to the challenge of “big data” is to find automated methods for analyzing unstructured narrative commentary, which is a potentially rich source of learning. In this respect, health care is no different to many other industries although it has perhaps been slower than other sectors to recognize the importance of it.As our confidence in techniques of data mining and sentiment analysis grow, information of this sort could be routinely collected, processed, and interpreted by health care providers and regulators to monitor performance. Moreover, information could be taken from a number of different text sources online, such as blogs and social media. If this information could be harvested from these locations and then processed into timely and relevant data, it could be a valuable tool for quality improvement. We have previously suggested that as the usage of rating websites, social networks, and microblogs increases ,4, this This work demonstrates that sentiment analysis of patients’ comments about their experience of health care is possible and that this novel approach is associated with patient experience measured by traditional methods such as surveys. This work adds to a growing body of literature opening up a new understanding of the patients’ point of view of care from their postings online—on social networks, blogs, and rating websites. Although at an early and experimental stage, it presents future possibilities to understand health care system performance in close to real time. Bates and colleagues have described the confluence of patient-centered care and social media as a “perfect storm” that is likely to be of major value to the public and to health care organizations . These e


Several studies suggest that referential choices are influenced by animacy. On the one hand, animate referents are more likely to be mentioned as subjects than inanimate referents. On the other hand, animate referents are more frequently pronominalized than inanimate referents. These effects have been analyzed as effects of conceptual accessibility. In this paper, we raise the question whether these effects are driven only by lexical concepts, such that referents described by animate lexical items  are more accessible than referents described by inanimate lexical items , or can also be influenced by context-derived conceptualizations, such that referents that are perceived as animate in a particular context are more accessible than referents that are not. In two animation-retelling experiments, conducted in Dutch, we investigated the influence of lexical and perceptual animacy on the choice of referent and the choice of referring expression. If the effects of animacy are context-dependent, entities that are perceived as animate should yield more subject references and more pronouns than entities that are perceived as inanimate, irrespective of their lexical animacy. If the effects are tied to lexical concepts, entities described with animate lexical items should be mentioned as the subject and pronominalized more frequently than entities described with inanimate lexical items, irrespective of their perceptual animacy. The results show that while only lexical animacy appears to affect the choice of subject referent, perceptual animacy may overrule lexical animacy in the choice of referring expression. These findings suggest that referential choices can be influenced by conceptualizations based on the perceptual context. Throughout the languages of the world, the influence of animacy turns up in numerous linguistic choices. For example, animate entities are more likely to be chosen as the subject or the topic of a sentence than inanimate entities  or a full noun phrase (“the girl”). These effects are generally explained as effects of conceptual accessibility . For example, entities such as machines and vehicles, or collectives such as companies and organizations, are treated linguistically as more animate than objects like books and tables linguistic studies on animacy also treat the conceptualization of entities only implicitly, presupposing an animate representation for an animate lexical item , and an inanimate representation for an inanimate lexical item . For example, Prat-Sala and Branigan  assume tHowever, it is clear that people do not always assign the same degree of animacy to the same  concepts. Like discourse salience , this is something that can vary with context. Notably, in some contexts people can conceptualize usually inanimate entities as animate. In cartoons or fairy tales, for example, inanimate entities or animals are often anthropomorphized. This also happens in real-world contexts, as when someone says “The tree wants to catch me” for a tree with branches sticking out like arms. The reverse, treating animate entities as inanimate, is theoretically also possible, although this may be less likelydance). Within such contexts, a normally well-formed utterance such as “The peanut was salted” became more difficult to process. This suggests that people can easily accommodate to contexts in which normally inanimate objects are presented as animate, and that these objects are treated as fully animate from that point on. This makes it clear that the classification of concepts according to their lexical-semantic animacy should be distinguished from contextually inferred animacy , and the perceived animacy based on the referent’s movements  in Dutch spoken language production. That is, we investigate whether lexically inanimate referents that are conceptualized as animate and lexically animate referents that are conceptualized as inanimate are different from the congruent cases with respect to referential choices. We examine both the choice of referent (which entity is referred to as the subject) and the choice of referring expression (use of pronouns and full noun phrases).The question we ask in this paper is how lexical-semantic animacy and contextually driven animacy interact in determining referential choices in language production. To address this question, the present study investigates the interplay between the animacy associated with lexical concepts . The animate and inanimate animations were paired, such that for each animate animation there was another animation featuring the same objects but in which the target figure moved in an inanimate way. An example of an animate stimulus item is given in Figure padvinder “boy scout”) or inanimate . The animate and inanimate labels were matched (across items) for frequency and number of characters. The complete list of lexical labels can be found in Table Each target figure was given a linguistic label (in Dutch), either animate  = 114.48, p < 0.001, MSE = 1.88).The animations  were pretested for perceived animacy of the target referent in a perception study. Eight participants were asked to rate the target referent in each of the animations for animacy on a seven-point Likert scale, with one being “clearly lifeless” and seven being “clearly alive”  The competitors could be referred to in any way they wanted. To ensure lively retellings, participants were further instructed to retell the animations “in a fanciful manner, as if telling it to a child.” The experiment started with three practice trials, after which any remaining questions could be asked. The experiment leader gave only minimal feedback during the experiment . There were no further interactions between participant and experiment leader while the experiment was running. It took about 25 min to complete the experiment.Crossing the factors lexical animacy and perceptual animacy resulted in a 2  × 2  within-participants and within-items design. Participants were randomly assigned to one of four lists, which were created such that from a given item each condition occurred on a different list. The items were presented in a random order. The same order was used across all lists.zij “she”), reduced pronouns , demonstrative pronouns , and zero anaphora . Henceforth, we will use the term “pronoun” to refer to all these types of referring expressions. If there was more than one clause describing the action, we only coded the first one. Trials in which the transitive action was not described were excluded from analysis. In addition, we excluded trials in which reference was made to a person or object that was not present in the animation, since this could have altered the interpretation of the referent’s animacy, as well as its discourse accessibility. Finally, we excluded trials in which the target figure was referred to with an indefinite NP , referred to with a proper noun , or not referred to at all. In all, 96 cases (19.0%) were removed. We controlled for discourse salience by coding whether the target figure was mentioned in the sentence directly preceding the clause under consideration, and if so, in what grammatical function.The data from one participant were discarded, because this person retold the animations while watching them instead of afterward. The data from the other participants were coded by the first author. Uncertainties were resolved through discussion with the other authors. First, all stories were divided into fragments containing descriptions of the three episodes . We focused on the descriptions of the transitive action, since these were the fragments that were expected to show most variation in choice of referent for the subject position and choice of referring expression. Next, the fragments were coded for whether the target figure was made the subject of the critical clause (referent choice), and whether the target figure was referred to using attenuated expressions (choice of referring expression). We coded all grammatical subjects of both main and subordinate clauses as “subject,” and everything else was coded as “object.” We defined attenuated expressions as all referring expressions that were not full noun phrases. These included full pronouns , and for the cases in which the referent was not mentioned in the directly preceding sentence (n = 124)p < 0.05. The difference between lexically animate and inanimate referents that were discourse salient was not significant, β = 0.74, SE = 0.45, p = 0.10. Again, perceptual animacy was non-significant in both data sets, β = 0.42, SE = 0.47, p = 0.37 and β = 0.30, SE = 0.46, p = 0.52, respectively; interactions: β = 0.70, SE = 0.91, p = 0.44 and β = −0.03, SE = 0.91, p = 0.97, respectively.To examine whether the effect of lexical animacy was confounded by the salience of the target figure in the discourse, we performed separate analyses for the cases in which the referent was mentioned in the directly preceding sentence , and one for the cases in which it was not mentioned (n = 124). The results, presented in Figure p = 0.14; perceptual animacy: β = 0.31, SE = 0.62, p = 0.62; interaction: β = −0.05, SE = 1.20, p = 0.97). However, when the referent was discourse non-salient , perceptual animacy had a significant effect on the choice of referring expression, β = 1.35, SE = 0.47, p < 0.01: more pronouns were used when the referent was perceptually animate. The effect of lexical animacy was no longer significant, β = 0.66, SE = 0.46, p = 0.15, suggesting that this factor may indeed be partly confounded with discourse salience  and non-subject position (n = 56). The results, presented in Figure p < 0.01: more pronouns were used when the referent was perceptually animate. There was no effect of lexical animacy, β = 0.22, SE = 0.34, p = 0.51, and no interaction, β = −0.91, SE = 0.68, p = 0.18. Although Figure p = 0.24. The same held for lexical animacy, β = 0.99, SE = 0.67, p = 0.14. There was no interaction, β = 0.67, SE = 1.33, p = 0.62. Again, these patterns suggest a confound of discourse salience/grammatical function with lexical animacy, but not with perceptual animacy.We also investigated whether the grammatical function of the referent in the current sentence showed the same confound. To this end, we performed separate analyses on referring expressions in subject position (ion n = 5. The resion n = 5. The resde padvinder duwt de pestkoppen weg “the boy scout pushes the bullies away” than they were to say de steen duwt de pestkoppen weg “the stone pushes the bullies away” (in which case sentences such as de pestkoppen worden weggeduwd door de steen “the bullies are pushed away by the stone” were more frequent)The results of Experiment 1 showed differential effects of the two types of animacy manipulations. Firstly, in descriptions of the transitive event in the animations, which involved an interaction between the target figure and the two competitor figures, the target figure’s lexical animacy, but not its perceptual animacy, influenced whether it was mentioned as the subject of the sentence or not. For example, participants were more likely to say hij duwt ze weg “it pushes them away” than they were to say de steen duwt ze weg “the stone pushes them away,” when the referent was an animate moving stone. Again, this effect was confined to the cases in which the referent was discourse non-salient; when the referent was discourse salient, participants used pronouns almost exclusively, masking any effects of animacy. In addition, the effect of perceptual animacy was also confined to the cases in which the referent was the subject of the current sentence, suggesting that the environments in which perceptual animacy becomes relevant are cases of topic shift. Although pronominalization of lexically animate referents was also somewhat more frequent than pronominalization of lexically inanimate referents, this difference was not significant when controlling for discourse salience, suggesting that the effect of lexical animacy may be partly indirect, i.e., lexically animate referents are more likely to be subjects, and this in turn increases pronoun use. These findings show that the choice of referring expression can be influenced by factors induced by the non-linguistic context, such as perceptual animacy. Surprisingly, the effect of perceptual animacy was equally large in the lexically animate and lexically inanimate condition, suggesting that lexically animate referents can as easily be conceptualized as inanimate as lexically inanimate referents can be conceptualized as animate.Secondly, the choice of referring expression to refer to the target figure in the transitive action seemed to be affected by perceptual animacy: more pronouns were used when referents were moving in an animate way, independently of their lexical animacy. For example, participants were more likely to say In Experiment 1, we tried to manipulate perceptual and lexical animacy independently. The results suggest that the two factors affect choice of referent and choice of referring expression differently. In the choice of referring expression, perceptual animacy seems to be a stronger cue for accessibility than lexical animacy, at least when discourse salience is low. Although lexical animacy does not seem to be completely overruled, this finding is in line with Nieuwland and van Berkum’s  findingsIt is possible, however, that the lexical items influenced perception in the experiment, and that therefore the two factors were not independent. For example, while an animation of a circle bouncing in a very regular manner is likely to be interpreted as inanimate movement , calling the circle a “prince” may encourage the viewer to find an interpretation of the movement that matches the animacy of the lexical item. In this example, one could come up with a story about a prince jumping on a trampoline (and some participants did). Similarly, a circle trying to climb up a slope might look very animate-like, but calling the circle a “stone” may cause the viewer to come up with an interpretation in which the stone was pushed with such force that it could withstand gravity and roll upward. This makes it unclear whether the factor perceptual animacy really measured what it should measure, namely the impression of animacy people would get from purely perceptual features, i.e., movements. Experiment 2 was set up to deal with this potential complication.Experiment 2 was similar to Experiment 1, except that we replaced the lexical labels by nonsense words. These words were chosen in such a way to avoid intuitions about the animacy of the word as much as possible. In this way, we expected to minimize the chance that the lexical labels would influence the interpretation of the movements, and to get a clearer picture of the effects of perceptual animacy on referential choices.Fifteen undergraduate students from Tilburg University participated in this study as speakers. Another 15 naive participants acted as addressees. Ten speakers and nine addressees participated for course credit; the others volunteered. All gave their consent to the use of their data. None of them had participated in Experiment 1.daptinder from padvinder (“boy scout”). Together with a number of real words, these constructed words were entered into a pretest in which nine participants indicated for each word whether they knew the word or not, and if not, to what degree they thought the word could refer to a person, an animal, or a thing. Participants marked their answers on five-point Likert scales . Eight nonsense words that were indicated as “unknown” by all participants, and had average scores around the middle of all three scales were selected for the present experiment. As in Experiment 1, they were presented together with the target figure just before the start of each animation. To ensure that the labels would be interpreted as nouns referring to the target figures, the labels were preceded by the phrase dit is een “this is a.” A list of all nonsense words can be found in Table The animations were identical to those used in Experiment 1. However, instead of real words, the lexical labels consisted of nonsense words. These words were constructed by altering the real words from Experiment 1, while keeping the length in characters and the number of syllables the same  because either the transitive action was not described, or the given lexical label was not used.p = 0.36. Random slopes were not included, since they did not improve the model’s fitFigure p < 0.05. Random slopes were not included, since they did not improve the model’s fitFigure The aim of Experiment 2 was to exclude the possibility that the perceived animacy of referents is influenced by the animacy of their lexical descriptions. By using nonsense words for which people have no strong intuitions about animacy, we controlled for this possible influence. The results largely confirmed the results of Experiment 1. An effect of perceptual animacy was found on the choice of referring expression in the descriptions of the transitive action. Here, perceptually animate referents were more likely to be pronominalized than perceptually inanimate referents. As before, perceptual animacy did not affect the choice of whether the referent was placed in subject position. These findings again suggest that perceptual animacy, a factor that is dependent on the visual context, can influence the choice of referring expression.This study was conducted to investigate whether perceptual animacy of referents influences referential choices, and how this interacts with lexical animacy. Firstly, the results of Experiment 1 confirm that lexical animacy affects the choice of referent for the subject position: lexically animate referents were more likely to be mentioned as the subject of a transitive sentence. This is in line with research indicating that animacy affects grammatical function assignment . Although these cases might be errors, they were confined to the lexically animate-perceptually inanimate condition, suggesting that conceptual information associated with the lexical item was overruled by a different conceptualization. However, given the gradual nature of animacy  with inanimate movement, such as “fall,” “bounce,” and “slide,” there were also a few cases in which objects were referred to with pronouns of which the gender did not match with the noun (e.g., using  Comrie, , most obThese results have several theoretical implications. First of all, they suggest that which entity becomes the subject of the sentence is affected by the animacy of the lexical items, but not by the conceptualization of the entity based on perceptual cues. This seems inconsistent with a conceptual accessibility account of linearization (e.g., Bock and Warren, In addition, Van Nice and Dietrich  found thA second implication of our findings is that the choice of referring expression can be influenced by non-linguistic, perceptual information. This is unexpected under an account in which the choice of referring expression is only determined by local discourse factors, such as givenness, grammatical function, and topichood (e.g., Ariel, Combining our two main findings, a pattern emerges that seems contradictory: whereas a referent’s perceptual animacy can override lexical animacy in determining the choice of referring expression, this does not happen in the choice of referent for the subject position. This is not in line with accounts of referent accessibility in which the choice of referent for first mention and the choice of referring expression are both dependent on the conceptual accessibility of mental representations (e.g., Arnold, An explanation for the apparent contradiction may lie in the task-dependent effects outlined above. While the choice of referent and the choice of referring expression may both be influenced by the referent’s extra-linguistic conceptual accessibility, in the case of choosing a referent for the subject position this process may receive competition from the animacy of the lexical items when these are already given. That is, the presentation of a lexical item activates the corresponding lexical concept, which may boost the speed of retrieval of the lexical item in production (e.g., Bock and Irwin, per se, we cannot exclude the possibility that perceptual animacy does have an effect on linearization independently of grammatical function, as has been suggested by several studies (e.g., Branigan and Feleki, However, since we investigated the number of subject references, and not first mention Still, it is not clear how our finding that perceptual animacy affects rate of pronominalization would be accounted for in models of language production. It could be argued that this effect is mediated by other factors, such as information structure or agency. For example, animate entities may be more likely to be topics (e.g., Givón, As for agency, this is another factor that is likely to affect a referent’s conceptual accessibility (e.g., Van Nice and Dietrich, These issues notwithstanding, the present study has shown that referential choices in Dutch can be influenced by factors that go beyond the linguistic context, and may even be perceptual in nature. We have focused on the interaction between two sources of animacy, and although many studies have shown that animacy is not reducible to an epiphenomenon of some other accessibility-related factor, it is clear that it interacts with many other factors (e.g., Comrie, In summary, the present study provides evidence for differential effects of perceptual and lexical cues for animacy on referential choices. Perceptual animacy appeared to overrule lexical animacy in the choice of referring expression, extending previous findings. On the other hand, the choice of referent for the subject position appeared to be affected only by lexical animacy. The results raise new questions about the nature of animacy effects on referential choices in particular and of accessibility in general.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.http://www.frontiersin.org/Language_Sciences/10.3389/fpsyg.2013.00154/abstractThe Supplementary Material for this article can be found online at