While vaccines are now authorized for use against the SARS-CoV2 virus, they remain inaccessible for much of the world and widespread hesitancy persists. Ending the COVID-19 pandemic depends on continued prevention behaviors such as mask wearing, distancing, hand hygiene, and limiting large gatherings. Research in low- and middle-income countries has focused on the prevalence of adherence and demographic determinants, but there is a need for a nuanced understanding of why people do or do not practice a given prevention behavior. The Breakthrough ACTION project led by Johns Hopkins Center for Communication Programs conducted a qualitative study in November 2020 in Côte d’Ivoire to explore people’s experience with and perceptions of the COVID-19 pandemic. We conducted 24 focus group discussions and 29 in-depth interviews with members of the general population and health providers. This analysis explores barriers and facilitators to seven recommended prevention behaviors with a particular focus on response efficacy, self-efficacy, and social norms. We found these constructs to be salient for participants who generally felt that the behaviors were useful for preventing COVID-19 but were difficult to practice for a variety of reasons. The perception that COVID-19 prevention behaviors were anti-social emerged as a key theme. Behavior change interventions must reframe the recommended behaviors as pro-social, while making them very easy to practice by removing social and structural barriers such as the expense or inaccessibility of masks and hand sanitizer. Despite the rapid development of several vaccines against the novel SARS-CoV2 virus and its associated illness, COVID-19, a vaccinated globe remains far out of reach. Shortages in vaccine supply for low- and middle-income countries continue ,4. MeanwWithin this context, prevention remains critical to reducing the social and economic impact of the pandemic . EffectiUnderstanding the factors that prevent individuals from engaging in COVID-19 prevention behaviors is necessary to the design and implementation of effective public health programs and to reduce the effects of the COVID-19 pandemic globally. Barriers to desired COVID-19 prevention behaviors are multilevel and multifaceted and operate at the individual, social, and policy levels . IndividThe Extended Parallel Process Model (EPPM) is a useful behavioral framework that considers how people respond to a health concern, particularly based on their perceived susceptibility to the risk and the perceived severity of the consequences . In the Côte d’Ivoire, a West African setting with a moderate burden of COVID-19, is a helpful case study for exploring drivers of COVID-19 prevention behaviors. As 2021 closes, Côte d’Ivoire had 61,800 reported cases and over 700 deaths related to the SARS-CoV2 virus since the first documented case on March 11, 2020 . The casThe Breakthrough ACTION project, led by Johns Hopkins Center for Communication Programs, was tasked with addressing COVID-19 in Côte d’Ivoire through social and behavior change communication. The Breakthrough ACTION team conducted a qualitative study in Abidjan in November 2020 with funding from the United States Agency for International Development (USAID). The larger study focused on stigma related to COVID-19; the current analysis focuses on a subset of the data involving COVID-19 prevention behaviors. Findings from the study informed the COVID-19 response in Côte d’Ivoire.The study included in-depth interviews (IDIs) with survivors of COVID-19, individuals who had lost a family member to the disease, and health workers . Some of the health workers had also recovered from COVID-19, and the sample included those who had directly treated COVID-19 patients and those who had not. We also conducted focus group discussions (FGDs) with members of the general population to explore social norms and community perceptions related to COVID-19. The research team selected a sample size using standard approaches for qualitative research to ensure that the sample sizes were sufficient to achieve information redundancy in the interviews and FGDs ,24. The The research team used purposive sampling, an approach common in formative research to inform public health programs . ParticiThe Ivoirian national research ethics committee  approved the study, as did the Johns Hopkins Bloomberg School of Public Health Institutional Review Board [IRB#13757].The study team used a written informed consent process that involved reading the information note to potential participants. Willing participants used a disinfected pen to sign consent forms prior to the FGD or IDI, and the research team kept the signed forms. COVID-19 safety procedures required by the government and the ethical review boards involved holding FGDs or IDIs outdoors or in a large room with open windows–typically at community centers or private offices. A limit of six participants per FGD enabled physical distancing. Participants and study team members were given masks and hand sanitizer. The research team verbally instructed participants to contact the study coordinator if they received a positive COVID-19 diagnosis in the two weeks following the FGD or IDI, and that request was also highlighted in the information note retained by participants. No COVID-19 cases were reported during the data collection period or in the two weeks following.The data collection team was comprised of Ivoirian researchers with qualitative research experience and advanced degrees in sociology or demography. The principal investigator, the study coordinator, and the on-site lead researcher collaborated to facilitate a training that included research ethics as well as an orientation on the protocol and the interview guides. As part of the training, data collectors conducted a pretest with 10 individuals (2 interviews and 2 FGDs with 4 participants each), which were not included in the final sample.The research team collected data from November 11–25, 2020. The interviews and FGDs were facilitated in French and were audio-recorded. On average, FGDs lasted one hour and fifty-nine minutes and IDIs lasted forty-three minutes. FGD guides explored attitudes and norms toward seven key COVID-19 prevention behaviors  through In the FGDs, participants were first asked to sort behaviors based on response efficacy. According to the EPPM, response efficacy reflects whether individuals feel the behavior is effective in limiting the spread of the disease. Researchers asked the groups to categorize each behavior as “very useful,” “somewhat useful,” or “not at all useful” for preventing COVID-19. Ensuing conversations around the usefulness of the behavior allowed the research team to explore the reasons people felt each behavior was or was not effective. Participants were then asked to classify each behavior based on self-efficacy. Self-efficacy is also a central component of the EPPM, as described above, and reflects people’s confidence that they can perform the desired behavior. Researchers asked the FGD participants to sort each behavior based on whether it was “very easy to do,” “somewhat easy to do,” or “not at all easy to do.” Discussions that followed on how to categorize each behavior allowed researchers, during the analysis, to understand factors that influence people’s self-efficacy. Interviewers also asked participants to sort each behavior by perceived social norms or whether participants felt there was “a lot of pressure,” “some pressure,” or “no pressure” to observe the recommended behavior. For each sorting exercise, the interviewers probed for further insights as participants discussed and debated. Both the final consensus and any dissenting opinions were noted. The interviewer then further explored attitudes and social norms by asking what people thought of those who practiced these behaviors. Interviewers did not conduct the pile sorting activity in IDIs with COVID-19 survivors or those who had lost family members to COVID-19, but rather explored individuals’ personal experiences with COVID-19 from diagnosis and treatment through recovery and return to the community. The IDI guide for health workers elicited insights on barriers and facilitators to preventive behaviors as well as overall perceptions and experiences treating COVID-19. As this analysis focuses on the seven key prevention behaviors outlined in The research team transcribed all IDIs and FGDs word-for-word in French. A member of the research team validated all transcripts by spot checking five minutes of audio to the transcription in three places for each transcript. The transcript was sent back for a full review if any errors were found, and the process repeated until the transcripts accurately mirrored the audio.The research team conducted a preliminary thematic analysis of the data through a participatory data analysis workshop ,27. A grAdditional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information .Overall, 156 individuals participated in this study . There wIn the following sections, we examine perceptions regarding seven COVID-19 prevention behaviors through an exploration of two key elements of the EPPM–namely, participants’ response efficacy and self-efficacy to perform the desired behaviors–as well as perceived social norms. While these constructs cut across the behaviors, we analyze each behavior in turn, as the nuances specific to each behavior are important to consider as health authorities make decisions about which restrictions to maintain and how to encourage widespread adoption.Participants described low uptake of the seven COVID-19 prevention behaviors, while expressing a strong belief in the usefulness of certain behaviors for preventing infection. Even for behaviors considered useful (response efficacy), low self-efficacy hindered the ability of individuals to adopt or sustain the behaviors, particularly after the initial phase of the pandemic. Rumors questioning the existence of COVID-19 in Côte d’Ivoire or touting African immunity trivialized the disease and related prevention behaviors. Meanwhile, unfavorable norms reinforced the perception that behaviors were unnecessary or impractical. Furthermore, participants framed their resistance to many of the behaviors in term of social cohesion, feeling that masks, distancing, limiting travel, quarantine, and even handwashing were anti-social and undermined interpersonal relationships. Participants rated quarantine for COVID-19 patients as a very effective behavior and understood the importance of preventing further transmission but emphasized the economic and social difficulties.If a person suspects they have the disease, because of the eyes of others [stigma] and fear, they will say if I go there, they will retain me and put me in quarantine. So that person starts to treat themselves by taking indigenous remedies” .Support for self-imposed isolation due to potential exposure was virtually non-existent, but, in general, participants agreed that someone who has COVID-19, as confirmed by a positive test result, is morally obligated to isolate themselves from others to prevent the spread of the virus. People who questioned the usefulness of quarantine, also questioned the validity of the COVID-19 test, asking what proves that the person has COVID-19. This lack of trust in the COVID-19 test, reflects a broader distrust in the government when it comes to COVID-19 and a sentiment that the matter of quarantine was poorly handled by the government in Côte d’Ivoire. Across numerous FGDs and IDIs, participants recounted that, at the beginning of the pandemic, celebrities  and relatives of government officials returned to Côte d’Ivoire from abroad, refused to respect the government-imposed central quarantine and were allowed to quarantine at home. This favoritism undermined the legitimacy of the pandemic in Côte d’Ivoire and contributed to a pervasive fear of quarantine in government facilities. Participants equated quarantine to a “death sentence” or even a “slaughtering house,” and shared the general perception that COVID-19 patients in government facilities were not well cared-for. Fear of forced quarantine paired with fear of stigma also led to a fear of testing and avoidance of hospitals. As one FGD participant said, “Quarantine, in the mentality of most people, is a prison, a deprivation of liberty that is difficult to accept” . A FGD participant said, “I would say very very difficult. As I said before, every man aspires to move freely. Staying in quarantine is very difficult” . Overall, people who did self-isolate if sick were viewed positively, as sacrificing themselves for others. However, the word “quarantine” was tainted by the negative perceptions of quarantine in government facilities, in contrast to self-isolation at home which wasn’t labeled quarantine by some, and by stigma. Quarantining, either at a government facility or at home, was felt by some to betray a COVID-19 positive status that would leave a permanent mark on the family. Participants expressed an internal, moral pressure to quarantine if a person knows they are sick and an external pressure to quarantine if others know you are sick. Participants who had never met anyone with COVID-19 or who doubted its existence abstained from questions around normative pressure to quarantine, having not experienced contact with the disease first-hand.Quarantine was viewed as an economically and psychologically difficult sacrifice for the greater good. Participants felt that, in absence of support from the government, quarantine for two-weeks was only feasible for people with economic means. Most Ivoirians, who earn their living day-to-day, neither have the space in their home to quarantine, nor the ability to meet their daily needs for food, water, and rent, during a two-week quarantine. Participants voiced the need for government support for sufferers of COVID-19 and their families, in the form of humane government quarantine facilities and compensation for lost income during quarantine. This government support was largely felt to be completely lacking or misappropriated. Participants also spoke of the psychological toll of quarantine, describing Ivorians as people who value freedom, mobility, and crave social interaction. A health worker said, “In Côte d’Ivoire, and in Africa in general, [quarantine] is the measure that is the most difficult for the population to accept…. It isn’t in the culture. If you are sick, you have family around you. Isolating people like that is the measure that will derail the entire system because, in our culture, if you quarantine someone, you stigmatize them” . Positive deviants among the participants expressed that it is possible to isolate a sick family member at home while respecting all safety measures and still caring for them, not abandoning them. A FGD participant said, “If my family were contaminated, I would follow the measures listed here, but I wouldn’t abandon the person. It isn’t humane” . Another FGD participant said, “If a brother or someone I know is sick, we’ll adopt the barrier measures. He will be quarantined in a room, and we’ll give him the necessary love” .In Côte d’Ivoire, isolating a sick person is to stigmatize them and goes against the Ivoirian culture. As one health worker explained, “Despite the documented importance of physical distancing in the fight against COVID-19, there were differing perceptions of its usefulness among study participants. This ambivalence was reflected in the respondents’ practical assessment of the effectiveness of physical distancing in relation to barriers in the social context.I think that when there are ceremonies and marriages and things that it is useful to maintain distance because there are more than 50 or 100 people, more than 200 people. So I think it is good” . Distancing was not framed in terms of usefulness or uselessness, but rather in the context of social dynamics and mobility that punctuate people’s daily lives. In other words, people considered whether the behavior is “useful” less from a medical perspective and more from the angle of the social proximity in which travel and valued interpersonal interactions take place. Also, this behavior was perceived as non-useful and trivialized for those whose interpretation of the pandemic was influenced by misinformation, as exemplified by a participant who said:Most participants understood how physical distancing can limit the spread of the virus; however, successful application of distancing was thwarted by a strong desire for social cohesion. People valued distancing as an alternative to avoiding crowds, as one FGD participant said, “People who insist on the one meter are stupid because in the first place we’ve told you that it doesn’t exist, you’ve never seen it, because us Africans, we like to see to believe, so something that I’ve never seen, that I’ve never even seen, and around me, no one has it, my head isn’t in it, so I can’t worry about one meter. And now you apply it, I already find you bizarre, what are you looking for? Because there is nothing. Corona is for the whites, it’s for the rich, we haven’t had it yet, so it isn’t in our heads to say one meter like that. Other participants similarly described the belief that Africans are more resistant to COVID-19, that the virus has a mystical origin, or that COVID-19 is over in Côte d’Ivoire.People think that they need to keep a distance from people that aren’t from the family, that aren’t from the neighborhood. So, if you go to a supermarket, you know it’s a measure, so you keep your distance. Because you don’t know them, so there it is easy, but in the community, in the neighborhood, in the house, it isn’t easy” . In some cases, people who insisted on social distancing among familiar others were mocked as overly compliant “puppets” of the government.Physical distancing confronts the norms that govern social interactions in Côte d’Ivoire. Gestures of familiarity such as greetings, handshakes, and hugs reinforce social bonds. Distancing, by definition, sets one apart from others which goes against the very grain of Ivorian culture. Keeping 1 meter from others was perceived as more feasible among strangers than among friends and family, as one participant described, “In addition, socio-economic factors contributed to an inability to maintain physical distance between individuals. Indeed, housing and travel patterns (overcrowded housing and public transport) limit the feasibility of this behavior. Difficulty in complying with distancing was more marked in spaces with intense and "uncontrolled" interactions such as markets and public transportation, in contrast with other settings such as places of worship, pharmacies, supermarkets, and banks, where distancing was often imposed. The inability to systematically maintain 1 meter from others led some participants to prioritize other behaviors such as handwashing, use of hand sanitizer, or mask wearing to the detriment of respecting physical distancing. On the other hand, some participants felt keeping 1m distance was easier than the other behaviors because it did not require purchasing anything, such as soap, sanitizer, or masks.Perceived social norms were unfavorable to physical distancing and reflected the government’s failure to model recommended COVID-19 prevention behaviors by holding political rallies and televised funeral rites for a deceased minister. Reported lack of compliance with distancing in health centers further undermined normative support for this behavior. These actions were seen as contradictions by study participants or even as reinforcing misinformation that questioned the existence of the virus.Participants were divided on whether masks were useful, but most people felt masks were not easy to wear routinely or long term given the cost and hot climate.come from China and the disease started there. The Chinese want to propagate [the disease] here, so one thought is that it is in the masks” . On the other hand, some people did not feel the masks were useful or necessary because they did not believe in COVID-19 at all or that COVID-19 was still in Côte d’Ivoire. A participant said, “they are fed-up. When you say, ‘you have to wear a face mask,’ insults follow: ‘You are pissing people off with your Corona business… there is no Corona here’” . As with other preventive behaviors, this doubt about the existence of the virus undermined compliance with mask wearing. Health workers, on the other hand, valued mask wearing as a way of protecting others. One health worker explained, “If you love your neighbor, it means that you also love yourself. So, you have to wear your mask correctly” . Participants in the general population often framed the need for a mask around whether they were around people close others or strangers. One individual differentiated between the home neighborhood as opposed to the larger city, saying “Here, in the neighborhood, when we don’t go out, we’re just here in our sector, we find that it’s not useful [mask wearing]. But when we want to go out, it is imposed on us” . The only valid time to wear a mask in the neighborhood was if you were diagnosed with COVID-19, a belief that led to harmful assumptions about people who did wear masks. One participant described being afraid of people wearing a mask, saying, “someone who always has their mask on, we fear him, because we think he has the disease” . Another participant described being temporarily expelled from her housing situation because wearing a mask exposed her COVID-19-positive status.There was considerable variation in beliefs about whether masks are helpful, neutral, or harmful. Some thought that masks were contaminated with the SARS-CoV2 virus and would infect people. The suspicion about masks intersected with stigma around the origin of the illness, as described by a participant who said that most masks “suffocate them. So, some people don’t wear them. Not because they don’t know its importance! But some people say that it makes them tired, so that’s why people have let up [on mask wearing].” . Particularly in the heat, masks were considered untenable. As with other barrier measures that had to be purchased, the cost was prohibitive for some participants.Wearing a mask was difficult for community members to respect. According to participants in FGDs as well as health workers, the main issues were comfort and cost. Participants described people objecting that masks “we find him superior to us, because he thinks his Corona, his COVID-19, is so important” . COVID-19 survivors were more determined to wear masks; their experience with the illness gave them motivation to overcome unfavorable social norms. One participant who had survived COVID-19 said that, after having COVID-19, he continued to wear a mask even when others did not, saying, “with respect to the barrier measures, I was the first to wear a mask” . Another participant who had recovered from COVID-19 perceived her risk to be higher, saying she was now convinced COVID-19 exists and “in my opinion, the only way to avoid the disease is to wear a mask.” .Mask wearing, except in places and spaces where it was required, was considered unacceptable for most people after the initial phase of the pandemic. Wearing a mask was seen as setting oneself apart, as described by a participant who said, “In my church, there are people who come without a face mask, but it is mandatory, without a face mask, you can’t enter. So, they are obligated to wear it. If it were just up to them, they would enter without a face mask” .People described that wearing masks in public places was acceptable where it was required. Mandates and enforcement appeared to have a favorable impact on mask uptake in crowded settings, as a participant explained, “The behavior of handwashing benefited from prior promotion. Perceived usefulness was undermined by misinformation (rumors), and people felt that the behavior was somewhat inconvenient to practice.Among participants who felt that COVID-19 was both real and severe, handwashing was valued as a way to protect oneself. Those who questioned the efficacy of handwashing often also questioned the existence of COVID-19 in Côte d’Ivoire and subscribed to a narrative of African invulnerability to the disease:In the beginning, there was really a scare everywhere. But after that, people in families, in neighborhoods, people don’t pay much attention anymore. Me, for example, at my work there was a time when everyone washed their hands. The buckets of water are still there today, but it is rare that people wash their hands because, by the grace of God, God is with us, when you look at Africa, if it isn’t the white, yellow or other skin, in Africa, really, blacks don’t die like that. Even the second wave that is disfiguring Europe, America, in Africa we don’t hear that.” .I don’t care. It is finished. I don’t care… what will happen, will happen. I’m careful to a certain extent, I wash my hands, but I’m no longer like I was before, at the beginning, when we barricaded our noses, we didn’t visit, we didn’t touch people. Listen, I go where I want” . This fatalism regarding infection was common among people who felt both low risk perception as well as low self-efficacy to maintain the prevention behaviors.Other participants felt that handwashing was the only behavior worth continuing in light of waning risk perception, as described by one individual who lost a family member to COVID-19, “At the beginning, we washed our hands a lot. Every time we went out, we washed our hands. In every courtyard, even, some people even put buckets and things, but as we went along, we started to tend to live a little bit with the disease” . As the pandemic progressed, fear waned as did compliance with the prevention behaviors.The installation of handwashing stations at the entrances to communities, businesses, and homes temporarily boosted self-efficacy and favorable perceived social norms at the beginning of the pandemic. However, self-efficacy eroded over the course of the pandemic as people felt unable to maintain the initial systematic handwashing over the long term and began to feel impervious to the disease, as described by a participant, “very few people will wash their hands. Imagine that you shake my hand and that you immediately go and wash your hands. What impression would I have of the fact that after shaking my hand, you go and wash them? That’s not accepted in our culture” . Across groups with respect to public places, participants characterized the existence of handwashing stations as a form of pressure as well as being asked to wash hands before entering a places like supermarkets. At the household level, participants who knew someone who had had COVID-19 appeared to feel and exert more pressure within families to wash hands regularly.Handwashing benefitted from prior normative support, as a practice that predates COVID-19 and has long been promoted to fight infections. In that regard, handwashing escaped the stigma attached to other prevention behaviors that emerged specifically in response to COVID-19. Promotion in schools and through various disease-based programming has led to general acceptability of handwashing as a preventative practice. However, the acceptability of handwashing is often limited to specific times or rituals . A health worker explained that the inappropriate timing of handwashing can be perceived as insulting: “The convenient and pro-social nature of hand sanitizer was offset by the cost and inaccessibility at certain points during the pandemic.Participants generally expressed the belief that using hand sanitizer not only prevents COVID-19 but is also effective against other diseases that can be transmitted by dirty hands. However, some participants from the general population, especially those who did not know someone who had had COVID-19 and/or who did not believe in the disease, did not believe that hand sanitizer was useful in preventing COVID-19.One of my friends was telling me that when he wears the mask, it suffocates him. So everywhere he goes he takes hand sanitizer. Every time he touches something, he puts a little in his hands” . Given that cost (and stock outs at the beginning of the pandemic) were the primary barriers to frequent use of hand sanitizer, some participants advocated for making hand sanitizer available to the population free of charge. Hand sanitizer is relatively low cost, quick and fun to use, portable, discrete, and therefore inoffensive, and easy to share making it a prevention behavior that contributes to social cohesion and is culturally acceptable. A health worker described this link between self-efficacy and social cohesion, saying, “If you have your little hand sanitizer, that hand sanitizer, it can be shared, you see? You can share it, so it is easy for them to have” .Frequent use of hand sanitizer was perceived by study participants to be the easiest COVID-19 prevention behavior to adopt and maintain over time. They opted for hand sanitizer as a way of foregoing other, more challenging, behaviors to adopt, as described by a participant who said, “Frequent use of hand sanitizer as a social norm ebbed and flowed with risk perception related to highly mediatized public health threats. Participants recounted that hand sanitizer was made available in most public places during the Ebola crisis in 2014 and then disappeared when the perceived threat of Ebola was gone, and a similar pattern was emerging with COVID-19. The availability of hand sanitizer and reminders to use it before entering public places  generated a positive social norm around the frequent use of hand sanitizer and boosted self-efficacy by overcoming barriers related to access.Both avoiding large gatherings and choosing to limit one’s own gatherings to fewer than 50 people were felt to be useless and difficult, both because people did not understand the benefit and large gatherings are part of the fabric of Ivoirian culture.at first it was 50 people but now they’re saying it’s 200 people. You see, I think that even here, I think that the State itself thinks that it is not important” .Most study participants were skeptical of the response-efficacy of limiting gatherings to 50 people. Participants questioned the scientific basis for the 50-person threshold and felt that limiting gatherings to 50 people would not guarantee protection against COVID-19. Changing guidance about the number of people who could safely gather and large public events undermined trust in the efficacy of this recommendation, as described by an individual who said, “Self-efficacy related to avoiding large gatherings or limiting gatherings to fewer than 50 people was low, given socioeconomic and cultural constraints. Participants expressed being unable to avoid crowded places like markets and public transportation. Institutions such as administrative offices, banks, pharmacies and places of worship were able to impose restrictions on the number of people, but individuals expressed being unable to ban family members and friends from events they would have otherwise attended.not easy at all because the men, the people in the community are called to live together, every day, they have to share their problems, their worries, their emotions together. Forcing them to respect the fifty people, the fifty people in a gathering, I think that it is impossible, it is difficult” .Social norms favor large gatherings for the celebration of important life events as opportunities to express social solidarity, strengthen social ties and show hospitality. Participants described others who tried to limit the size of social gatherings as “mean,” “selfish,” “cheap,” and “antisocial.” One participant described it as “Limiting travel was a complex behavior as participants weighed the perceived importance of the prevention behavior against the duration of lockdown.they don’t find it useful, they say to themselves that they can travel, they can move around, there is no problem. What people have retained in this story of Coronavirus, what they have retained to fight disease is masks, hand sanitizer. As for traveling, I don’t think it is important, he moves about. If he’s in a car and he wears a mask that is enough” . This tendency to observe certain prevention behaviors and not others was common and often influenced by economic realities.Participants understood why limiting movement would limit the spread of the virus, but the term “non-essential” created confusion because most travel was deemed essential for economic or sociocultural reasons. Participants described maintaining certain behaviors while allowing themselves to travel, “maybe for 1 month you can limit [travel]. Beyond that, there are difficulties, for example, there’s a funeral, the guys have to go to the village” . The ease or difficulty of complying with this behavior also depends on social status and type of work. Many participants expressed that it would be easy for well-to-do families (with stored resources to meet their needs for a longer period of time) to limit their travel, and more difficult for those who are less well off or are living hand-to-mouth. Receiving material assistance and food supply facilitated adopting this behavior, whereas misinformation–particularly skepticism that COVID-19 exists–undermined compliance. As limited travel disrupts social habits that involve mobility, contact and interaction with others, participants expressed considerable skepticism that the behavior could be maintained long term.Participants felt they could postpone certain travel, yet family obligations were particularly difficult to avoid, as described by a health worker who said, “Participants felt that members of the general population did not limit travel and pointed to a lack of modeling on the part of public figures. Within communities, there was little or no pressure from peers to limit non-essential travel, both due to a general disbelief in COVID-19 and a shared understanding that socioeconomic priorities came before observing ambiguous government restrictions. People who encouraged others to limit travel were perceived as "wimpy," "lazy," "overzealous," or "rich”. Notably, those who felt the behavior was important tended to have some personal exposure to COVID-19 through their family or social networks.In this qualitative study, participants exhibited moderate response efficacy and low self-efficacy for the majority of recommended behaviors. Self-efficacy was particularly limited by economic realities–the inability to afford products like masks and hand sanitizer or the need to travel and interact with others to earn a living inhibited physical distancing or quarantining. With the exception of hand hygiene, social norms were highly unfavorable to the prevention behaviors, in part because of a lack of modeling by public figures and pervasive misinformation and conspiracy theories, such as beliefs that questioned the existence of COVID-19, insisted that Africans were immune, or promoted alternative prevention methods and therapies. The influence of social cohesion on each behavior was striking–behaviors that undermined interpersonal connectedness were perceived to be unacceptable or impossible. Taken together, these findings are consistent with other studies that suggest low risk perception of the disease, cultural norms, and misinformation reduced adherence with recommended COVID-19 prevention behaviors ,28,29.Overall, people felt the prevention behaviors were very or somewhat useful. Participants close to someone who had survived or died from the virus tended to express higher response efficacy. Except for limiting gatherings to 50 people and the problematic term “non-essential” travel, participants largely understood how the other COVID-19 prevention behaviors could help limit the spread of the virus. Consistent with other studies in the region, a belief that certain prevention behaviors are necessary to control the pandemic appeared to influence individual compliance . HoweverSelf-efficacy is inextricably intertwined with cultural acceptability and socioeconomic factors. The prevention behaviors that are not culturally acceptable, most often because they are perceived as creating social distance, also suffered from low self-efficacy because people did not feel they could sustain behaviors that others may find offensive. In addition, almost all the prevention behaviors had barriers related to socioeconomic status and participants delineated the differences between people who had the luxury of following the prevention behaviors because they had a comfortable and spacious place to live and all their needs were met without having to leave the house and people who needed to leave the house on a daily basis or they and their families would not eat or be able to pay their rent. Furthermore, people often felt that the prevention behaviors were feasible for a limited period (high “acute” self-efficacy), but that feasibility deteriorated as the pandemic lingered (low “durable” self-efficacy). Participants expressed high compliance with the recommended prevention behaviors at the beginning of the pandemic when everyone was afraid, but low compliance at the time of data collection, ten months later. This drop-off in compliance is consistent with findings reported elsewhere in the region ,11.Participants in the study described social norms that were largely unsupportive of COVID-19 prevention behaviors and particularly unsupportive of behaviors that bucked cultural norms around greetings, hospitality, and care for the sick. For a short time at the beginning of the pandemic, social norms stretched to accommodate more frequent handwashing, frequent use of hand sanitizer, and mask wearing. As perceived risk waned, social norms returned to pre-pandemic standards and the aforementioned prevention behaviors were relegated to places and spaces where they were required (for example wearing a mask in public transportation or washing hands before entering a pharmacy). Stigma related to COVID-19 further undermined normative support for the prevention behaviors as the behaviors became associated either with being ill  or with negative stereotypes of people who embrace the prevention behaviors as fearful, gullible, or stupid. Prevention behaviors that predate COVID-19, like handwashing, or that were perceived to protect against a broad array of diseases, like use of hand sanitizer, escaped stigma to a certain extent. More novel behaviors such as masks were less acceptable.The drive for social cohesion permeates every aspect of Ivoirian culture in the minds of study participants. Any prevention behavior that could be perceived as creating physical or social distance between oneself and others threatened social cohesion. At the beginning of the pandemic, people could comply with the prevention behaviors without being labeled “anti-social” because everyone was afraid, and the temporary norm was to comply. In this sense, during the acute phase of the pandemic, the prevention behaviors aligned with dimensions of social cohesion such as belonging and participation, the sense that we are facing this threat together and a willingness to participate in a shared response . But sooThe prevention behaviors intersected and promoted or hindered one another. Certain behaviors are considered useful only as they facilitate other behaviors; for example, limiting gatherings to 50 people is only useful in allowing people to maintain 1m distance. Similarly, participants described selecting which behaviors to follow, hoping that the behaviors they found easier to implement would be sufficiently protective.In terms of limitations of the study, the focus groups were mixed on age and gender, and some participants expressed discomfort sharing their age, which limited our ability to analyze the data by age and gender. The study also took place in an urban setting and did not account for viewpoints from rural participants. Future studies could complement these findings by conducting FGDs with homogeneity by gender, age, and urban or rural setting to facilitate comparisons across these important social locations.The findings from the study described here informed the social and behavior change strategies adopted by the Breakthrough ACTION project to combat COVID-19 and continue to shape them as the pandemic evolves. Specifically, messaging from the government and partners has sought to augment and sustain risk perception so that people understand that the disease is still present and a risk, even as the pattern of caseloads may seem to trend downwards. Messaging has also focused on capitalizing on the social influence of community and national leaders to highlight the importance of key prevention behaviors and normalize continuing certain behaviors such as mask wearing and social distancing. Even as the COVID-19 vaccine campaign began in Côte d’Ivoire, concurrent communication campaigns have emphasized the importance of sustaining other prevention behaviors, particularly considering the threat of new variants.Based on these insights, the authors offer the following recommendations for actors involved in the challenge of improving adherence to COVID-19 prevention behaviors in an evolving and enduring pandemic:Make behaviors that are perceived to be “antisocial” as easy as possible to practice. Practices such as mask wearing, distancing, handwashing, or quarantine were acceptable during the pandemic’s early phase of heightened fear, but have diminished greatly in social acceptability over time, making it harder for even those conscious of the risks posed by COVID-19 to comply. To counter this, it is important that policymakers and those developing guidance try to make these preventative behaviors easier for people to do. For example, it may be important to consider how to reduce the financial barriers to purchasing masks and consider how to simplify the quarantine process for those potentially exposed.Track and address rumors and conspiracy theories influencing risk perception. No amount of promotion of prevention behaviors will be effective when the population believes that COVID-19 does not exist or that it does not affect certain groups. Misinformation continues to circulate on social media and in communities, and it is important to have a process for tracking and addressing them as they arise, using credible messengers and the channels most trusted by communities.Address stigma attached to certain prevention behaviors. Many Ivorians now associate mask wearing or post-exposure quarantine with COVID-19 infection. Messages should aim to reframe prevention behaviors as broadly protective against myriad diseases rather than as a sign of having or fearing COVID-19. Associating influential figures with social and behavior change messaging may help break stigma. Much as was done during the 2014 Ebola outbreak, when familiar forms of greeting such as handshaking and embracing had to be set aside, it is important that people see more socially difficult prevention behaviors as a show of caring for others.Continue to highlight survivor stories to make the continued risk of COVID-19 infection real. The challenge of declining risk perception is only likely to increase the longer the pandemic lingers. To achieve a meaningful protective effect through prevention behaviors people need to see the continued impact of infection with COVID-19 and the risks that it presents, especially for that portion of the population that may know someone who has had the disease.Ultimately, reinforcing a narrative of cohesion and shared commitment is critical to building a social movement to end the pandemic. High-level leaders could do much to strengthen this framing but must be perceived as having integrity and “practicing what they preach” to be effective. Empathetic messaging that reinforces people’s collective power to protect one another and defeat the pandemic together appeals to the high value placed on social cohesion.S1 Questionnaire(DOCX)Click here for additional data file.


Introduction: Functional neurological symptom disorder (FNSD) is a common diagnosis among adolescents. However, we feel it is a difficult diagnosis to assess because of the diversity of its clinical manifestations, the rapid changes in its nosography over the years, and its common imbrication with established somatic diagnoses. We would like to illustrate this hypothesis through a case presentation and the original diagnostic process that emerged from it. Methods: We chose to present our diagnosis approach through the case of an 11-year-old boy who showed a progressive loss of motor and sensory function to the point of total dependency, and then suddenly switched between this state and a “normal” physical presentation, while deliriously claiming to be an angel. Results: All possible infectious, autoimmune, metabolic, and toxic disorders were ruled out. After the successive therapeutic failures of antidepressants and neuroleptics, FNSD was diagnosed. Conclusion: The DSM-5-TR classification was insufficient to explain the full clinical picture and a complementary approach  was used to analyze the cause of this atypical presentation. Conversion disorders, referred to as hysterical neurosis conversion type in earlier editions of the Diagnostic and Statistical Manual , were asMany labels and etiological theories, varying between cultures, have been attached to these disorders throughout the ages. First referred to as “hysteria” in Greek antiquity, this disorder was mainly characterized by the onset of nonepileptic seizures. It was believed that the god Asclepios could heal patients with hysteria by communicating with them during their dreams. Special temples were constructed across Greece, where priests would accompany patients into the land of dreams.The Marquis de Puységur later theorized this phase of induced dreaming. Inspired by the practice of Mesmer, who used magnets to induce hysterical attacks artificially to heal patients , the MarStudies on Hysteria, Freud assumed that this attack arose from repressed traumatic ideas or memories in the unconscious that were “converted” into physical symptoms. It would cease only if these ideas came freely to the patient’s conscious awareness, brought by the patient without any suggestion by the therapist [In his book herapist . This leThe history of mental suffering through bodily expression and somatic symptoms has focused on females, with hysteria derived from the Greek term “hystera” meaning “uterus”. Nonetheless, these symptoms currently appear to be prevalent among adolescents ,9,10,11 A recent literature review  identifiThe international community agrees on the beneficial effect of cognitive behavioral therapy and family therapy  for FNSDIn view of the various clinical expressions of this diagnosis, its changing nosography over time, and its very common overlap with verified somatic diagnoses, as well as with cultural beliefs and interpretations, we think that the diagnostic approach to a patient presenting such symptoms cannot be restricted to the DSM-5-TR classification alone. We would like to illustrate this hypothesis through a case presentation and the original diagnostic process that emerged from it.We describe the case of an 11-year-old patient admitted to the general pediatric ward and initially referred on suspicion of an acute/sub-acute encephalitis . The initial somatic work-up included the study of the cerebrospinal fluid (CSF) that was strictly normal for biochemistry, hematology, and viral/bacterial/fungal infection. There was also no sign of an active infectious event explaining the symptoms . There was no overexpression of interferon genes in the CSF either. Metabolic investigations in blood, urine, and CSF  were normal. The autoimmune tests for blood autoantibodies or in the CSF  were negative. Tests for a toxic cause  were negative as well. The immune tests and study of the complement were normal. The ophthalmologic and Otorhinolaryngology work-up carried out showed no notable organic anomaly. The brain and spinal cord MRI were perfectly normal. Several electroencephalograms were performed including during sleep and over a long duration with video recording, but no seizures or abnormalities of the tracing were recorded. All the investigations carried out are summarized in the Patient informationObadiah is an 11-year-old boy from Saint Lucia, a Caribbean island. His parents have been a couple for 18 years but have been always living apart. Although his mother has three other boys, all adopted, he is his parents’ only child. Obadiah is baptized. His name means “servant of God”. He is a social and cheerful boy and dreams of becoming a musician. He is in the sixth year of school and has good grades. No history of school bullying is reported. Obadiah’s mother was initially pregnant with twins: Obadiah and a little girl, who died in utero 3 days before delivery. The cause of death was unknown as it was detected in a follow-up ultrasonography without any symptoms. At the request of the family, no autopsy was carried out after delivery. Obadiah’s mother went through postpartum depression, for which she received medication and psychological counseling. At around 6 years old, shortly after being told about his twin sister’s death, Obadiah started developing phobias of water, cemeteries, funerals, and the dark. The case history up to Obadiah’s transfer to Martinique University Hospital can be found in Clinical findingsAt physical examination upon his transfer to the pediatric unit of the Martinique University Hospital, at the age of 11, Obadiah showed no reaction to sensorial stimuli: no speech but only grunts, no response to simple orders, and no active mobilization, with bilateral corticospinal tract dysfunction and horizontal nystagmus. He was fed via a gastric tube and urinated and defecated in a diaper. The fever was not confirmed during hospitalization.Diagnostic assessmentAcute/subacute encephalitis was initially suspected. The explorations included a study of the cerebrospinal fluid, several blood and urine tests, brain and spinal MRIs, and video electroencephalography. This work-up found no infectious, toxic, metabolic, or autoimmune disorders.On a somatic level: He did not show any complications from the long bed rest. As nurses followed the protocol for mobilizing patients, the child’s positions that were observed did not concur, which led us to believe that he might have changed position by himself when left alone. The partial regression of neurological symptoms was noted early during the stay. All medications were stopped and the neurological improvement continued throughout the stay.On a psychiatric level: Fourteen days after the beginning of his hospitalization in Martinique, and shortly after the arrival of his father from Saint Lucia, Obadiah presented a brutal and total transformation. He presented himself as a walking and talking boy, explaining that his name was Xzavia and that he was an angel who had taken possession of Obadiah’s body to explain to us humans that he had been sent by God to save Obadiah from his illness. When asked what kind of illness Obadiah had, he would say that he suffered from autism and an abdominal illness. Xzavia would write lists of complaints and requests to “help Obadiah’s mother get her son well”. These lists included special foods Obadiah wanted to eat (mainly fast food) and things he wanted his mother to let him do . Xzavia appeared with a normal degree of consciousness and was well oriented in time and space. Although Xzavia showed appropriate behavior and no sign of neurological impairment, his thought content appeared delirious and around mystical themes. His report that he communicated with God led us to suspect intrapsychic hallucinations with mental automatism. He also said he could see God, which caused visual hallucinations. Xzavia could recall some events that had occurred while the patient presented as Obadiah and could report some of Obadiah’s thoughts. He was able to walk and eat normally. He had a normal appearance, with hospital clothing, good hygiene, and appropriate posture and gestures, although there was some doubt about possible facial mimicry. He showed appropriate behavior with good eye contact and appropriate body language and response to questions. Speech and language were normal in terms of volume, tone, rate, flow, and use of words. His attention was focused on the discussion, without interruption or any listening attitude. He showed good memory, easily recalling our last conversation and elements of Obadiah’s life story. His affect and mood were stable. His conviction that he was an angel sent by God to save Obadiah was unshakable. There were no elements of dissociation and the delirious process seemed quite logical and structured.On the other hand, Obadiah had an encephalitis-like physical presentation. He had a constant upward gaze that made eye contact impossible. His head was hyper-extended. His left arm was hyper-flexed and he would grumble and show facial rictus whenever we tried to change his position. However, when he slept, his limbs were relaxed. He did not speak a word, could not walk, could not eat, was fed through a gastric tube, and urinated and defecated in a bucket. All communication with him was impossible.The patient alternated, sometimes several times a day, between presenting as ‘Xzavia’, who could walk and communicate normally, and ‘Obadiah’, who had an encephalitis-like clinical picture and with whom any contact was impossible. Surprisingly, Xzavia could talk about some of the events that had occurred while Obadiah was in his encephalitis-like clinical presentation, and he would tell us some of Obadiah’s thoughts. Xzavia would only appear at the request of a few people, including Obadiah’s father, the hospital priest, and the hospital chaplain, but none of the doctors, nor Obadiah’s mother, whom Xzavia often rejected and insulted. The diagnosis of FNSD remained.Therapeutic InterventionNone of the medication improved his clinical presentation . The story of Jonah’s engulfment by the whale calls attention to the great dangers of introspection and of searching for one’s self and one’s goal in life. Being vomited up from the whale’s belly might be considered a rebirth. Obadiah is a young adolescent, not yet even a teenager, facing difficult questions and trapped in his body. Showing physical regression might be a way to reflect on his future life goals. Erich Fromm, on the other hand, saw Jonah’s story as expressing this unwilling messenger’s determination to escape from all human life and regress to a fetal state in his mother’s belly, metaphorically presented first by the ship’s cargo hold and then by the whales belly . ObadiahThe DSM-5-TR FNSD diagnosis was insufficient to explain the full clinical picture in such cases, and at times a more comprehensive/complementary approach may be more beneficial. Applying the principle of complementarity—in this case, history, religion , and psychoanalysis—recommended by Devereux  has led


By bridging critical pedagogy and environmental praxis, the contributions in this forum build on Freire’s legacy while stretching his work. As the authors attend to more-than-human life, they theorize and enact relational ways of knowing. Through participatory and multisensory pedagogies, they counter dichotomies between nonhuman and human nature, student and teacher. In this response, I consider how this (re)centering of more-than-human relations expands—and counters—Freire’s thinking, including how he articulates humanization as a primary, liberatory aim of teaching and (un)learning. Along with insights from Black geographies and Black feminist ecologies, bell hooks guides my response. hooks critiqued and engaged with Freire’s work with radical care, with space for complexity and accountability. This way of reading feels particularly suited to this forum, as the authors reimagine Freire’s contributions to critical  pedagogy for the twenty-first century and beyond. As I read this forum, I kept thinking of bell hooks’ reflections on Freire’s work. Really, thinking came second. First came a vision of hooks and Freire having tea or a meal together. The vision looks like a photograph: these two ancestors of critical pedagogy, having a conversation in the afterlife or in some other dimension where they meet again.Pedagogy of the Oppressed (1970) influenced her as a learner and teacher. In Teaching to Transgress . In Pedagogy of Hope (1992), for example, Freire addresses feminist criticisms of his earlier work directly and at length. This moment further inspires that vision of hooks and Freire sharing a meal: there is a sense of meaningful dialogue.hooks recently passed away in December 2021, while Freire passed away in 1997. We know from hooks’ interviews that she treasured Freire’s work. We know ansgress , she refThe pieces in this forum both build on Freire’s work and stretch his work, and hooks models how to be with the complexity of his legacy. In their articles, the authors emphasize process, challenge the “banking” method of education, engage in learning beyond the conventional classroom, and challenge dichotomies between “student” and “teacher.” They contextualize learning within broader power dynamics and histories; they articulate relationships between theory and practice. As they do so, they offer practices fellow educator-activists may take forward. Following Freire’s emphasis on communication, these articles attend to communication as not only essential for learning but as a site of learning. Their praxis is deeply relational, in the sense of fostering and centering relationship. At the same time—and here is where hooks’ way of critique becomes important—the forum authors stretch Freire’s critical pedagogy beyond human relations. As they reimagine critical environmental education, they acknowledge and theorize how human and ecological relations entwine, how they are mutual. As they analyze “collective becomings” through an art and permaculture cooperative in Argentina  and a youth naturalist program in the United States (Hecht), this relationality ranges from situating human relations within nonhuman nature, to tracing human–environment relations, to centering the agency of nonhuman nature, such as animals, plants, and water. The authors emphasize plural knowledges as they (re)center Indigenous, local, and multisensory ways of knowing alongside Western science. While the terms “nonhuman nature” and “more-than-human” are less-than-optimal and still do not quite capture relational ways of knowing, I use them throughout this response to better draw out the relationships lifted up by the authors. They theorize and enact relational ways of knowing which assume the interconnectedness of nonhuman and human life, center relationship, and counter Western dichotomies between nonhuman/human nature, mind/body, and student/teacher, among others. As they do, they insist on engaging with more-than-human relations for collective and planetary thriving.Situating this forum within the ever-evolving landscape of research on relationality in critical and environmental education. Rather than an exhaustive literature review, I underscore some of the works that this forum brings to mind. This brief review also reflects what I have been thinking and feeling through as an educator–scholar. In Grounding, I share more about my location at the crossroads of Black geographies, Black feminist ecologies, and embodied praxis. This interdisciplinary foundation shapes my response, while teaching about Black botanical geographies inspires my commitment to relational and reflexive pedagogies. From here, I revisit how Freire centers human relations, including key critiques about the anthropocentrism of his work. When I turn to the pieces in this forum, I propose that their attention to more-than-human relations involves much more than illuminating yet another “set” of relationships. The authors inspire questions: By bridging Freire’s insights on critical pedagogy with wide-ranging environmental theory and practice, how do the authors extend (and even counter) Freire’s work? How do they enact relationality, not only as a concept, but as living practice? How does doing so disrupt underlying assumptions of Western science? And, why is this reimagining critical now?I begin by In this response, I engage with these questions and raise others. hooks especially guides how I critique Freire’s work. As a fellow Black educator based in the United States context, I share hooks’ appreciation of Freire’s work. I mutually appreciate how Freire offers language for understanding and dismantling power dynamics, for harnessing collective power. Furthermore, in the spirit of Black feminism, hooks considers her lived experiences with race, gender, class and other structural identities integral to her intellectual autobiography. My interdisciplinary location is inspired by living, studying “old ways,” and community organizing as a Black and Blaxicana educator-researcher. I am practicing awareness of both the privileges and oppressions I bring to this response as a Black scholar based in the Global North. By reading the forum articles in conversation, and by being in conversation with them, I seek to practice the dialogue hooks and Freire lift up. May I bring openness and a willingness to learn.relationality in critical science and critical environmental education: When Rocio Martín et al. emphasize plural knowledges and the necessity of engaging Indigenous and Western scientific thought, they bring to mind Megan Bang and Marin’s  justice, among human and nonhuman life, recalls how Bazzul and Tolbert  theorizeoutside of ourselves, we consider our social locations, roles, and relationship to Black botany as living practice and philosophy with implications for the planet—people, plants, animals, earth. But reflexivity does not necessarily disrupt human/nature dichotomies.This brief situating reflects the crossroads where I do “the work”. For research and pedagogy, I attend to how relational epistemologies have been carried forward and carried out through community-led Black botanical medicine. This involves attending to everyday relations with plants for medicine and as medicine; to relations with plants in expressive culture such as poetry and music; to ritual relations with plants and how plants connect with people; to the agency of plants themselves, not only as teachers or kin, but on their own terms. Without grounding in critical theory, this pedagogy risks perpetuating colonial legacies, among them the reductive “listing” of plants and practices without addressing power. Such cataloguing facilitated colonialism and genocide; this cataloguing undergirded hierarchical taxonomies of people, animals, and plants, laying the groundwork for scientific racism and its legacies Smith . Buildinbetween epistemologies—dichotomies such as Western science/Indigenous science, or dichotomies constructed between the epistemologies of historically-oppressed communities. Voeks and Rashford . In Pedagogy of the Oppressed, he argues, “To surmount the situation of oppression, people must first critically recognize its causes, so that through transforming action they can create a new situation, one which makes possible the pursuit of a fuller humanity” (47). Dialogue is necessary, he proposes, for practicing fuller humanity, and the capacity for dialogue, the capacity to transform the world, distinguishes the oppressed from things. Freire holds, “In order to regain their humanity they must cease to be things and fight as men and women,” and he continues, “They cannot enter the struggle as objects in order later to become human beings” (68). Freire understands oppression as dehumanizing, for both the oppressed and the oppressor: liberation and humanization entwine (more on this later). There is, of course, much more nuance in Pedagogy of the Oppressed, and in Freire’s broader body of work, but these examples point to how Freire centers human relations and humanization.becoming human means. Here is where provocative critiques and debates about his analysis of nonhuman nature arise. For instance, in Pedagogy of the Oppressed, becoming is the purview of humans. Freire  writes, “Indeed, in contrast to other animals who are unfinished, but not historical, people know themselves to be unfinished; they are aware of their incompletion. In this incompletion and this awareness lie the very roots of education as an exclusively human manifestation.” In Pedagogy of Hope , he argues, “Throughout history, we men and women become special animals indeed, then. We invent the opportunity of setting ourselves free to the extent that we become able to perceive as unconcluded, limited, conditioned, historical beings. Especially, we invent the opportunity of setting ourselves free by perceiving, as well, that the sheer perception of inconclusion, limitation, opportunity, is not enough.” He makes similar observations of plants, which warrants particular attention for this forum because the authors teach through gardens, farms, and urban parks: botanical life is central to their critical pedagogy. Freire observes: “The transformation occurring in a seed which under favorable conditions germinates and sprouts, is not development. In the same way, the transformation of an animal is not development. The transformations of seeds and animals are determined by the species to which they belong; and they occur in a time which does not belong to them, for time belongs to humankind” . Here, plants and animals lack agency as well as the capacity to transform and exist outside of time, or perhaps outside of time in a sense that matters.When Freire discusses nonhuman life such as animals or plants, he typically does so to differentiate what Pedagogy of the Oppressed.” The missing chapter Misiaszek and Torres envision, are not a critique of anthropocentrism in Freire’s work. Rather, they imagine this chapter, envisioning what Freire might have written about oppression of the environment. As they construct this chapter based on his body of work, they approach ecopedagogy as teaching focused on “connections between human acts of environmental ills and social conflict  for praxis to end oppressions”; they emphasize how this is one way to understand ecopedagogy, inspired by Freire’s environmental thought (465). Following Freire, this definition points to human acts and their impacts, alongside the human capacity to transform those acts. They carry this argument forward when they differentiate the World, defined as human interactions, from the Earth, or nonhuman life. Again, this differentiation extends Freire’s arguments: “All organisms utilize their environments; however, only humans reflect upon their actions upon Earth—the environment, other animals, and each other ” (472). For Misiaszek and Torres . This critique builds, in part, on Bell and Russell  arise when reading interventions from Black Studies alongside Freire’s work. For example, Jackson . He acknowledges the implications of oppression, including how oppression dehumanizes everyone. However, humanization and dehumanization occupy a binary here. The oppressed and the oppressors, are either humanized or dehumanized; Freire assumes humanization universally attainable. In a sense this speaks to his politics of radical hope, and this universality risks minimizing racial, sexual, and other hierarchies. Put plainly, if humanization is a dialectical process that requires agency and recognition, does everyone really have the ability to be recognized as human? What of how the category of “human” relies on colonial legacies?Misiaszek and Torres point to critics’ limited engagement with Freire’s broader scope of work. They emphasize the need to engage with his full body of work, to approach his work as  Jackson  unsettle Jackson , 34. JacBy interrogating the category of “the human”, Jackson and work by scholars such as Sylvia Wynter and Katherine McKittrick challenge humanization as an emancipatory aim, while (re)turning to more-than-human relations. In terms of critical pedagogy, these interventions open up the aims and scope of critical  education. Although the arguments touched upon in this section debate the position of the human in Freire’s work, each presses for careful consideration of more-than-human relations for collective and planetary thriving.generative comes to mind.Which brings me to the pieces in this forum. By bridging theory and practice, the authors in this forum not only assume relationality in terms of interconnectedness, implication, and involvement, but they seek to cultivate and practice these. In the case of Reciclando Utopias (Recycling Utopias), relations again encompass humans as well as nonhuman nature. Martín et al. describe the cooperative as a “learning context,” grounded in art and permaculture in Central Argentina for almost 10 years. Through practices such as design workshops and theatre, eco-construction and crafting sustainable products, Reciclando Utopias cultivates relations among community members, and between people and nonhuman nature. While one aim of the cooperative has always been to create meaningful work and provide jobs, Reciclando Utopias further creates opportunities to learn and reimagine relations. Here relations are explicitly social and ecological; and in some aspects, these become one in the same. For example, building on the work of Mollison and Holmgren, among others, the cooperative understands permaculture as “a holistic design system based on direct observation of nature, learning from ancestral knowledge and findings of modern science” . All coop activities emphasize “permaculture in everyday life”, such that permaculture constitutes social and ecological praxis: praxis that attends to cooperative, democratic social relations among humans, always in relationship with nonhuman nature and the planet. When witnessing the cooperative, the word Pedagogy of the Oppressed. In this case, however, nature is also a teacher. The authors include testimonies from APC members. I keep returning to how the APC president describes the water cycle and the everyday washing of hands: “You don’t do anything to complete the water cycle. As soon as you understand that water is a living being you start to think differently. You are not washing your hand, they are washing your hand” . This testimony points to how members of the cooperative expand relations. Water is not a resource to manage here; water is agentic and alive. Water teaches.By creating spaces of “encounter” and workshops at the intersection of arts and permaculture, the APC attends to human relations in a Freirean sense. For example, some of the encounters are designed for the cooperative members, to promote learning among members and community-building, while others are for external participants. In doing so, the cooperative offers multiple opportunities for collaborative reflection. Furthermore, the coop considers how learning and teaching can be simultaneous, reflecting Freire’s point in how they are expressed? How does the art and permaculture cooperative nuance human relations, by engaging mind, body, and spirit ? How does this attention to expression extend to “writing up” research? For instance, Martín et al. begin with a poem on “recycling utopias,” the inspiration for the cooperative. Through the cooperative, art in the form of poetry, theatre, and more are mobilized as a way to both express social–ecological relations and learn about them. I also wonder how expressive modes of learning and teaching facilitate paradigm shifts. Building on permaculture, bridging “ancestral knowledge and findings in modern science” , involves tensions. The authors point to these tensions when they emphasize holding multiple knowledges, building on de Sousa Santos’ theory of an ecology of knowledges. What power dynamics must be acknowledged and named, to hold these multiple knowledges? How does understanding water as agentic, relate to Indigenous and Traditional ways of knowing that have already been practiced locally or globally? And, how/does permaculture make its engagement with Indigenous Knowledge in this context?I keep returning to these words. They move me; they evoke Freire’s attention to love and hope as not only emotions but as catalysts for transformation. Throughout, this case study lifts up how love, hope, and more might be cultivated and expressed through learning. In doing so, the authors open up questions about art and aesthetics in critical environmental education. How is critical environmental education not only about which relations are expressed, but about how her autoethnographic reflection is written is part of ecopedagogy as praxis. Building on the work of Katherine McKittrick  together in pedagogical context. As a learning context, the Young Naturalists Program fosters dialogic learning, in part by intentionally involving youth from different racialized, class, geographic, and other backgrounds. Hecht observes how dialogic learning emerges without specific prompts, but instead in the course of collaborative work as the group “cut down vines choking young trees; hauled logs to build erosion and deer protection structures; learned names of birds and trees and insects; held moths gently in our hands; talked and listened to each other, a group of people that might never connect in other circumstances; discovered that these people were our people.” As Hecht suggests, and as Freire emphasizes, this kind of emergent dialogic learning is not guaranteed. Intentional human relationships are fostered. As I witnessed Hecht’s reflection, I wondered what scaffolding supported the learning? Would Hecht consider practices like community agreements or otherwise, as scaffolds for the space? And what did/do these look like, as the youth learn about nature with/in nature?Her observations especially reflect on nature, including the common and binomial names for plants, insects, and animals. As she discusses cultural and social diversity among humans, she lifts up diversity among other forms of life. But rather than uphold a human/nature binary, I think Hecht grapples with humans as nature as well, as she is “working to reveal the connections between biological and cultural diversity and the ways in which the loss of one is intimately tied to the other.” Relations again take multiple forms here, as Hecht considers how human relations within the program, unfold amid intricate, ecological relations that do not require human intervention or awareness. She writes, “microscopic fungal organisms [Mycorrhizae] connect trees to one another, connect trees to other flora. Each part not only relies on other parts of the system, they are part of one another, making up the whole of the thing we call forest. There are no individuals here. The value of diversity is for the collective, for the community” . As she centers Mycorrhizae, Hecht moves beyond nature-as-metaphor; her observations are about more than equating the importance of biodiversity to human diversity, but about how these are always in relationship and involve each other. Meanwhile the words “what we call the forest” opens up space for wonder. What are names for forests? What might forests call themselves? Hecht inspires this wonder, partly because she emphasizes curiosity and inquiry, but also because she centers the lives of Mycorrhizae.In fact, I appreciate how Hecht specifies interbeing, the interconnectedness of all life and the aliveness of nonhuman nature. Maybe she would share this with Freire, along with the personal stories she shares throughout her body of work. In one short essay, she invites the reader to, “Stand on solid ground and be a true witness” . Freire addresses human relations at length. relational in the sense of upholding communication, dialogue, and mutual recognition of humanity. However, Freire does not make that leap to a more expansive relationality, one that engages more-than-human life such as animals and plants, or nonhuman nature such as water, as agentic and knowledge-producing. Moreover, interrogations of “the human” raise questions about the emancipatory possibilities of humanization.and still finding meaning in his work. She would repeat: “I came to Freire thirsty, dying of thirst , and I found in his work  a way to quench that thirst. To have work that promotes one’s liberation is such a powerful gift that it does not matter so much if the gift is flawed” (Similar to how Misiaszek and Torres , these c flawed” , 50. hoo


Background: Fredet’s fascia represents a crucial landmark for vascular surgical anatomy, especially in minimally invasive complete mesocolic excision (CME) for right-sided colon adenocarcinoma. Fredet’s fascia allows access to the gastrocolic trunk of Henle (GCTH), the most critical step in both open and minimally invasive right-sided CME techniques. Despite this, a recent workshop of expert surgeons on the standardization of the laparoscopic right hemicolectomy with CME did not recognize or include the term of Fredet’s fascia or area. Hence, we undertook a systematic review of articles that include the terms “Fredet’s fascia or area”, or synonyms thereof, with special emphasis on the types of articles published, the nationality, and the relevance of this area to surgical treatments. Methods: We conducted a systematic review up to 15 July 2022 on PubMed, WOS, SCOPUS, and Google Scholar. Results: The results of the study revealed that the term “Fredet’s fascia” is poorly used in the English language medical literature. In addition, the study found controversial and conflicting data among authors regarding the definition of “Fredet’s fascia” and its topographical limits. Conclusions: Knowledge of Fredet’s fascia’s surgical relevance is essential for colorectal surgeons to avoid accidental injuries to the superior mesenteric vascular pedicle during minimally invasive right hemicolectomies with CME. In order to avoid confusion and clarify this fascia for future use, we suggest moving beyond the use of the eponymous term by using a “descriptive term” instead, based on the fascia’s anatomic structure. Fredet’s fascia could, therefore, be more appropriately renamed “sub-mesocolic pre-duodenopancreatic fascia”. Colorectal cancer represents the third most common cause of cancer death, with 1.8 million new cases in 2018 worldwide .More recently, CME has been further optimized through the use of minimally invasive techniques such as laparoscopy and robotics , which mHowever, the actual mesocolic anatomy and its dissection planes are a relatively recent discovery.Quite surprisingly, for over a century the anatomical description of the mesocolon widely accepted in teaching and all related sciences originated from the observations made by the British surgeon Sir Frederich Trèves in 1885 [In 2012, this traditional and well-established concept was refuted by Culligan , who docInterestingly, these findings confirm those of Austrian anatomist Carl Toldt, who, in 1879 [Most importantly, this new paradigm represents the rationale for surgeons to conduct colonic mobilization as an intact package along the avascular mesocolic planes. In keeping with this, several studies have shown that Toldt’s fascia is the natural embryonic dissection plane for the conduction of complete mesocolic excision (CME) in colon cancer surgery .However, while CME with D3 lymphadenectomy (D3-L) is widely performed for left colon cancer, CME in right colon cancer turns out to be more challenging.On the right, in fact, the reflection of the lower peritoneal sheet of the transverse mesocolon on the duodenopancreatic peritoneum forms a distinct but not widely known embryological fascial plane: the Fredet fusion fascia , which sThis embryological plane is named after the French surgeon Pierre Fredet (1870–1946), best known for the Fredet–Ramstedt’s surgical technique for the treatment of newborns with hypertrophic pyloric stenosis. In fact, Fredet also performed original anatomical and embryological studies on renal capsule formation and pre-pancreatic and mesocolic fascia. The French surgeon clearly differentiated this fascia from that of Toldt .The real relevance of this fascia, however, derives from its arrangement. In fact, an extended dissection over the descending portion (2nd part) of the duodenum and pancreas head with exposure of the upper mesenteric vessels is necessary for the mobilization of the ascending colon in the context of right-sided CME.Crucially, only the dissection of the Fredet’s fascia allows for the exposure of the submesocolic anterior aspect of the duodenum and pancreas and to enter the surgical area of the gastrocolic venous trunk of Henle (GCTH). The latter is located at the head of the pancreas where it drains into the superior mesenteric vein (SMV). The GCTH represents the most critical point of dissection in both open and minimally invasive right-sided CME techniques. The SMV is located at the medial limit of Fredet’s fascia and represents an important surgical landmark for CME .Despite its topographical relevance, a recent workshop of expert surgeons on the standardization of laparoscopic right hemicolectomy with CME did not recognize or include the term of Fredet’s fascia or area . The detThe aim of this study is, therefore, firstly to clarify the anatomic description of Fredet’s fascia and its relevance in colon cancer surgery, and, secondly, to evaluate the use of the term “Fredet’s fascia” in the current international scientific literature.“Fredet” on PubMed, WOS, and SCOPUS“Fredet’s” and “area” or fascia”, and pancreatectomy” on PubMed, WOS, SCOPUS, Google, and Google Scholar“Fredet’s” and “area” or fascia”, and “gastrectomy” on PubMed, WOS, SCOPUS, Google, and Google Scholar“Fredet’s” and “area” or fascia”, and “colectomy” on PubMed, WOS, SCOPUS, Google, and Google Scholar“Preduodenopancreatic” and “fascia” on PubMed, WOS, SCOPUS, Google, and Google ScholarWe conducted a systematic review up to 15 July 2022 on PubMed, WOS, SCOPUS, and Google Scholar without any language restriction. Our comprehensive searches were performed using the following strategies:https://books.google.com, accessed on 3 July 2022)The search was also performed on additional texts identified through the references of the original articles and relevant grey literature through Google Books  from each article, we grouped the definitions into categories using an emergent coding approach and tabulated the frequencies and percentages of each. We did not use advanced statistical synthesis techniques because the usefulness of this review depends on its capacity for describing the variety of anatomical definitions in use rather than generating very precise pooled prevalence and heterogeneity estimates.Secondary outcomes included the nation where the study was performed, publication source and type  and publication topic, .http://www.crd.york.ac.uk/prospero accessed on 3 July 2022).The protocol for this systematic review was submitted and accepted by PROSPERO: CRD42019122985 (n = 26) originated from Italy which amounted to 57.8% of the contributions in the field, with 42.2% of the remaining studies originating from 12 other countries: China (n = 3), Germany (n = 2), Spain (n = 2), Argentina (n = 2), Greece (n = 2), USA (n = 2), France (n = 1), Romania (n = 1), Serbia (n = 1), Turkey (n = 1), U.K. (n = 1), and Japan (n = 1).The PRISMA flow diagram shows the results of our systematic search. Ultimately, our search yielded 45 publications ,52,53,54Among the included publications, the studies from Siani et al. appear five times, the studies from Pugliese, D’Annibale, and Garcia-Granero appear twice.Fredet’s fascia” definition was equivalent to the “sub-mesocolic pre-duodenopancreatic fascia” or “Fredet area”; such an area has a precise topographic localization in front of the duodenum and the head of the pancreas, and behind the root of the transverse mesocolon, to the right side of the superior mesenteric vein (SMV). Six studies reported more than one synonym . Some articles used the terms “Fredet right transverse mesocolon fascia”  and “Fredet sub-mesocolic duodenal-pancreatic fascia”  (The term “Fredet’s fascia” was only used by 29 out of 45 (64.4%) authors: different synonyms were reported in the other studies. Investigators used the terms “Fredet’s fascia” and “Fredet pre-duodenal pancreatic fascia” as synonyms in the minority of the studies . Surgeons claimed that the “5, 2.2%) .The “Fredet’s fascia” was mostly defined as “the area below the right transverse mesocolon as a result of the joining of the inferior layer of the root of the transverse mesocolon to the visceral peritoneum layered onto the duodenum and the pancreas” , with few studies  reporting that it is the area “below the root of the mesocolon, the fusion of the inferior lining of the transverse mesocolon (right and left) to the ventral surface of the pancreas (body and tail)” .Fredet’s fascia” or one of its synonyms, the vast majority refer to laparoscopic/robotic right colectomy; only a few articles mention other surgical techniques such as pancreaticoduodenectomy, gastrectomy, or distal pancreatectomy  is primarily that its sharp dissection in the avascular plane allows the best exposure of the gastrocolic trunk of Henle (GCTH) and of the anterior surface of the SMV. This latter anatomical landmark represents the medial limit of this area .Consequently, “Fredet’s fascia” (“sub-mesocolic pre-duodenopancreatic fascia”) is an important anatomical landmark for the vascular surgical anatomy of the right colic vein, the right gastroepiploic vein, the gastrocolic Henle’s trunk, and the SMV—the most important anatomical landmark in CME for right colon cancer .The latest advancements in surgical oncology for colorectal adenocarcinoma emphasize the crucial role of a radical approach performed along the embryonic developmental planes . Hence tRegarding Fredet’s fascia’s topographical limits, some considerations are necessary. The root of the transverse mesocolon divides the abdominal cavity into two main compartments, the supra and inframesocolic, which are then divided into subspaces. This root is oblique from right to left and from inferior to superior. It crosses the lower third of the right kidney, the descending portion (second part) of the duodenum, and the head of the pancreas; then, it passes over the duodenojejunal flexure and runs along the inferior border of the body and tail of the pancreas to finish at the upper third of the left kidney.Crucially, the inframesocolic compartment is further divided by the root of the small bowel mesentery, in two unequal spaces: the smaller right inframesocolic space and the larger left submesocolic space. The root of the mesentery starts crossing the duodenum mostly at the level of the union of the horizontal portion (third part) with the ascending portion (fourth part) of the duodenum and continues running obliquely to the ileocaecal valve.In the right inframesocolic space, the parietal peritoneum, after having overlaid the lower third of the right kidney with its proximal ureter and gonadal vessels, the subpapillary lower half of the descending portion (second part) of the duodenum, and the whole horizontal portion (third part) and the lower third of the head of the pancreas reflect from back to front to form the inferior sheet of the transverse mesocolon; to the right, it adheres to the overlying fixed portion of the ascending mesocolon (both forming the right Toldt’s fascia); to the left, it continues with the right sheet of the mesentery root; at the bottom, it descends on the anterior aspect of the right psoas major muscle .In keeping with this, Fredet’s fascia corresponds with the fusion plane between the inferior layer of the right transverse mesocolon and the anterior duodenopancreatic peritoneum.More specifically, its anatomical boundaries are as follows: upward, the right root of the transverse mesocolon; downward, the inferior border of the duodenal horizontal portion (third part), below which Fredet’s fascia continues as the right of Toldt’s fascia; to the right, the medial margin of the hepatic flexure where Fredet’s fascia merges into the right fascia of Toldt’s; to the left, the right sheet of the mesentery root and immediately after, the Henle’s trunk and the medial border of the SMV.Henle’s trunk is formed  by the convergence of the stomach-draining right gastroepiploic vein (RGEV), the anterior superior pancreaticoduodenal vein (ASPDV), and the colon-draining superior right colic vein (RCV) and drains into the superior mesenteric vein (SMV) at the inferior border of the pancreas head  Figure . It is nTherefore, knowledge of Fredet’s fascia’s vascular surgical anatomical relationships is essential for colorectal surgeons to avoid accidental injuries to the superior mesenteric pedicle during right hemicolectomy with CME. Such knowledge then becomes indispensable in transferring CME from an open to a minimally invasive setting. It is also worth noting that laparoscopic and robot-assisted CME is an increasingly commonly performed procedure for the surgical treatment of colorectal cancer techniques by the authors of our systematic review, as shown in retropancreatic fusion fascia or fascia of Treitz, dorsally, and the sub-mesocolic pre-duodenal-pancreatic fascia or Fredt’s fascia, ventrally.Moreover, Fredet’s fascia cannot be identified as Toldt’s fascia, which represents a distinct fascial plane apposed between the retroperitoneum and the right and left mesocola. However, it is also useful to note that the right Toldt’s fascia at the right inframesocolic margin of the second portion of the duodenum divides to merge into the fascia of Treitz (behind of duodenum) and the right fascia of Toldt, respectively. Conversely, in front of the subpapillary second duodenal portion and the lower third of the head of the pancreas, the fusion of the right inferior layer of the transverse mesocolon under its root, to the pre-duodenopancreatic peritoneum, constitutes the sub-mesocolic pre-duodenal-pancreatic fascia or Fredet’s fascia (This description fits well with classic anatomy textbooks such as Testut and Latarjet : the fats fascia .Terminologia Anatomica (TA) of the Federative Committee on Anatomical Terminology [area of the peritoneum corresponds to any part of the mesothelial surface of a single peritoneal layer (or sheet) while a fascia is a “generic” anatomical term that refers to a variety of the body’s soft fibrous connective tissue parts.Regarding Fredet’s fascia’s anatomical terminology, it is correct to use the term “fascia” and not the term “area”. According to the minology , in factfusion fasciae, which only occur in the peritoneum during the rotation and posterior attachment of the primitive gut tube. Even more specifically, fusion fasciae are formed through the adherence between the mesothelium of the embryonic mesentery with the mesothelium of the embryonic retroperitoneum.In particular, as mentioned above, Fredet’s fascia, as well as Toldt’s and Treitz’s fascia, are The concept of “fusion fascia” is indispensable when considering the relationship between the peritoneum and the mesenteries at the end of intestinal rotation around the axis of the superior mesenteric artery (SMA). Classic anatomical teaching holds that the intimate apposition of two mesothelially covered surfaces is followed by the disappearance of the mesothelial cell layer, leaving only the immature connective tissue of the developing peritoneum, designated as a “fusion fascia”.In actual fact, as elegantly demonstrated by Culligan et al. , the twofusion fascia is a thin connective tissue plane sandwiched between two mesothelial cell layers, which form a bloodless cleavage plane allowing the retroperitoneal portions of the bowel to be safely mobilized and also limits the spread of diseases.In keeping with this, a Likewise, Fredet’s fusion fascia is a connective tissue plane situated between the deep mesothelial layer of the right transverse mesocolon and the mesothelium of the visceral duodenal-pancreatic peritoneum.The present study suggests that the eponymous fascia of “Fredet” is poorly known and inconstantly used. Moreover, even if the debate over the use of eponyms in medicine continues, the anatomical terminology trend is to consider them obsolete. Their critics, in fact, contend that eponyms are inherently inaccurate and variable, frequently overlap in meaning, sometimes honor the wrong people, lack scientific descriptiveness, and are inconstantly interpreted in different countries.In conclusion, they may be an impediment to efficient communication and learning.Moreover, the synonyms utilized in the majority of studies such as “anterior pancreatic fascia” and “pre-duodenal fascia” or simply “duodenal fascia” are not consistently used across the literature and in any case refer to a partial (duodenum/pancreas) anatomical structure and not to its inframesocolic portion specifically.Therefore, in order to avoid confusion and clarify this fascia for future use, we propose using a more comprehensive non-eponymous term, such as “sub-mesocolic pre-duodenopancreatic fascia”, which is centrally based on the anatomical structure in accordance with their embryonic development.Our systematic literature review confirms that the term “Fredet fascia” is poorly or incorrectly used by some authors, likely due to the lack of both a comprehensive understanding of its anatomy and the standardization of its terminology.“sub-mesocolic pre-duodenopancreatic fascia” instead. This term complies with the descriptive, topographical, informative, didactic, and communicative criteria of the International Anatomical Terminology, which, since 1933 and with few exceptions, has considered eponyms unofficial terms [As we are aware that the standardization of terminology is very important for international communication, research, and medical education, we suggest using a “descriptive” term such as al terms .The authors’ explicit intention in recommending this term has been to facilitate clear and unambiguous international and interdisciplinary communication on this embryologic fusion fascia, in order to help standardize surgical practice, especially for more recent minimally invasive techniques, such as robotic and laparoscopic-assisted right-sided colon cancer surgery.