As result of the COVID-19 restrictions, PA, wellbeing and QoL of people with ESRD were found to have been hindered. However, widespread support for the continued use of telemedicine was strongly advocated and promoted independence and satisfaction in patient care. These findings highlight the need for more proactive care of people with ESRD if asked to shield again, as well as increased awareness of safe and appropriate PA resources to help with home-based PA and emotional wellbeing.Early in the coronavirus-2019 (COVID-19) containment strategy, people with end-stage renal disease (ESRD) were identified as extremely clinically vulnerable and subsequently asked to ‘shield’ at home where possible. The aim of this study was to investigate how these restrictions and the transition to an increased reliance on telemedicine within clinical care of people living with kidney disease impacted the physical activity (PA), wellbeing and quality of life (QoL) of adults dialysing at home (HHD) or receiving in-centre haemodialysis (ICHD) in the UK. Individual semistructured telephone interviews were conducted with adults receiving HHD ( Early in the coronavirus 2019 (COVID-19) global pandemic, people with some pre-existing medical conditions were identified as having an increased risk. Since chronic kidney disease (CKD) is associated with a greater risk of both inpatient and outpatient pneumonia . Indeed,People with ESRD were now experiencing a change to much stricter regulations. Although aimed at limiting COVID-19 transmission, these new restrictions reduced social contact and physical activity (PA), potentially leading to negative health implications ,6. HowevGeneral population data and reports from early in the COVID-19 pandemic highlighted that shielding can have a detrimental impact on the mental health and wellbeing of older people ,10, as wAn additional consequence of the COVID-19 pandemic was a rapid change in the way clinical care was delivered. Specifically, face-to-face contact between clinicians and people living with kidney disease was abruptly reduced and replaced by an increased reliance on telemedicine and remote clinics ,26,27. TThe present study therefore aimed to explore the experiences of the initial COVID-19 restrictions on PA, wellbeing and QoL in shielding adults with ESRD in the UK receiving ICHD or HHD, as well as their experiences of telemedicine.This study consisted of individual semistructured interviews conducted over the telephone between 10 June and 10 July 2020. Semistructured interviews provide a rich, personal narrative of participants’ experiences and rely upon the rapport and relationship between researcher and participant. This time period was chosen to correspond with the initial COVID-19 containment strategies concerning human movement in the UK and following the reclassification of people with CKD and ESRD as ‘extremely clinically vulnerable’. The study was designed and conducted in line with Guba and Lincoln’s criteria for rigour in qualitative research  and repon = 10; 61.2 ± 8.9 years; 8 males; time on dialysis: 44 ± 58 months) or HHD  were invited by a member of their primary clinical team or the principle researcher (JA) to participate. Fully informed verbal consent was obtained prior to participation. Inclusion criteria consisted of being ≥18 years of age, willing and able to provide consent and being free from any psychiatric or neurological diagnosis at the time of interview. Recruitment continued until data saturation was reached , with dialysis prescriptions varying between short daily dialysis to alternate day nocturnal regimens, utilising dialysate volumes ranging from 20 to 60 L. Dialysis prescriptions are adjusted to achieve a standardised weekly adequacy (2.4 Kt∙V-1), with flexibility given to individuals with a significant residual urine volume.People receiving ICHD must attend three sessions per week, which typically last 3–5 h depending on the time required to achieve adequate waste removal and fluid removal. Most of these individuals also require patient transport services to assist with travel to and from their dialysis unit. The Wessex Kidney Centre HHD programme exclusively uses the NxStage®-https://www.myrenalcare.com/) before the COVID-19 restrictions were implemented. This system was developed by Ardia Digital Health Ltd.® in collaboration with the Wessex Kidney Centre. It is a purpose-built, integrated telehealth platform for people with ESRD and their clinicians, which aims to help people living with kidney disease take ownership of recording clinical and technical information about their HHD sessions and patient-reported outcome measures. This was continued during the COVID-19 restrictions.Before the COVID-19 pandemic, people with ESRD attended routine quarterly face-to-face clinics with their renal consultant. For those on ICHD, this usually involved attending the dialysis centre and conducting a consultation at the bedside. As a result of COVID-19 restrictions, it was necessary to undertake these routine reviews by telephone rather than face-to-face. For people with additional comorbidities , additional telephone clinics were also required with other specialties. For people receiving HHD (but not those on ICHD), the Wessex Kidney Centre HHD introduced a digital remote monitoring platform  and were concluded when each participant felt that they had nothing further to add. The interviews were audio recorded and then transcribed verbatim. All audio recordings/transcripts were only available to members of the research team and all transcripts were anonymised immediately.Transcripts were analysed using NVivo 12 software package  and coding and thematic analysis undertaken using a systematic approach . An abduTwenty adults with ESRD (10 receiving HHD and 10 receiving ICHD) were enrolled in this study. Throughout the interviews in this study, it became clear that people expressed the impact of the COVID-19 restrictions through how aspects of their lives had changed or indeed remained similar to before the pandemic. Within this, the dimensions of PA, wellbeing and QoL, and medical care were discussed, and several key themes identified .Some of the participants described how their levels of PA have either remained the same or even improved. Indeed, one individual stated that their PA did not change, “because we have largely gone about our normal business and near here there are walks around here that you can do without meeting anyone anyway”. Similarly, another stated: “I go for quite long walks with the dog. Again, it’s only in the fields and stuff, I don’t go to any built-up areas, but I am following the guidelines to protect myself, but I am also kind of stretching them a bit to suit myself”.With regard to PA, participants described two changes as a result of the COVID-19 restrictions, with the first being changes in frequency of PA, where individuals described a notable change in the amount of time spent being physical active compared to before the COVID-19 restrictions. One participant said: “Oh, well yes they [PA levels] have gone down quite a lot obviously”. On the contrary, one participant described an increase in the amount of PA they were undertaking, due to the impact of working from home and the extra time this gave, saying: “I think, they have actually gone up, randomly. I really took the opportunity because I enjoy my running, so I have really taken the opportunity to get back into that and yes, we have been cycling regularly”, which suggests not all individuals were strictly shielding.The second change was in the modality of PA, which saw individuals changing their approach to PA as a result of the restrictions, including gardening or indoor alternative to exercise. For example, one participant said “Yes, so I started doing P.E. [Physical Education] with Joe Wicks and I started doing that Monday to Friday”. Another participant said: “We are lucky we have a garden, so we have been doing gardening. We have had plants delivered and made use of the garden and working in the garden”.Participants in the HHD group described four areas which they felt had remained constant from prior to the COVID-19 pandemic and associated restrictions in relation to their wellbeing and QoL. The first of these areas related to the participants’ employment, with a number of individuals stating that they felt the support received from colleagues had remained consistent. For example, one participant said, “one of the assistant managers phoned me later and then I felt supported”. A second area described was the stability in their psychological wellbeing, which had remained constant throughout COVID-19. For example, one participant said: “Predominantly over the last three years I have been having counselling [to support my wellbeing] and I think yes, COVID-19 was in there [so my psychological wellbeing has remained constant]”. Thirdly, participants described their renal treatment and how their exposure to a chronic condition prepared them for the social requirements of COVID-19, with one participant stating: “We had to alter our lives so dramatically because of dialysis, which is a daily event … in a way, we had a prelude to losing freedom”. Finally, participants described their experience as having no change, with many expressing the lack of effect as a result of the COVID-19 restrictions. For example, when asked what had changed, one participant stated: “Well not a lot really because we didn’t used to socialise that much, only to see the family”. Furthermore, another said: “We can be pretty productive, and I don’t really feel as though we have suffered particularly”.Participants described four areas they felt had changed in relation to their wellbeing and QoL as a result of the COVID-19 restrictions. The first of these related to their behavioural changes, as they had to adjust to adhere to social distancing guidelines. For this group of extremely clinically vulnerable individuals, this mandated complete isolation if possible, including from exercising outdoors. One individual noted: “Yes, well obviously, it affected what I do when I go out. I have been out a few times and if I have gone out at all it has been very early in the day when there are very few people about, and I do tend to give people a very large margin when I do go out walking”. Another participant described changes in communication methods saying: “It has changed, in the way that we normally speak and see people. We tend to have a lot of people coming around to see us for coffee, not parties or anything but just general, so that has been quite different, but we have done some stuff on Zoom and texting and stuff like that”.A second area of change was described as feelings of independence and captured the emotional responses felt by participants through changes caused by COVID-19. When asked to describe how they felt, one participant expressed upset: “In the point that none of us can live our lives the way we would like to”. The third area of change was described as the emotional impact of the COVID-19 restrictions, where participants felt left behind or disappointed due to their vulnerability to COVID-19, with one participant saying “I was a bit disappointed to receive it [the letter informing them of their vulnerability status], but that is something which is just personal disappointment that I wish I wasn’t that much more vulnerable than anyone else”. Moreover, another participant stated that: “I was very tentative and didn’t really know what to expect and I felt like the rest of the world had already done it [left the house] and I was the last person to do it, if you like”. The final area of change was described as an increased concern, including concerns for job security, obtaining essential supplies and feeling safe to leave the house. When probed, participants expressed their “only worry was with work, was I going to have a job at the end of this isolation and the end of the shielding”, “That was really difficult to begin with, we really struggled with that [obtaining essential supplies] to begin with because we couldn’t get a supermarket slot” and “I would be concerned about going into hospital because I’ve heard a few stories of people going in and actually catching [COVID-19] it in hospital”.When individuals described their medical care during the initial COVID-19 restrictions, two distinct unchanged experiences were noted. First, confidence in renal staff, with individuals describing their maintained confidence and outspoken praise for their clinical teams. For example, when asked about any changes to their medical care as a result of COVID-19 and the restrictions put in place, one participant said: “No, none at all, it has all been as it always has been. I am very applauding and grateful for that because at no stage was there any feelings of fear or anxiousness”.The second unchanged experience was the support from the HHD team, with individuals describing a constant and proactive approach from the HHD team to ensure their welfare. For example, one participant said: “Well actually, a bit more support this time. Since the COVID-19 lockdown, I have had more support than before. I mean, before the support was always there available but now it is more proactive where I actually get called”.Participants described two areas where the COVID-19 restrictions have resulted in change in their medical care. The first of these related to communication difficulties, with some individuals describing incidents where communication was lacking, with one individual saying “Yes, I mean, to be honest with you, that has been the [most] frustrating thing of all, is not knowing what the results were and being able to actually talk them through”. One participant also described how the proactive response of the HHD team may have been unnecessary: “For a while after a few weeks ago, I was having weekly phone calls and I almost found them unnecessary, because I didn’t need them before, my situation hasn’t changed in the fact that I am a home patient so I knew that if I had an issue, there would be someone there for me”.The second change related to concerns with future care where individuals expressed their concerns regarding future transplants and concerns returning to clinical environments: “Yeah, we are concerned that if it’s going to interrupt the prospect of transplants with the people and operations and all the rest of it so that concerns me”.Throughout these discussions, participants described two areas relating to the use of telemedicine during the COVID-19 restrictions. The first of these was support for telemedicine, where individuals expressed their support for the use of telemedicine and described positive experiences they have had utilising remote medicine within their clinical care: “Oh, I would be more than happy actually [to continue remote clinics]. It saves me travelling a long way. Absolutely fine, I would prefer [to continue remote clinics], I think”. However, individuals generally expressed their opinion that the use of video conferencing would be more beneficial than a telephone call, as it allows the use of nonverbal communication: “It would be better if you could do it via video link because then you can see the other person”. These experiences were for routine care where there is no particular issue, and many expressed that should an issue arise, they would rather a face-to-face consultation: “Yes, that would be fine to say yeah, I mean, obviously, if I did start not feeling well, or things, then I would like to see face-to-face but in general, I can’t see a problem with that”.The second area relating to the use of telemedicine, was concerns about remote medicine, where individuals expressed their dislike for the formality of telephone appointments and the lost elements of nonverbal communication when utilising telemedicine: “I probably wouldn’t mind for the next three months when things are still settling or whatever, but I honestly don’t think you can beat hands-on seeing somebody”.Within the changes in PA, two areas were described. These two areas were changes in frequency and changes in modality. When this topic was discussed, most people fell within these areas. One individual discussed their reduction in frequency as “My PA was walking, and, in the house, there isn’t a lot of walking that you can do. They say to run up and down the stairs, but I can barely make it upstairs once let alone run up them”. Another described a change in modality as “Well there is a strange thing called housework and that has been receiving more attention than in the past, shall we say”.During the discussions, all participants expressed two aspects of wellbeing and QoL that have remained the same during the COVID-19 pandemic. The first aspect is described as that of no change where many individuals described the lack of changes to their lives compared to the time before the pandemic. For example, two individuals said: “I can’t say that it has affected me a great deal” and “To be perfectly honest, it [COVID-19 restrictions] has changed our lives very little”. Secondly, many people reported that they were accepting of vulnerability and did not seem to be affected by their addition to the clinically extremely vulnerable list: “No, I don’t think it affected me. If something is going to happen, it is going to happen, isn’t it?”When discussing aspects that have changed, five areas that have changed over this period were identified. The first of these being an impaired wellbeing, where individuals have described how the changes made during the COVID-19 pandemic have affected their lives: “It has upset my complete wellbeing. I was in a routine for so long and then all of a sudden it changed”.A second aspect that had changed was social interactions, with all people interviewed who were receiving ICHD describing a reduction in their social interactions, but an uptake of social media use. One individual said “Oh, unbelievably so. I was talking to my partner, I would say 85% of the time and conversations get a bit strained after a while, there is only so much we can talk about”.Issues with societal restrictions were also noted, with individuals describing how they were out of touch with social distancing and societal requirements due to their time shielding: “I went into the main door and I walked straight to where we normally go to speak to a waiter and he said sorry madam, back to the cross on the floor because I am not used to it”.Concern for the future was also identified, with many describing their worry and anxiousness for what is to come: “A bit scared for the future quite honestly, because I don’t think that’s the last we are going to see of it. I have a feeling that once the winter sets in, it will be back”.The final aspect is one of a positive experience where individuals have identified communal support whether this be from family, neighbours, friends or local councils to assist them throughout the pandemic: “The council here, have been very good. They have tried to send us a food parcel and all of that”.When discussing their medical care, two themes were identified to have remained stable over this time. The first of these was administrative issues, which involved the difficulties with dialysis sessions, test results and facilitation of routine care: “Well obviously, they have moved me from QA  to Havant, and that was just a total nightmare for the first 4 to 6 weeks, it was horrendous” and another saying “Well, they come too late to get you to your appointment and they don’t take into account the fact that they bring you in late and they expect you to be ready on time”.The second of these is communication difficulties with staff, where many issues and difficulties were caused by communication, or lack thereof with members of staff: “There has been no follow-up, no how are you getting on? No, this that or the other”.When discussing their medical care throughout the COVID-19 pandemic, three changes experienced were identified. The first of these is that some of individuals have reported to look forward to dialysis as it acts a break from the lockdown and the restrictions and provides social interactions: “But I mean as far as I am concerned, in terms of the pandemic, it was a bit of a release to be honest of you being able to get out of the house three times a week to go to the dialysis and see other people”.The second of these is the confidence in renal staff, where individuals have described the confidence that they feel from the nursing staff taking care of them: “Yes. Yes, as I said, they are really good there, so they all talk to you and if you feel down or you want to talk to someone, they are there. You know, that we all have a laugh and that”.The final experience identified is surrounding concerns for attending hospital, where many individuals have expressed their wariness of attending hospitals for routine appointments and even for dialysis: “Yes. I felt more at risk, obviously even though I was putting on PPE to go into a taxi, so I felt more at risk doing that and going to the dialysis centre than because of the environment”.When discussing the experience of telemedicine two themes were identified. The majority of the responses were in support for remote clinics, describing the benefit of reduced travel and waiting time and not having to attend the hospital for a quick chat with one describing it as “Providing the physicians are up to speed with what is going on in your life and your records, I think it is an extremely good way of doing it. It cuts down on travel time and their time”. Certain points were raised however in support of face-to-face appointments, when the patient or clinician identified a problem that they would like to discuss.The second theme was regarding the dislike of remote clinics, where individuals described how they enjoyed the conversation and took comfort in seeing the clinician taking notes and providing an action plan in person. For example, when questioned, an individual said: “Yes, because I think if you talk to someone face-to-face about your problems and what you have got going on, I find that they understand and listen more. If you do it over the phone, I don’t know, I just feel like, I know they are good and they do take stuff on board but, you know, it’s just like a phone call, you know what I mean”.The primary aim of this study was to explore the impact of initial COVID-19 shielding restrictions to human movement (March–July 2020) on PA, wellbeing and QoL of ‘extremely clinically vulnerable’ adults with ESRD in the UK who were receiving ICHD or HHD. Furthermore, this study sought to ascertain their experiences of an increased reliance on telemedicine within clinical care. The principle findings were that, irrespective of dialysis modality (HHD or ICHD), PA, QoL and wellbeing, as well as medical care, were all impacted during this period. All individuals receiving ICHD reported negative consequences to their PA, QoL, wellbeing and medical care, whereas conversely, those receiving HHD primarily reported feelings of little change or a positive impact on their day-to-day life. However, a positive observation was the widespread support for the use of telemedicine within clinical care, regardless of whether people were attending ICHD or dialysing at home.Early in the COVID-19 global pandemic it became apparent that, although shielding aimed to reduce the health risks posed to more vulnerable individuals, it also had the potential to bring about a number of negative physical and psychosocial health consequences. For example, a major immediate consequence of the restrictions to human movement was a reduced ability for many people to perform their typical frequency and preferred modality of PA , particuReduced PA as a result of the COVID-19 related restrictions is particularly concerning given that people with ESRD were generally engaging in less PA than recommended prior to these constraints, with a previous trial in the United States reporting that 56% of their cohort of people with ESRD were only active once or less per week . This nePrior to the COVID-19 pandemic, wellbeing and QoL were often reduced in people with ESRD ,43, espeIn the present study, it was not only the volume but also the type of PA that was impacted in adults with ESRD, with all interviewed participants from both groups reporting that this had changed. Those who has previously undertaken frequent trail and group walking, cycling and personal training type activities reported a shift to walking alone, indoors and outdoors, and an increase in home-based activities, such as housework and/or gardening. In contrast to recent findings in people with cystic fibrosis  and genehttps://beamfeelgood.com/kidney-disease) has been developed; an online platform which aims to help with PA and emotional wellbeing in people with kidney disease that is free for people in the UK until 30 November 2021.Although general recommendations regarding alternative home-based PA during COVID-19 restrictions have been shared for the general population ,54, and In addition to PA, other contributors to reduced wellbeing and QoL were reported in our cohort of shielding adults with ESRD. Many described reduced social interactions, with this being particularly apparent in people receiving HHD compared to those attending for ICHD. Although attending dialysis has been highlighted as an increased risk factor for contracting COVID-19, partly due to the large groupings of people within a relatively small clinical area , our cohThe secondary focus of this study was to capture the experiences of adults receiving ICHD and HHD with regards to changes to their clinical care and the necessary increased reliance on telemedicine. More specifically, there was a need to move routine medical care to virtual delivery and for some ICHD dialysis sessions to change location. A primary positive finding was that people receiving HHD during this time period felt that they received constant proactive support, in the form of consistent and regular phone calls. Since the treatment of people receiving HHD is largely independent and requires minimal day-to-day input from clinicians, a largely unchanged treatment experience was noted in this group, despite reduced face-to-face contact with their renal clinician. People dialysing at home also reported few issues or concerns with regards to their medical care. However, the experience of people receiving ICHD was affected to a greater extent.The clinical care of people receiving ICHD requires input from dialysis nurses and therefore incorporates travelling to a clinical facility three times per week. The ICHD group in the present study reported a number of administrative issues and communication difficulties, which at times resulted in problems with their medical care, such as delayed prescriptions, missed clinic appointments and even missed dialysis sessions. Similar issues to our cohort in the UK were identified in adults receiving ICHD during a COVID-19 lockdown in India where specifically, COVID-19 had similar effects on the dialysis infrastructure resulting in missed dialysis sessions and appointments and, consequently, a negative patient experience . These o® and were more accustomed to remote medicine and feedback than those dialysing in-centre. Generally, individuals in this study supported the use of remote clinics and telemedicine saying that it was nice to reduce waiting and commuting time. This supports recent findings [A positive finding in the present study was, however, the experiences with telemedicine and an increased use of digital health technologies, which lends support to the NHS five-year forward view to use more technology within routine care . More refindings , which fPrior to COVID-19, the use of telemedicine to perform renal clinics was shown to be accepted by clinicians with benefits of reduced travel time, more efficient use of staff time, and a strong sense of job satisfaction being reported , akin to® application which, although originally developed for HHD, may have potential use for the monitoring of people receiving ICHD, particularly on nondialysis days. Moreover, this study highlights the need for more proactive care if/when people may be asked to shield again and support for the implementation of telemedicine in routine care, in line with the NHS forward view [Several participants also had negative experiences with the current use of telemedicine or aspects of it, with some highlighting that they felt that the face-to-face interaction with their consultant or medical professional would provide more comfort in the depth of care they were receiving. This is in line with findings by Fieux et al. , which fard view ,60 and tard view . FinallyThe present findings need to be interpreted in the context of several methodological considerations. First, it has been acknowledged that the modality may alter the interview and, more specifically, the use of telephone interviews for qualitative research is considered by some to reduce the quality of data obtained . HoweverIn conclusion, this study provides valuable insight into the experiences of shielding adults with ESRD, receiving ICHD and HHD in the UK, during the initial COVID-19 restrictions. During this period, PA behaviours, wellbeing and QoL, as well as confidence in care in the ICHD group, were all negatively affected. The majority of people interviewed had positive experiences of the increased use of telemedicine within their clinical care. These findings highlight the need for more proactive care if people are asked to shield again, as well as increased awareness of safe and appropriate PA resources to help with home-based PA and emotional wellbeing, such as the newly developed Kidney Beam platform.


Taking as a starting point the frequent characterisation of self-harm as “an adolescent thing for girls,” this paper offers a sociologically informed, qualitative exploration of self-harm as a gendered practice. We move beyond statistical constructions of this “reality,” and critically examine how this characterisation comes to be, and some of its effects. Our data are drawn from a pilot study that developed a collaborative arts-based inquiry into meanings of self-harm. The authors worked with two groups: one of practitioners and another of people who had self-harmed, meeting over six sessions to discuss and make art in response to a range of themes relating to the interpretation and explanation of self-harm. Through data generation and analysis, we collaboratively seek to make sense of the gendering of self-harm, focusing on a series of dualistic Cartesian “cuts” between male and female, violence and vulnerability, and inside and outside. In conclusion, we call for more multi- and interdisciplinary explorations of self-harm, and greater use of diverse, arts-based, and qualitative methodologies, in order to further expand and nuance understandings and ethical engagements with self-harm, and those who are affected by it.  Added to this—and often unspoken—is that self-harm is framed as a practice of adolescent girls who are also white . Each ofStudies that attempt to map the epidemiology of self-harm have historically used a range of definitions—self-mutilation, self-injury, nonsuicidal self-injury, deliberate self-harm, and more ,11,12. Tsomething is happening. However, it is also clear that whatever is happening in terms of gender and self-harm builds on a long history of self-harm being framed and understood as a female act. Therefore, we must understand these latest developments in this light.Recently, concerns have been raised about an apparently stark rise in the numbers of young women reporting and being treated for self-harm , rising feminine practice. Published papers routinely excluded men from their analysis as “not typical patients,” or described them as “effeminate.” Brickman argues that the reason these researchers worked so hard (against evidence in some cases) to frame self-injury as a feminine practice was that the alternative might be to accept that women could engage in “aggressive” or “violent” (“masculine”) acts. This analysis questions the naming of the practice as “delicate”—unsettling the use made of language that seeks to artfully feminise a practice that might just as easily be read as violent, aggressive, and masculine. Historical work has demonstrated how meanings of self-harm have varied over time ,11,12. Tthe answer, and no other interpretations are sought out. This is problematic, because it takes for granted and does not seek to further interrogate why there might be a relationship between experiences of abuse and the enactment of violence or harm against the self. Further, it leaves unanswered how and why people may come to self-harm in the absence of such experiences. Aside from these critical reviews of historical clinical literature, and despite the frequently gendered findings regarding self-harm, attempts to more deeply explore the relationship between gender and self-harm have been surprisingly scarce ,20. ThisAnother important way in which self-harm is gendered is via the gendering of suicide . CanettoIn this paper, we interrogate the construction of meanings about self-harm as gendered, and we consider the effects of such constructions as illustrated and enacted by ourselves and our participants within collaborative arts-based workshops. In doing so, we seek to show the role of socially mediated, cultural meanings of self-harm in producing it as gendered. This approach goes beyond statistical approaches that construct self-harm as gendered via findings that show that “self-harm is more common in girls”—and looks to other ways in which self-harm is gendered, made sense mainly as a practice of young (white) women. We argue that attending to meaning as well as prevalence is essential if we are to develop responses to self-harm that trouble rather than reinforce oppression and control. This was a pilot study testing a novel method. We sought to explore meanings of self-harm through a combination of group discussions and art making. The project was designed in response to concerns that surveys or qualitative interviews tend to fix meaning, resulting in increasingly standardised explanations for self-harm that do not well reflect the complexity of experience and meaning that self-harm can involve . Our proIn the study, we were concerned with exploring meanings of self-harm among people who had a stake in the issue: people who had self-harmed and practitioners working with those who have self-harmed. Acknowledging the limitations of words in articulating meaning, we designed the study to make space for nonverbal means of meaning making—informed by Tarr and colleagues’ arts-based research workshops on pain  and FostWe held six art- and discussion-based workshops with two separate groups in a UK city. The first group included two practitioners, both white cis women who worked for a mental health organisation and supported people who had self-harmed through one-to-one therapeutic work. The second group included three white young people—two cis women and one nonbinary person—recruited through the same mental health organisation, who were aged 21–26 and who had all previously self-harmed. Two of these participants indicated they had last self-harmed over a year previously, with one participant indicating this was an ongoing practice. With each group, our workshops were based around the same themes . Box 1Communication, silence, and privacySkin and painRitualGender and cultureLife course, age, and cultureOpen sessionFor each workshop, researchers brought a selection of four to five materials, mostly excerpts from publications, but occasionally images and videos, that presented different perspectives on a particular theme . The matWorkshops lasted 90 min, beginning with a 30 min recorded discussion about that session’s theme and materials. These discussions began with each of us taking turns to read one of the short excerpts. This was initially offered as a suggestion (not a requirement), designed to allow each person to speak at the very start of a workshop and bring their voice into the room. In practice, all participants were happy to take part in this, though we imagine that not all groups would have similar levels of literacy, confidence, or comfort to allow for this type of engagement. After 30 min of initial discussion, the recorder was switched off, and we spent 30 min of quiet art making. A selection of materials was made available, and each of us worked individually to explore the theme further through art making. No expectations were placed on artistic ability, and a supportive atmosphere was generated by both Zoi’s expertise as an art therapist and Amy’s explicit presentation as someone who did not “do art.” That said, all participants were clearly comfortable and experienced with art making, which likely guided their initial interest in taking part in the project. After 30 min, we switched the recorder back on for a final 30 min discussion, during which we shared what we had made and reflected further on the topic of the week. Our data comprised approximately 1 h of recorded talk per workshop, which was transcribed ; fieldnotes from both authors; and the pieces of art made by the researchers and participants. Analysis of these diverse forms of data has drawn on the principles of feminist poststructuralist qualitative inquiry  and writThe dynamics of the group and our analysis of the data are invariably shaped by our own positionality and experience in relation to self-harm. Amy is a sociologist who has previously self-harmed and has researched the topic professionally for many years, while Zoi is an academic in counselling and psychotherapy, as well as a practicing art therapist who has worked with young people who have self-harmed but came to the topic as an academic more recently. Thus, both researchers brought different types of knowledge of self-harm to the research. The study was assessed by the Institutional Research Ethics Committee. All the participants chose pseudonyms and provided informed written consent to take part. We approached ethics as an ongoing, negotiated, and relational process. This included checking in on participants’ well-being before and after workshops and maintaining contact between and after the workshops were completed. We met with both groups prior to publicising any findings, and all the participants joined us at public engagement events, where we shared and discussed initial findings. Thus, while we focus on our engagement with the participants around the workshops in this paper, we have benefitted from ongoing relationships with the participants as part of a relational ethical praxis ,33. In the remainder of this paper, we introduce three aspects of the gendering of self-harm, which we drew out of the data, via writing as inquiry and through our collaborative work within the groups. In presenting the findings, we make clear the intertwined roles of art, discussion, and our own analytic and imaginative reflections  in produGender was a frequent presence—and absence—within our discussions. Even during the workshop where gender was the main topic, a notable feature was the difficulty that all of us—participants and researchers—had in talking directly to gender. Thus, one of the themes we draw out is “unsettling talk about gender and self-harm,” which we illustrate through an exchange with Jessica, one of the practitioners, who made this difficulty visible in her art. Through this, we introduce the presence of several binary oppositions that characterised our attempts to make sense of self-harm as gendered. These included aggression and vulnerability, inside and outside, and through these, the binary oppositions that are invoked when considering self-harm as “masculine” or “feminine.” Throughout this analysis, we are mindful of Whynacht’s  cautionsBefore turning to these more substantive issues, we introduce the resources we brought and the images that we created with the participants during Workshop 4, where we explicitly addressed the theme of gender. These are instructive and help to show how this theme took shape within our discussions and later writings into what happened in these workshops. The Cutting Edge: A Newsletter for Women Living with Self-Inflicted Violence. The poem was confronting and explored themes relating to gender, gendered oppression, racist and sexist violence, as well as challenging interpretations of “self-harm” as being about hurting oneself. Our materials for the workshop on gender included excerpts from Brickman , Inckle In our first group, Anna and Jessica, the two practitioners, created images that included an abstract, flowerlike, circular, messy image ; an abstract image of two handlike or veinlike objects coming together, coloured pink and blue, with the centre a thickly rendered grey explosion Jo, see ; a smallIn both the quote and the image , Jessica“As I was doing the artwork, I had the same problem as you, I found it very hard to talk about, find the words for, or to think about in a way, and kind of ignored in some ways the gender, things like that were too difficult somehow, but felt like there was somewhere within that conflict, there seems to be tension between vulnerability and sort of aggression, and a relationship between the two, ’cause I think they’re joint, and I was interested in how, sort of people perceive that and just that there is back and forth between the two, not necessarily linked to gender but linked to maybe how people see gender and not, yeah, part of it being quite, unsure what is what.”JessicaIn our fieldnotes, both authors noted the “heaviness” this topic brought to the room. Our workshops were often marked by periods of silence and reflection, but both of us noted a different, harder quality when we attempted to discuss gender. This difficulty speaks to a challenge that the discipline of sociology grapples with regularly: how to connect individual experiences (private troubles) with larger social structures (public issues) . This was emphasised in the second group, where we discussed how limiting a view of self-harm as “female” or “male” was—Chloe underlined self-harm as personal, which made it difficult to apply a binary of “male or female”:“At the same time self-harm is very personal, is like not a gendered thing, I mean like it may depend on so many things in your character or your personality or you know that you could probably find a group of men, or women doing that in the same way and then yeah I don’t know it doesn’t seem, those claims, assuming that ‘this is that,’ ‘this is that,’ it just sounds so limited, so small, so, yeah even as you’re saying, you’ve got to choose, this or that, there’s nothing in between, is like no space for, for confusion.”ChloeIndeed, the inherent limitation of developing explanations or making sense of self-harm using a binary definition of gender was further challenged by Jo as they discussed their image :“I’ve got the masculine and man and feminine and womanhood like being seen as opposing forces, being seen as opposite and different and the only options, and I think I guess I felt a little bit, invisible within the readings, and having dealt with that, kind of, feeling pulled and having to choose and having to align myself ’cause even in like being nonbinary, it sounds like are you transmasculine or are you trans-feminine, and it’s like no, I am nothing, I am—no, I am not that, I am not within that kind of context, and it’s painful to kind of have those opposing kind of forces and then the idea of being like ripped open and revealing your kind of inner self, […] and I accidentally bent the grey pastel in half (laughs) so I apologise, I got a bit violent at the end…”JoJo’s image  and discViolence and aggression are key resources through which self-harm is gendered in existing research and commentary. Brickman  and Chanself-harm, with fighting or violence against others necessarily involving other-harm as well as self-harm. For instance, each group spoke to the idea that men may be more likely to use fighting as a form of or alternative to self-harm. This suggestion serves to blur the very notion of Jessica: I don’t know if this is based on anything whatsoever (laughs), but often people do say […] you know […] is a female girl thing, but it’s this thing that I have heard and probably said it myself too […] that typically women turn things inwardly while men take things—Anna: FightJessica: Fight, externalise them more, and I don’t know that’s just sort of something like that they say I have no idea if there is any basis for that.Anna: It’s easier to hide self-harm if you’re a rugby player and you come out all bruised and battered, there’s something like you can’t hide that, whereas maybe women don’t have the same exposure to the physical sports that they could get that release from… …I don’t know, maybe that’s how men have found certain ways of self-harming and women have found other ways of self-harming.This argument was present in the reading we shared by Inckle . One of How wounds or injuries are interpreted by others makes up another route through which self-harm—and suicide —is gendeAmber’s picture of the bruise  holds so“I ended up thinking about, more of the how different types of self-harm are viewed as more acceptable, thinking about the bruising aspect, I coloured in a bruise (showing her artwork), […] and yeah, I am not really sure how that fits in with identity and gender, […] I mean I don’t know if this is related to the subject at all, but, the kind of thought that bruising is very easily interpreted as being inflicted by someone else, whereas cutting is a lot more kind of obviously well maybe self-inflicted, but that sometimes kind of the reaction to that it’s, one realises that something that they thought someone else did to you was actually what you did to yourself, they can be quite shocked by that, I had a nurse once that saw some bruises on my rib cage, and she asked, ‘Someone else did it?’ And I said no, that was me, and she was quite concerned by that.”AmberThe bruise on the paper and Amber’s bruises in her accompanying story were subject to multiple readings. A nurse asked if “someone else did it.” This question—assumption perhaps—that someone else must have caused harm to Amber’s rib cage speaks to the more usual way in which violence is gendered when read on a female body: it is assumed to have come from “another,” often a “male other.” When enacting violence both on the self and on others, violence and aggression from women elicit shock, disbelief, disgust—pathologisation . Writing after the workshop had ended, Zoi recalled Amber’s bruise and her story: “Amber speaks of how ‘something they thought that someone else did to you was actually something you did to yourself.’ She says that people can be quite shocked by that. I feel shocked. I tell her, about the violence towards the self as the violence towards the woman or towards the woman who harms herself. She stays silent. I feel anxious. I look for her eyes to ease my worry that I have just harmed her with my words.”This reflection draws attention to the relational way in which we make meanings out of self-harm between ourselves. These meanings are not fixed—they are alive —and the “a bruise is that much more ambiguous than a cut.” However, we wonder if in part this relates to the type of body—gendered, raced—on which the injuries are seen. Would Amber have been asked whether “someone else did it” if she were male, older, not white? Perhaps on other bodies, questions would be asked differently, or not at all.Amber notes that cutting—which she had also done—was much less subject to this type of interpretation. Self-inflicted cuts were “more kind of obviously … self-inflicted.” This is important to notice; cuts are indeed more easily viewed as self-inflicted. As Amy wrote in her notes following this workshop, a “common-sense” idea about men and women where “women turn things inwardly” while men externalise—they “fight.” This discussion has parallels in existing literature about gendered distress and mental health, which draw on similar imaginaries  There is something fleshy that runs through the narratives as we tell ourselves in the room. Our bodies—streams of red crayon—cannot be held back from how we read or how we are read.”down. A more oppressive move, perhaps.Within the workshop, the “body of red crayon” was read differently—Amy saw an explosion, a volcano, red fire—blood—streaming upwards and out. From slightly different vantage points in the room, the others all saw this initially as a red liquid pouring The different readings of Anna’s image recall the different interpretations of Amber’s bruise . Rather The Gender of Suicide, Jaworski [In Jaworski  asks “whJaworski ,46. The Recent writing on self-harm has emphasised the importance of bodies, relationality, and repetition in making sense of the practice. This has included considerations of the binary oppositions that we have sought to unsettle in this paper in terms of how self-harm is gendered. Steggals and colleagues, reflecting on the importance of a more relational and sociological interpretation of self-harm, suggest that:“The monadic, self-sufficient individual, or homo clausus , and the whole binary structure of inner/outer, individual/social and private/public that goes with it  must be reframed as patterns of enacted and embodied values rather than as ontological givens”  (p. 168)Considering such binaries as “enacted” is useful and provides a way of understanding them as produced rather than “natural.” Heney  takes thAs a pilot study, drawing on close and collaborative work with two small groups of participants, our findings and discussion are inherently limited. In particular, our groups were composed mostly of white cisgendered women, though undoubtedly conversations were enhanced by input from Jo, who is nonbinary, and helped us to acknowledge and raise questions about our own assumptions and those present in existing literature. The richness of the data we were able to generate together and the subsequent depth and nuance to our analysis would have been harder to attain with a larger sample—this is one of the strengths of qualitative research. That said, we suggest that our approach could and should be tried with more diverse groups of people. A significant gap in existing research on self-harm, which we have now further contributed to, relates to race and ethnicity—we have maintained an uncomfortable focus on whiteness, which is largely unmarked here .Using art and words and bringing materials that invited complexity into the room, our workshops successfully made space where participants were able to explore meanings of self-harm without “fixing” them. In doing so, we were guided by Back’s call for research that seeks to “account for the social world without assassinating the life contained within it”  (p. 21).However, complexity aside, there is much at stake when considering the gender of self-harm. The heaviness we felt in the room during our sessions discussing gender, and the pain, discomfort, and oppression that the participants recognised in the reading materials and connected to their own lives attest to this. We suggest that a further benefit of our use of arts-based, “live” methodologies to study meanings of self-harm and gender is the potential capacity for social action and transformation. On a small scale, the workshops offered a space where alternative meanings of self-harm could be repeated and practiced and where more dominant readings of gender could be challenged. Though this is a hugely fraught area, as Foster  has expl


Background: Adolescent non-suicidal self-injury (NSSI) is becoming a serious public health concern worldwide. In recent years, there has seen a significant increase in both the growth rate and cases of NSSI in Eastern countries, such as Japan, India, and China. In China, most schools have a mental health office that comprises mental health professionals (MHPs), who are the first to respond to student mental health problems, which include NSSI. MHPs possess comprehensive knowledge as well as unique insight into adolescent NSSI. However, very few studies on NSSI have incorporated their perspectives. In this work, we seek to add novel insight by conducting a study focusing on adolescent NSSI from the perspective of MHPs.Methods: We recruited a total of 24 MHPs from different schools using purposive sampling and conducted a semi-structured interview on NSSI-related issues. Each interview was voice recorded and lasted ~30 min. A thematic analysis was performed for the responses to study the most common and concerning issues underlying NSSI.Results: We extracted three major themes and eight sub-themes from the interview records, which included (1) the impact of Chinese culture on NSSI ; (2) life events in school ; and (3) opinions on the status quo of NSSI in China (ignorance and stigma).Conclusion: Results showed that culturally sensitive influential factors, such as sex-bias discrimination, the imposing of unrealistic expectations for personal achievement, and inappropriate parenting style, should be given more attention to prevent, assess, and intervene in NSSI. Emerging factors of modern society and adolescent lifestyles, such as academic pressure, internet use, and romantic relationships, should also be considered for treatments. Non-suicidal self-injury (NSSI) refers to the intentional damage of one's own body tissues without suicidal intention. This behavior is not socially sanctioned –3. It coOver the years, numerous studies have investigated NSSI behaviors and their causes. Most of these have approached the problem from two perspectives. The first is exploring the risk factors of NSSI and the degree to which they contribute to the possibility of engaging in NSSI . SeveralFurthermore, most previous studies were performed in developed countries, and studies considering race, ethnicity, and culture in developing countries are scarce . For exaFew qualitative studies on NSSI have considered current mental health practices in schools. In China, schools are required to have a mental health office/department. The primary responsibilities of MHPs include providing mental health care classes, psychological counseling, prevention of mental illness, and crisis intervention for students. Generally, schools regularly perform mandatory mental health assessments for students and identify those at high risk of engaging in NSSI and other life-threatening behaviors. MHPs will be responsible for providing preventive intervention to these students. These can be psychotherapy or referral to other professional psychiatrists. In the event where it is found that a student engages in NSSI, MHPs are typically the first point of contact to call upon to handle the incident. For many students, they are the most crucial source of support. Therefore, they are in a unique position to identify and respond to NSSI behavior among youth, and they play an essential role in the education, prevention, and timely treatment of NSSI in schools , 24. StuMeanwhile, the current studies on NSSI-associated factors have focused primarily on the family environment –27, chilTherefore, we conducted a culturally sensitive qualitative study of NSSI behavior in the context of the Chinese cultural background. We studied the influential factors of NSSI within a socio-cultural background from the perspective of school MHPs. Specifically, we aimed to identify several important contextual influencing factors related to NSSI, which might include gender, family, and culture. We also try to figure out and explained various events/factors in the school life of individuals that correlated and contributed to NSSI. Also, by exploring the attitudes, views, and understanding of NSSI of school MHPs, we could analyze the status quo of NSSI in China which could be used in the following-up prevention and interventions to help adolescents in the future.We adopted the purposive sampling method. A total of 25 MHPs from school counseling associations who had previous experience in dealing with NSSI cases were recruited for an interview. Twenty-five participants came from the eastern province of China and two came from the countryside. One participant withdrew because of quarantining because of COVID-19. Thus, 24 MHPs completed the study. The study ran from February 2020 to June 2020 and was approved by the medical ethics committee of Southern Medical University. All participants were informed of the study's purpose, methods, and privacy and provided written informed consent. Details are provided in An in-depth and semi-structured interview was conducted in a private psychological therapy room. Participants were informed that following the interview, they will be asked demographic questions. The outline of our interview questions was designed according to existing literature and in-depth discussions with experienced school psychologists, psychiatrists, and clinical social workers working with adolescents engaging in NSSI , 26, 35.At the end of each interview, three researchers independently transcribed the voice recordings and encoded the data. The three researchers came from backgrounds of psychiatry, psychology, and clinical social work, respectively. General information was extracted into a table. Data coding was performed using NVivo software, version 12 Plus. For the thematic analysis, we followed the six-step process of Braun and Clarke . SubthemThree major themes were extracted from the thematic analysis on the responses of the participants: (1) Impact of Chinese culture on NSSI, (2) life events in school, and (3) opinions on the status quo of NSSI in China see . Within Sex-bias discrimination was a contributing factor to NSSI behavior, according to several participants. In some families, girls were long considered lower priority than boys and were subject to low self-esteem. Girls were under more pressure from parents' constant ignorance of their emotional needs, and for some, NSSI had become a coping strategy for dealing with their emotional and mental problems.In some families, it is still possible that boys are held at higher importance over girls. As a result, girls may start suffering from low self-esteem from childhood. They tend to underestimate their own value a lot, which, in some, leads to NSSI…” (p. 10).“In some families with many children, parents may not treat each child with an equal amount of care. Some children who receive little care may engage in NSSI to gain more attention…” (p. 11).“…Some participants reported that this situation was more common in areas where a preference for sons was prevalent. It was usually girls at home who engaged in NSSI.the population here is mostly composed of families from Chaoshan, where the preference of sons over daughters is deeply rooted in their values. Some families have more than five children who all studied in the same school. Usually, children who engage in NSSI are girls. They receive little to no attention from their parents, yet, they are still responsible for undertaking family chores and various requests from the parents, including academic performance. In contrast, boys have very little pressure and worries and are offered an effortless life. As a result, girls are subject to much higher pressure and are more prone to NSSI…” (p. 13).“…This kind of family generally has more children. Girls are not able to get sufficient attention…” (p. 17).“…Girls in families from Chaoshan generally have very low self-esteem. They are always ignored, which makes it easier for them to engage in NSSI behavior…” (p. 21).“Several participants mentioned that there is a deeply rooted value in Chinese culture that the next generation must be better than the parent generation. As a result, parents often have very high expectations of their children, especially in regard to academic achievement , 40. ThiWhen parents fail to achieve the life they want, they pass it onto their children, pushing them to work extremely hard, hoping that their children will be able to achieve what they were not able to…” (p. 10).“…In Chinese culture, parents making children successful is highly valued, where each generation should be better and end up in a higher social class than their parents. Parents nowadays are increasingly anxious about this. To many parents, it is unacceptable that their children end up worse than them because their children were born in a much better time with much better material support…” (p. 13).“…Parents pay exclusive attention to children's academic performance and tend to care less about their emotional and mental health needs…” (p. 15).“…Many participants also reported that Chinese parents tend to be overly controlling, use an authoritative parenting style, and have little respect for their children. Some adolescents chose to harm themselves and engaged in NSSI after being subjected to such highly pressured parenting styles over a prolonged period as a way to rebel against their parents.In overly protective and controlling families, children do not dare stand up against their parents. When they are pressured and their feelings are suppressed for too long, they tend to resist through self-injurious behavior as a way to get back at their parents and make them feel guilty…” (p. 4).“…Participants also reported that many parents also held the idea of “spare the rod, spoil the child.” These parents believe that physical punishment is necessary to educate their children. Such practices caused severe psychological harm to adolescents. Moreover, this led children to punish themselves, which caused NSSI.In many NSSI cases, children had been abused by their parents previously. Even when they become teenagers, they may still be subject to physical punishment by their parents. Children exposed to such prolonged periods of abuse are more prone to engaging in NSSI…” (p. 14).“…In Chinese culture, tolerance and toughness are valued highly. Most participants stated that children were often encouraged and educated to suppress their feeling of sadness, fear, and anger. To some degree, this led to an increase in NSSI among children to seek relief from suppressed emotions.I once knew a child who was not allowed to cry in front of the family since childhood. Whenever he did so, his parents would lock him out until he stopped. This continued for more than a decade. The child always told himself not to cry. But sometimes, he was so depressed that he had no other way to cope with it. As a result, he started engaging in NSSI as a way to seek relief. Children were discouraged from expressing their feelings and emotions openly. They were usually taught to suppress them.” (p. 2).“…The lack of freedom in openly expressing emotions and feelings, the overly controlling and protective parenting style, and the practice of physical punishment in the family has resulted in children's use of extreme coping strategies for dealing with negative emotions and difficulties in their life, which in many cases led to NSSI” (p. 24).“According to participants, the internet was a strong influence on children's NSSI behavior. Children can easily access a large amount of self-injury- and violence-related information on the internet. Some children thought it was simply “cool” and “fun” and imitated the NSSI behavior they saw on the internet.Because they can now get so much information on the internet, they just thought it (NSSI) was fun and cool and they gave it a try…” (p. 11).“…When he saw this unusual behavior on the internet, he tried something similar out of curiosity…” (p. 18).“…I feel there is some kind of herd mentality behind NSSI behavior, like chasing a trend. When students see reports and cases of NSSI from the internet or the news without proper guidance, they may develop a curiosity to follow the practice and try it out…” (p. 12).“…Some participants reported that there exist online NSSI communities where people share experiences, related topics, and methods of NSSI behavior. Children can easily and quickly join these communities, which exacerbates NSSI behavior.There are some communities on the internet. Teenagers interact with each other in this community and engage in self-injurious behaviors together…” (p. 23).“…another point is that it is very common for two teenage users in these online communities to share similar experiences and thoughts regarding NSSI. This can be extremely dangerous as they tend to encourage each other further …” (p. 9).“…the culture in these NSSI communities, especially for teenagers, can be very toxic. They are constantly exposed to simplistic, dark, and negative information. In addition, these communities tend to be very extreme and biased. Whenever someone posts negative views and emotions, others echo and agree. As a result, such negative information and ideas are reinforced among the participants. If anyone stands up or tries to correct and help make sense of the negative information, they will be ignored and dismissed. Such an extreme and dark environment can be very harmful to teenagers…” (p. 4).“…Most participants reported that overwhelming academic pressure, which is very common in elementary school, middle school, and college students, directly contributed to NSSI behaviors.It is common for teenagers to injure themselves to cope with academic pressure, regardless of their academic performance. In many cases, the pressure comes from parents being pushy and having high expectations…” (p. 13).“…when teenagers engaged in NSSI, they were under great academic pressure most of the time…” (p. 14).“…often grades are the trigger for NSSI. In many cases, they injure themselves when they did not do well on a test or when they were struggling with a subject…” (p. 20).“…A few participants also mentioned that some teenagers engaged in self-harming behavior if they had romantic feelings for someone as an expression of love.For example, I once met a boy who had a crush on a girl. But for some reason, the girl hurt herself. The boy thought he could only be with her if they were the same. Then the boy also started to self-harm… Friends may also engage in self-injurious behavior together to demonstrate to others that they are in the same friend circle…” (p. 13).“…Some teenagers in relationships may use self-injurious behavior when they encounter conflicts.Sometimes when teenagers in a relationship fight, one may engage in self-harm to get attention and care from the other…” (p. 20).“…Some teenagers may get their boyfriend's or girlfriend's attention by hurting themselves. When teenagers in a relationship argue, one of them would cut themselves to get the other's attention. Moreover, they want their boyfriend/girlfriend to care about them…” (p. 20).“…Teenagers who are in a relationship may hurt themselves on purpose, take pictures, and post on social media as a threat to get his/her attention and care…” (p. 13).“…Many participants expressed that there was not sufficient awareness of NSSI behaviors in school.NSSI is given much less attention compared with suicide. This is likely because suicide causes death, which is a serious social event. The government usually has to impose censorship on the news when this occurs. However, for NSSI, many teachers consider it to be of little concern, and some even consider it simply as a student's trick for getting attention” (p. 13).“…In addition to the lack of awareness in school, some participants also reported that many parents lack basic mental health knowledge, which results in inappropriate perceptions of their children's NSSI behavior.Many parents consider their children to be fine as long as the problem is not severe enough to lead to suicide…” (p. 22).“…Some parents simply don't consider NSSI as a problem at all…” (p. 17)“…Her (a child who engaged in NSSI) teacher once reached out to her parents regarding her NSSI behavior. The parents were annoyed and did not show any concern. They even considered that their child was causing too much trouble for them. They also didn't believe that their child was depressed as they thought that whatever pressure their child was under, it was nothing compared with theirs…” (p. 18).“…Many participants considered NSSI to be associated with social stigma. This hinders timely interventions for students who engage in NSSI. Many parents were reluctant to seek professional help and some denied that their children had any problems. Moreover, some parents were concerned that seeking professional help would expose their children to judgment from others, which may negatively impact them.Many parents feared that they will be stigmatized because of their children's psychological problems; a small number of parents tried to avoid talking about related problems…Some parents were not even willing to let their children receive psychological counseling…” (p. 4).“…If you take him (child) to a psychiatrist, it puts a label on the child; a label that says he has a serious problem…” (p. 3).“…One parent I talked to expressed that turning to an intervention, psychiatrists, or medical help of any kind is not the solution to NSSI. They thought that it is a problem of mindset and educating the child to have the correct mindset would address these problems. A lot of parents share this opinion. As a result, many parents don't support their children in seeking help from psychiatrists. They consider it to be the children's problem and that children should be responsible for themselves…” (p. 17).“…Fortunately, according to many participants, many students in later generations were not concerned about stigmatization as much as their parents were, and many of these students actively sought help from psychiatrists.Students are aware of their psychological and personality problems, and they will actively seek help from teachers… some students will even proactively schedule time with teachers outside of school/working hours when they feel they need more counseling…” (p. 11).“Now, more and more students who have such problems are actively seeking help. Even when face-to-face counseling is not immediately available, they will still try to reach out to us about their problems using messages. Compared with previous decades, stigmatization seems to be getting better. Back in 2005 or 2006, many students feared being laughed at and judged if they sought help from psychiatrists…” (p. 18).“…Some students feel relief when they are diagnosed. I once had a student who struggled with school and was quite depressed and confused. He started seeking help and was diagnosed with mild depression. To my surprise, the student was relieved after learning the diagnosis. To him, it was like he finally found someone who could identify his problem and help him get through it…” (p. 18).“…To the best of our knowledge, this is the first study to investigate adolescent NSSI behavior from the perspective of school MHPs in China. Our findings bridge the gap in the literature on the factors that influence Eastern socio-cultural backgrounds from the perspective of school MHPs. We found that sex-bias discrimination (70.8%), overly high expectations (29.1%), and inappropriate parenting style (100.0%) influenced adolescent NSSI behavior in China. In addition, teenagers who fall in love at an earlier age (33.3%), widespread internet use (62.5%), and overly high academic pressures (75.0%) also triggered NSSI behaviors.Discussing NSSI in the cultural context is necessary. Although NSSI has been observed and described in almost all cultures, they do have different characteristics in different cultures. These include prevalence, gender difference, methods of self-injury, and motivation , 20. GivThere has not been a consensus on the percentage of the population engaging in NSSI and whether and why there is any difference in NSSI patterns between genders –47. In tNotably, we found that both parents' and adolescents' excessive anxiety around academic performance influenced NSSI behavior. Previous research showed that excessive academic stress is related to psychological problems, such as anxiety and depression . SeveralPrevious studies have shown a positive correlation between excessive internet use and NSSI. The results of our study can explain this finding. With widespread internet use, teenagers are increasingly searching for, discussing, and publicly showcasing their NSSI experience on social media. Studies have shown that the internet both catalyzes and reduces NSSI behavior –58. AccoOur result showed that NSSI receives insufficient attention in both school and family settings. This is primarily because NSSI is not a life-threatening behavior compared with suicidal behavior, which has led school staff and parents to not take NSSI as seriously. In addition to physical harm, the lack of attention and awareness is threatening the overall mental well-being of adolescents. Furthermore, the problem was compounded by the stigmatization (83.3%) of mental health disorders in China, which often results in parents ignoring and refusing mental health treatment for their children who engage in NSSI behavior. Such misunderstandings and perceptions of NSSI and other mental health disorders are consistent with the findings of previous research , 59, 60.A positive finding from our study is that according to MHPs, the later generation of adolescents perceives NSSI and mental disorders differently from their parents. They tend to possess more open and positive attitudes toward NSSI and mental disorders, which positively influences their awareness of their problems and promotes help-seeking behavior. The exact mechanism underlying how different perceptions of NSSI and mental disorders determine help-seeking behavior, and whether there is a causal relationship, remains uncertain. Exploring adolescent perspectives may offer significant benefits to the prevention and treatment of mental disorders, and this may be an avenue of future research.This study explored the influential factors of NSSI in the Eastern cultural context from the perspective of school MHPs. Our results showed that sex-bias discrimination, overly high expectations from the parent, high-pressure parenting style are the most significant factors contributing to NSSI among Chinese adolescents. The preference of boys over girls might make NSSI much more severe and prevalent among some girls compared to boys. Most parents in China have very high expectations for their children, especially in academic achievement. Over-controlling and authoritative parenting are common parenting styles in many of the families involved in our study. Children's mental health needs urgent attention from parents. In addition, our study suggests that researchers and clinicians should pay attention to how internet use, academic pressure, and romantic relationships can be related to NSSI. In particular, academic pressure is a trending cause of anxiety nowadays. Involution in adolescents' education has been a heated topic in recent years. Therefore, in future research, more quantitative research can be conducted to investigate the mechanism of how these factors contribute to NSSI and how they should be addressed in prevention and intervention. Besides, it is also essential to emphasize necessary psychoeducation for parents to address the negligence of mental health care needs for children.xiaoyupsychology@163.com.The raw data is related to the subjects' personal privacy. Requests to access these datasets should be directed to Xiaoyu Chen, The studies involving human participants were reviewed and approved by the Medical Ethics committee of the Southern Medical University. The patients/participants provided their written informed consent to participate in this study.XC and DL designed the study and wrote the protocol. LL, YZ, and YH assisted with the survey and managed the literature searches and analyses. XC, YZ, YH, and XY performed the data analysis. XC wrote the first draft of the manuscript. XY and XZ edited the final manuscript. All authors contributed, read, and approved the final manuscript.This work was supported by the National Natural Science Foundation of China (grant number: 72074105), the National Natural Science Foundation of China (grant number: 31800928), and the Natural Science Foundation of Guangdong, China (grant number: 2018A0303130044).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Purpose: This paper describes women’s opinions of the attributes of the ideal body image program to inform the design, development, and implementation of future programs for those diagnosed with breast cancer.Methods: Deductive-inductive content analysis of semi-structured interviews with 26 women diagnosed with breast cancer  was performed.Findings: Participants’ opinions regarding the ideal body image program are summarized into five themes, mapping the where , when (across the cancer continuum or at specific points), how , what , and who .Conclusion: This study provides useful data on what women believe are the attributes of the ideal body image program, which can contribute to efforts aimed at developing and delivering body image programs for women diagnosed with breast cancer that prioritize their needs and preferences. Worldwide, there are more than 2.1 million women diagnosed with breast cancer each year, making it the most common type of cancer diagnosed in women . Conventds = 0.15–1.43, g = 0.50, 95% CI , Two recent systematic reviews of studies with women diagnosed with breast cancer showed that body image programs comprised of psychotherapy, psychoeducation, or physical activity can have positive effects on body image , resulting in a variety of modes, formats, and content, and potentially programs that are not likely to match women’s needs and preferences . As suchwhat, when, where, who, and how of the ideal body image program. The aim of the present qualitative study was therefore to explore women’s opinions of the attributes of the ideal body image program. This manuscript describes their opinions and presents implications for future program design, development, and delivery.Public involvement in the development, design, and delivery of programs is highly promoted  and is vThis study used a qualitative interview design and adopted a constructivist paradigm approach wherein knowledge is considered introspective and co-developed based on individuals’ unique perspectives . Ethics Twenty-seven women provided consent prior to completing the interview; one was removed from this study because she did not answer questions pertaining to the current aim due to time constraints. Data from the remaining 26 women  were analyzed; n = 10), by telephone (n = 11), or via videoconferencing (n = 5). The latter two means were done to reduce barriers for participation  and permit interviews with women from a broader geographic area  reflected on their positions throughout the research process. They acknowledge that none had been diagnosed with breast cancer at the time of this study. As such, they were keenly aware of the differences between themselves and the interviewed women, especially in terms of disease history and age. Nonetheless, they had empathy for the interviewed women and the challenges they had faced as a result of having been diagnosed with breast cancer. Moreover, the interviewer felt compelled at times to reassure women and struggled to curb her urge to offer support in a matter that would take her beyond her role. To avoid this and protect against biases, she spent time debriefing with the first author after interviews.where, when, how, what, and who of the ideal body image program. Themes are summarized in Participants clearly had an overwhelming desire to access a body image program. Yet, the data collected in this study suggest they had a range of opinions regarding the attributes of the ideal body image program. Participants’ opinions were summarized into five themes reflecting their preferences for the there’s never going to be a convenient place for everyone at different times.” Of the 26 participants, two expressed interest in a body image program that could be undertaken within the community  for convenience. Four expressed interest in a body image program that could be delivered online to obtain easily accessible information at convenient times at their preferred location. Three mentioned that a body image program could be delivered in-hospital because it “makes more sense” and because they had “become accustomed to medical settings.” However, they did not necessarily feel it was the most appropriate setting. Moreover, five participants voiced concerns about having to go to the hospital for a body image program because they thought of the hospital as “such a sterile place that nobody wants to go to” and added that parking would likely deter participation.This theme refers to participants’ preferred location for a body image program. Based on participants’ collective accounts, body image programs should be delivered across different locations because “several sections. There would be a newly diagnosed section, then there’d be the treatment time, then there’d be the post-treatment time, and then there’d be the rest of your life.” Only one participant was of the opinion that a program offered pre-diagnosis would be of interest because “if you’re coming from a place of negative body image and then you have breast cancer, I mean, you would need a lot of help.” However, similar to two others, she also believed post-surgery would be good timing. Others described a preference for a program at diagnosis or immediately after (n = 4), during treatment (n = 3), or post-treatment (n = 6). Further supporting post-treatment timing, two participants expressed a negative opinion about having a body image program during treatment because they believed women would have other priorities . Thus, overall, participants were of the opinion that women should be able to undertake a body image program when they are comfortable doing so.This theme describes participants’ preferences for the timing of a body image program. Participants had a variety of opinions, highlighting that differential timing may be needed for different women. Only three participants were interested in accessing a body image program across the cancer continuum, suggesting there should be “there’s safety in small groups but sometimes there’s anonymity in big groups. So you might be doing the same things, but have two different kinds of workshops and you give them the option of what ones they would rather [attend].” Another option mentioned was to have a peer-led program (n = 7) or support group for women that facilitates discussion and encourages friendly relationships (n = 8). This was driven by participants’ belief that camaraderie would be built with other women diagnosed with breast cancer and that peer social support would be facilitated. Others, however, were more interested in receiving individual guidance or support such as through one-on-one counseling (n = 1) or by receiving a compilation of resources women can access on their own (n = 2). Whilst divergent opinions were shared by participants, they generally agreed that, regardless of the format, a one-size fits all approach would not work as “you’d probably have to cover quite a wide range because everybody has different problems depending on your age, your situation, and things are different.”This theme refers to the format participants were interested in for a body image program. Ten participants were interested in attending presentations or workshops focused on body image, and an additional five suggested special events. Whilst different terms were used by participants, they described presentations, workshops, and special events as one-time occurrences wherein information pertaining to body image  could be shared with attendees to facilitate knowledge. Yet, it is unclear what the size of the audience should be as “n = 3), encouraging physical activity for improved health and wellbeing (n = 6), giving sleep advice (n = 3), and discussing body size, shape, and weight management (n = 2). Of note, many of these participants expressed interest in multiple aspects of self-care. Within the realm of counseling and education, two key topics prevailed. Twenty-five participants expressed a desire for a program aimed at accepting and embracing their new normal, either by promoting self-compassion (n = 12), focusing on inner strength more so than appearance (n = 5), building resistance to body-based stereotypes/prejudices (n = 4), supporting spiritual growth – which can exist within or independent of religion – to feel more connected with life (n = 3), and building confidence (n = 1). Another 13 mentioned counseling and education related to addressing the side-effects of cancer treatment, including discussing typical physical changes (n = 6), learning to deal with stress and mental health issues (n = 2), and discussing sexuality/sexual health (n = 5). Raising awareness of how body image affects women (n = 3), especially with partners, was also mentioned and thus necessary to “focus on the people around, the support system, and yes, educate men. […] Like have him attend a meeting, educate him, this is how your wife is feeling.” In addition to discussing sexuality/sexual health, three participants mentioned wanting help addressing sexuality/sexual health concerns to help improve their body image. Finally, four participants expressed interest in receiving make-up and clothing tips for coping with body image changes, though two others held negative opinions toward make-up and clothing-oriented topics.This theme describes what topics participants would like to see covered in a body image program. Participants identified 13 topics, none of which were unanimously recommended, highlighting the personal nature of body image and the potential need for tailoring. Despite the diversity in participants’ preferred topics, these could be organized into five areas: self-care, counseling and education for oneself, education for others, support for addressing sexuality/sexual health concerns, and concealing treatment-related changes. Of the 26 participants, 14 mentioned an interest in self-care, including promoting healthy eating (n = 16) preferred that women previously treated for breast cancer be involved in delivering the program because “you need somebody that’s been in the trenches.” Similarly, four said that a promising option could be to have women previously treated for breast cancer partner with a health professional to deliver the program. The rationale provided was that “some people really like having the authority of having a medical degree behind the person speaking. Some people really like that and have difficulty if they don’t have that. Other people prefer a more peer type interaction with the person presenting. So those are dichotomies. How are you going to do that unless you have two people speaking, which obviously might work.” Generally, participants who desired that women diagnosed with breast cancer be involved in delivering the program were driven by the belief that having a shared experience was an essential component of a body image program. Eleven participants expressed an interest in having health professionals such as doctors (n = 6), nurses (n = 5), dieticians/nutritionists (n = 2), psychologists (n = 3), social workers (n = 4), fitness professional or physiotherapists (n = 3), or sex therapists (n = 2) deliver the program. Only one participant mentioned having a make-up artist and/or clothing stylist deliver the program. Given this diversity, delivering a body image program may require a multi-disciplinary team approach, whereby women previously treated for breast cancer partner with health professionals to design and deliver programs to meet an assortment of needs and preferences.This theme refers to the person(s) who participants felt should deliver a body image program to women diagnosed with breast cancer. Because the person(s) delivering the program is central to what and how the content is delivered, most participants , participants expressed a desire for group discussions and interactive activities that facilitate peer engagement, print or digital materials , and one-on-one counseling. In particular, a large proportion of participants expressed a desire to interact with other women diagnosed with breast cancer in order to have opportunities to ask questions and share experiences. Notably, interaction with others has been highlighted as an important component of creating an optimal experience in psychological and behavioral interventions for adults diagnosed with cancer . As reseThe limitations of this study should be acknowledged. It only included English-speaking women living in a high-income country. Relatedly, the high education and lack of racial and ethnic diversity in the sample is another limitation. It is possible that women living in lower income countries, women with lower education, or women from different racial or ethnic groups may have different opinions and preferences. Also, participants were post-treatment. By interviewing women post-treatment, it is possible that certain opinions were influenced by reduced recall. Prospective, longitudinal studies are warranted to understand women’s opinions at different points in time. Similarly, participants had completed treatment within the past 5 years. Accordingly, it will be necessary to determine if the opinions and preferences expressed by participants in this study are echoed by women further away from treatment completion. Additionally, data were analyzed to aid in the development, design, and delivery of future body image programs for women diagnosed with breast cancer that meet their needs and align with their interests and preferences. It remains to be seen if such programs are just as effective as others tested in the literature. However, the strengths of this study were its sample size, inclusion of women with a range of ages and cancer experiences to support a diversity of perspectives, and analysis conducted by two researchers experienced in qualitative methodology.what , when (across the cancer continuum or at specific points), where , who , and how  that should be considered when developing, designing, and delivering body image programs targeting women diagnosed with breast cancer. It is hoped this information will help in the creation of more meaningful, relevant, useful, and usable programs for this growing segment of the population.The objective of this study was to investigate women’s perspectives of the ideal body image program for women diagnosed with breast cancer. Participants’ accounts suggest that a body image program may be an effective way to help them feel better about their bodies in a world that constantly makes them focus on their perceived flaws, personal inadequacies, and failures. Although one specific formula for how to design, develop, and deliver a body image program to women diagnosed with breast cancer may not exist, the findings of this study lay the foundation for the development, design, and delivery of a more diverse and tailored approach to such programs. Specifically, findings provide a starting point for Jennifer.Brunet@uottawa.ca.The datasets presented in this article are not readily available because the data cannot be shared as participants were assured that their data would be kept private and confidential to the extent permitted by law and that only the research team would have access to the data. Requests to access the datasets should be directed to JB, This study involving human participants was reviewed and approved by the Ottawa Health Science Network Research and the University of Ottawa Ethics Boards. Participants provided their written informed consent to participate in this study.JB conceptualized and designed the study, oversaw the acquisition of the data, contributed to the interpretation of the data, and drafted the manuscript. JP led the analysis and interpretation of the data, helped draft sections of the manuscript, and critically revised the manuscript. CH assisted with the conceptualization of the study, participant recruitment, and revised the manuscript. All authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.