What were hospital clinicians’ experiences and perceptions of the Serious Illness Care Program (SICP), a multifaceted capacity-building intervention to improve communication with patients who are seriously ill?In this qualitative study including 23 clinicians from 2 hospitals in Canada, clinicians stated that the various structural and organizational elements of the SICP supported changes in their behavior, shifted the focus of goals-of-care conversations beyond discussion of resuscitation preferences , and influenced them on personal and professional levels.The findings of this study suggest that clinicians may find the SICP helpful in supporting them to engage in meaningful communication that goes beyond discussion of code status with patients who are hospitalized with serious illness. Discussions about goals of care with patients who are seriously ill typically occur infrequently and late in the illness trajectory, are of low quality, and focus narrowly on the patient’s resuscitation preferences , risking provision of care that is inconsistent with patients’ values. The Serious Illness Care Program (SICP) is a multifaceted communication intervention that builds capacity for clinicians to have earlier, more frequent, and more person-centered conversations.To explore clinicians’ experiences with the SICP 1 year after implementation.This qualitative study was conducted at 2 tertiary care hospitals in Canada. The SICP was implemented at Hamilton General Hospital  from March 1, 2017, to January 19, 2018, and at Foothills Medical Centre  from March 1, 2018, to December 31, 2020. A total of 45 clinicians were invited to participate in the study, and 23 clinicians (51.1%) were enrolled and interviewed. Semistructured interviews of clinicians were conducted between August 2018 and May 2019. Content analysis was used to evaluate information obtained from these interviews between May 2019 and May 2020.The SICP includes clinician training, communication tools, and processes for system change.Clinicians’ experiences with and perceptions of the SICP.Among 23 clinicians interviewed, 15 (65.2%) were women. The mean (SD) number of years in practice was 14.6 (9.1) at the Hamilton site and 12.0 (6.9) at the Calgary site. Participants included 19 general internists, 3 nurse practitioners, and 1 social worker. The 3 main themes were the ways in which the SICP (1) supported changes in clinician behavior, (2) shifted the focus of goals-of-care conversations beyond discussion of code status, and (3) influenced clinicians personally and professionally. Changes in clinician behavior were supported by having a unit champion, interprofessional engagement, access to copies of the Serious Illness Conversation Guide, and documentation in the electronic medical record. Elements of the program, especially the Serious Illness Conversation Guide, shifted the focus of goals-of-care conversations beyond discussion of code status and influenced clinicians on personal and professional levels. Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity.In this qualitative study, hospital clinicians described components of the SICP as supporting changes in their behavior and facilitating meaningful patient interactions that shifted the focus of goals-of-care conversations beyond discussion of code status. The perceived benefits of SICP implementation stimulated uptake within the medical units. These findings suggest that the SICP may prompt hospital culture changes in goals-of-care dialogue with patients and the care of hospitalized patients with serious illness. This qualitative study explores clinicians’ experiences with the Serious Illness Care Program 1 year after its implementation in 2 hospital wards in Canada. A systematic review of advance care planning for hospitalized older adults with frailty also concluded that physician experiences have not been well explored.22 The objective of this qualitative study was to understand clinicians’ experiences with the SICP 1 year after its implementation in the general internal medicine wards of 2 hospitals in Canada.Multiple educational programs and tools have sought to enhance this communication.26 Qualitative description emphasizes describing participant experiences in their language with minimal interpretation and is recommended for research questions that aim to report participant experience.25 The study was approved by the Hamilton Integrated Research Ethics Board. All participants provided written informed consent. This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline for qualitative studies.27We used qualitative description to focus on clinician experiences with the SICP.19 Other program elements include a patient preparation letter, a postconversation family communication guide, and a 2.5-hour interactive clinician training session. System-change components include routine identification of patients at high risk of death, a method to prompt clinicians to initiate the conversation, and a structured template for documentation.19The SICP is a multifaceted capacity-building communication intervention. Its principal component, the Serious Illness Conversation Guide (hereinafter referred to as the guide), provides evidence-based questions and a conversation framework to explore, with topics including illness understanding, prognosis, values, goals, fears, sources of strength, essential abilities, acceptable tradeoffs, and family understanding  . The SICThe Hamilton site used purposive sampling to intentionally include diverse clinician perspectives , whereas the Calgary site invited all physicians to participate. Clinicians received an email from the site’s primary investigator inviting them to participate. Interviews were conducted individually using a semistructured guide and were 30 to 45 minutes in duration (eMethods 2 in the 29 Independent line-by-line open coding of 5 transcripts was conducted (A.L. and M.S.), and a preliminary list of codes was developed through consensus during a series of meetings. The lead analyst (A.L.) coded the remaining transcripts. Coding reports from the entire data set and 4 transcripts were reviewed during 3 meetings with the analysis team; data saturation was confirmed. New insights identified during these meetings were incorporated into the analysis by the lead analyst; all decisions and coding revisions were documented in an audit trail.30 Associations between codes were discussed at these meetings and were used to inform the organization of codes into meaningful categories and higher-level clusters.31 The research team comprised a group of clinicians, nonclinician qualitative researchers, and a patient advisor. The interviewers had no relationship with the participants. Data were managed and analyzed using NVivo software, version 12 .Interviews were digitally recorded, transcribed, and deidentified, and analysis was performed from May 2019 to May 2020. Conventional content analysis consistent with the qualitative descriptive approach was used to analyze transcripts.Among 23 clinicians enrolled and interviewed, 15 participants (65.2%) were female . The meaThe 3 main themes were the ways in which elements of the SICP implementation (1) supported changes in clinician behavior, (2) shifted the focus of goals-of-care conversations with hospitalized patients beyond discussion of code status, and (3) influenced clinicians personally and professionally.Clinicians said that several elements of the program supported behavior change: (1) having a unit champion present, (2) engaging interprofessional team members, (3) having copies of the guide accessible, and (4) documenting conversations about serious illness using a template in the electronic medical record. Together, these elements of the intervention were described as providing structure. As 1 clinician described, “it sort of legitimizes this [having serious illness conversations] as something that’s very important for physicians to do.”Many described the presence of a unit champion as one of the most important program elements. One clinician said, “There’s a cueing reminder, there’s an administrative burden removed where someone else is scheduling and letting me know when it [the conversation] is, based on my availability, and that really helps. The patients and family are primed on it. It was just any time I wanted to do it, and whenever we planned to do it, it just happened. Everyone was on board, and everything was set up.”Many clinicians expressed opinions that were similar to 1 clinician’s statement that “the biggest challenge is sort of creating a formal time or space to have these conversations.” However, the unit champion’s coordination of a scheduled time to meet helped in overcoming this challenge: “I think the nudging from…[the unit] champion, supporting the program, is probably the thing that’s facilitated the most in terms of actually using the guide, of getting over that hurdle to make the time to do it.”Many clinicians described the ways in which the program empowered nonphysician members of the interprofessional team, especially with patient identification. As 1 clinician stated, “It was the bedside nurse that said, ‘You’ve made this care plan, but whenever I go in there, he keeps refusing things. Can you please check and make sure this is what he wants?’…I feel like without this program, she might not have felt empowered to voice it.”A similar experience was shared by a nurse practitioner, who said, “I also feel like the whole team has embraced this process from all the varied allied health professions. Everyone is very aware of the process and so, when someone brings it up, it’s like, ‘Yeah, you’re right. That would be appropriate.’ I think we’re all so invested in this process because we know it helps and it helps to give better care to our patients.”One clinician recognized improvements; however, the clinician was uncertain about the factors to which that success should be attributed, stating, “I think we’re doing a better job of identifying these patients earlier, and whether it’s attributable to this program, specifically, or this is just supporting a culture shift in that regard, I’m not very sure.”When asked about which elements of the program facilitated participation, many clinicians referred to having copies of the guide accessible. One clinician responded, “Having copies on the ward. There’s a place that all the materials are kept on our unit, and they’re laminated guides. So, I would take one of those with me every time…to refresh my memory as to how the conversation unfolds and the specific phrasing of the questions.” Another clinician responded, “The sheets with the conversation guide that you can take off the wall and take into the patient's room with you. You can just take it and do it, like, right there. So, that makes it really easy to use.”The inclusion of a formal documentation step within the program was described as bringing more attention to the conversation among the medical team and facilitating care over time that was more consistent with patient wishes. “When we did our training, we were asked to document the conversation in our electronic medical record under a certain document…I have found that very, very helpful,” a clinician said. Another stated, “If you're dictating in a conversation, it’s clear to everyone that this is what this person wanted, and it’s dictated, it’s easy to pull up, people readily access it. Even the dictations that I’ve dictated…I have had people readmit and they get readmitted to our team and even it’s been some time later. It’s like, okay, this is what the person wanted in this serious illness conversation at this time.”However, the benefit of tailoring care to support patients’ wishes in the long term through the documentation process was not recognized by all. One clinician stated, “It’s going to become a highly personalized experience, but then, unfortunately, we’re on for 1 week at a time, and here I am collecting all this information and whatnot…and then I never see the patient again.”Clinicians described 3 important elements of the program that shifted the focus of conversations: (1) changing what is asked and creating space for conversations, (2) facilitating understanding of the patient’s illness, and (3) altering clinician agendas.Many clinicians discussed the SICP’s role in changing what is asked and creating space for conversation. As 1 clinician said, “[The guide] creates a completely different environment because you’re asking questions about their bigger life values and goals…We don’t ask these things. It’s really pivotal for me; it really changes my practice.”With regard to booking a scheduled meeting in a space other than the patient’s room, another clinician stated, “I think what I found most useful was a separation of time and space; [it] created a moment to build a relationship in a way that we don’t always in acute care because we don’t either have the time or the dynamic is different.”Clinicians mentioned the role of the SICP in facilitating patient and family understanding of the patient’s illness, saying that it helped to “have everyone on the same page.” One clinician stated, “I had 1 family where there were things that [the patient] expressed that they hadn’t known…it was clear that this family hadn’t gone through this before, or the kids had not appreciated their father’s concerns…they came later and really thanked me for having [the conversation].”Many clinicians said that the program and guide altered their agenda for conversations, which had often previously focused on obtaining the patient’s code status. According to 1 clinician, “Before, when we would say, ‘oh, we’re going to go have a goals-of-care discussion with that patient,’ invariably, it always meant we wanted to downgrade their goals of care from, you know, full code to something less than full code.”Another clinician also said that they “had more meetings where there really has been less of an agenda,” and using the guide helped them with “slowing down and just being a bit open-minded, not having your thoughts of a patient bound to a ‘ticky’ box…and really understanding each patient as an individual.”Clinicians also commented on observed changes in the dialogue between care team members. As 1 clinician stated, “When someone comes in sick, the first thing you want to do is to find out what their code status is…but I’ve noticed now that people are taking a pause on that issue [and] dealing with the person as a human being. When they do discuss code status, I hear it described a bit more as…people talk about the patient’s wants, needs, or values.”Personal and professional influences of the SICP that were identified by clinicians included (1) increasing comfort with having serious illness conversations, (2) bringing meaning to their work and reducing moral distress, and (3) humanizing care and tailoring a care plan to support patient wishes.Several clinicians described the ways in which their training and use of the guide made having decision-making conversations easier. According to 1 clinician, “Now that we actually have a formal template that’s being studied, and we have training on it, I realized how patients are so willing to open up and speak, and it actually does work, some of these specific questions, of areas to explore. It allows me to be more using of it, and it’s nice using something that’s been validated, researched, so it really adds to the toolbox. I might not have asked some of those questions before, but I’m far more confident to do it now.”Evidence of increased comfort with having conversations about serious illness was commonly found in clinicians’ descriptions of using the guide with patients “on the fly” and in other circumstances and settings. A clinician said, “I moved it across to more patients…I’ve done it in a more informal way…to explore, to some degree, even if not at complete depths, what it is the patient feels about what they’re going through and how I can help with the, especially, quality of their life.”Although many clinicians stated that their comfort with conversations about serious illness increased because of the SICP, a few said that it could disrupt the natural flow of a conversation. One clinician said, “I just think just the static nature of it makes it a bit difficult to adapt to an actual, real-life conversation sometimes.”Most clinicians found that the connections they made with patients as a result of using the guide brought meaning to their work. As 1 clinician said, “It definitely…makes the day feel much more fulfilling to be able to connect with the patient or family on that deeper level as opposed to the more superficial and very busy tasks of the day.” A nurse practitioner stated, “When I do have these conversations…it makes my work very meaningful.”A few participants described the ways in which using the guide helped them deal with moral distress, with 1 nurse practitioner saying, “even if I don’t agree [with] my challenging individual who wanted everything done, full code…I felt quite satisfied that I was respecting his wishes and that even though it wasn’t in accordance with my values, that we were doing the right thing.” Having a conversation about serious illness and “getting the patient’s input into what we were doing” was described by another clinician as relieving a “burden.”By supporting clinician participation and shifting the focus of the conversation, the patient-physician interaction was perceived by many clinicians to create more humanizing care, which also allowed care to be tailored to support patients’ wishes. One physician described providing “a different type of care and really a kinder type of care,” and another clinician described having “a little more of an empathetic edge,” explaining that “when it’s so busy, it’s easy to…and I don’t use it as a bad term in a bad way…dehumanize people and process people. Just because you’re trying to get through, you become mechanical in what you say and what you do.”One clinician said, “We explored other things that are meaningful for them right now and what would need to happen in order to be able to ensure that we maintain those wishes and look at how to help the individual feel as comfortable as possible. Like, one of my families was talking about Christmas and getting through the holidays and how to be able to have 1 more visit at home.”In this qualitative study, hospital-based clinicians described the SICP as supporting changes in their behaviors and shifting the focus of conversations from intervention to values. Clinicians reported many positive influences of this shift on both personal and professional levels.32 Primary care physicians who implemented the SICP described changes to their mindset and norms, such as an awareness of the need to prompt conversations earlier in the course of illness.33 The increased frequency and content of conversation documentation has been reported in other studies,34 including in a context identical to that of our study.34 The findings of the present study add data suggesting that hospital-based clinicians appreciated the accessibility of the guide and the clear documentation of patients’ values and goals during future encounters. In addition, the SICP’s role in bringing meaning to clinicians’ work and reducing moral distress supports the fourth facet of the quadruple aim of health care, which is improving clinician satisfaction.35The findings are consistent with other studies of clinician experiences after using the guide. A survey study of oncologists found that the guide facilitated timely and effective conversations and increased satisfaction with their role.36 including staff, organization, process,37 and patient factors,38 are known to have implications for conversations about serious illness and the uptake and sustainability of practice changes. Our findings highlight that the multifaceted design of the SICP, especially the system-change components , supported behavior change among clinicians. Moreover, we posit that the multifaceted system changes produced greater awareness of the program within the units and was associated with the improvements in the engagement of interprofessional team members reported by our participants.39Clinical contexts,40 This finding emphasizes the importance of system change for successful implementation of the SICP; other studies have found that serious illness communication training alone was not associated with such behavior changes.41Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity. However, clinicians nonetheless perceived changes in practice behaviors, suggesting that the system changes introduced by the SICP had benefits for workflow, including the cueing of practitioners and the creation of time and space for conversations.This study has limitations. These limitations include the use of purposive sampling at the Hamilton site, whereas a representative sample was sought at the Calgary site. Both sites yielded interviews with clinicians who reported a range of experiences and frequency of conversations using the guide. Interviews were conducted in person with clinicians in Hamilton and remotely with clinicians in Calgary. This decision may have produced differences in sharing experiences; however, differences in the depth of experiences shared between sites were not detected. Furthermore, we did not interview other unit staff, such as bedside nurses, nursing managers, or unit clerks, about their perceptions of the SICP. We also recognize that any changes associated with shifting the focus of conversations are only from the perspective of the clinicians, and this theme is not informed by patient insights.The SICP was described by hospital-based clinicians as supporting changes in clinician behavior, shifting the focus of goals-of-care conversations from an emphasis on code status to patient values, and influencing clinicians on personal and professional levels. By encouraging clinician behaviors that prompt the person-centered care and emotional support valued by patients, the SICP may help to facilitate therapeutic encounters that improve the quality of care for patients with serious illness and their families.


Parental alcohol consumption and alcohol-related behaviour play a critical role in shaping adolescent alcohol use, but comparatively little is known about the perspectives of parents regarding adolescent alcohol use from qualitative studies in England. This study aimed to explore parental views and attitudes towards alcohol use during adolescence, among their offspring and among young people in general.n = 19) between 2017 and 2018. Data were collected via in-depth one-to-one interviews and analysed thematically, using an inductive, constructionist approach.Twenty-three parents  of children aged 13–18 years were recruited via schools, workplaces and community settings, predominantly in the West of England (Five major themes were identified in the data: (1) the parental alcohol environment, (2) balance and acceptance, (3) influences of the parental approach, (4) boundaries and parental monitoring, and (5) wider influences shaping young people’s behaviour. Overall, parents were aware of the risks and consequences of alcohol use and the wide range of influences shaping drinking behaviour, and expressed broad disapproval of alcohol use among young people. However, adolescent alcohol use was viewed as inevitable, and set within a context of a tolerant drinking culture. Many parents therefore chose a balanced and reluctantly accepting approach. This approach was determined by weighing disapproval of drinking against consistency with wider culture and parental behaviour, support for autonomy of the child, and avoidance of social sanctions. Parents’ responses were also determined by a desire to protect the parent–child relationship, maintain an open, communicative and trusting relationship, and ultimately limit risk and minimise harm. Various boundaries and strategies were employed to this end, including care around role modelling, gradual introductions to alcohol, boundaried provision, clear risk reduction messaging and parental monitoring.Parents employ a range of mechanisms to reduce alcohol-related risk and to balance harms of alcohol use among their offspring against adolescent behavioural norms. A downward shift in community consumption and changing socio-cultural norms could alter the accepting context in which parents are required to navigate adolescent alcohol use. In the context of a broad array of factors that shape adolescent alcohol use –5, the fQualitative data further highlight the factors shaping parental attitudes and behaviours to adolescent alcohol use. Studies indicate how parents choose approaches and strategies thought likely to minimise risk and harm among their children, often in response to social norms , or a deRecent data highlight a downward shift in adolescent alcohol consumption, particularly among those drinking the most and to a greater extent among those in mid-adolescence compared to early adolescence . StudiesSince the views and attitudes of parents both contribute to, and reflect, drinking culture, and parent attitudes and behaviours play a critical role in influencing adolescent alcohol use , 21, then = 21 mothers, n = 2 fathers; none were guardians or caregivers; seventeen participants reported their ethnicity as White British, three as White Irish, one as Asian British Indian, one as Black British African, and one as Mixed Race Other). Participants reported variable levels of alcohol use, from abstinence to regular alcohol use. Fifteen participants were recruited in 2018 via workplaces  and community centres, snowball sampling, a regional public involvement network and Twitter. Participants resided mostly in the West of England (n = 19), but owing to the use of snowball sampling, also resided in the East of England (n = 1), South of England (n = 1), West Midlands (n = 1) and the Republic of Ireland (n = 1). Eight parent/guardians of young people aged 14–15 were recruited via secondary schools  in the West of England in 2017 as part of a separate study. No participants dropped out of the study. These participants were parents of students randomly selected from Year 10 who gave consent to participate separately in the study. Parents received a letter via the school inviting their participation and that of their child separately; for parents that took part, their child did not give consent in relation to their parent’s participation. The topic guide was consistent for all participants. Sampling, recruitment and data collection took place in 2018.Participants were eligible to participate in the study if they had a child aged 13–18 years. The study sample included 23 participants (In-depth one-to-one interviews (on average 55 min in duration) were conducted in private spaces in workplaces, in participants’ homes, or over the telephone, guided by a topic guide. The majority of one-to-one interviews were conducted by GJM  with additional interviews conducted by SM . Recruitment and data collection continued until saturation was reached. Both interviewers had previous experience in qualitative research. Before starting interviews, participants were aware of the aims of the study and reasons for doing the research. Interviews were facilitated by a flexible topic guide, which included questions around general attitudes towards alcohol use; perceptions of young people’s drinking, perceived influences on and risks of young people’s drinking; views on their own child’s alcohol use; the role of friends; parental decisions and influences; and the role of the family. Participants’ views on interventions for young people were also explored, but are not covered here. Interviews were audio-recorded and transcribed verbatim. Transcripts and findings were not returned to participants for comment or feedback. All participants received a £15 gift voucher for taking part.The aim of the analysis was to characterise and capture the attitudes, beliefs and influences underpinning and shaping parental viewpoints and approaches towards adolescent alcohol use. Since experiences and meanings relating to alcohol use can be socially produced and reproduced, rather than being solely inherent in individuals, analysis also sought to examine and theorise how parents construct meaning and develop ideologies and practices around alcohol-related parent–child behaviour through interactions with the social world and socio-cultural or wider environmental context. Our analysis therefore took a social constructionist perspective , 28.Data were analysed by thematic analysis at the latent level in NVivo 11  using an inductive approach, as outlined by Braun and Clarke . The resWritten informed consent was obtained from all participants prior to participation and the study was carried out in accordance with the Declaration of Helskinki and research governance principles. Ethical approval for the study was granted by the University of Bristol Faculty of Health Sciences Ethics Committee (Ref 61921 and 131443(8201)/2306).The major themes that were identified in the data were: the parental alcohol environment, balance and acceptance, influences of the parental approach, boundaries and parental monitoring, and wider influences shaping young people’s behaviour.Obviously when I was a student I used to drink and before I had kids. I have got kids to look after. I can’t possibly be drunk because I have got to look after them. I was mixing with people that were not using it [alcohol] well. I took a decision, and my husband did as well, not to drink because we were quite concerned that if we were to continue to have alcohol and use it in a way that we would normally, with young children growing up, we didn’t want them to have those kinds of influences Most participants aimed for moderate alcohol use or less, and described their close friends as having similar intake and attitudes. Participants described their own alcohol use in the context of their lifecourse, often being shaped by their previous experiences, observations of others, and experiences within their family. In particular, participants described a turning point when they became a parent, which entailed responsibilities and duties, and a desire to avoid role-modelling of alcohol consumption. Parents were aware of their role in setting expectations and norms, and the difficulties of setting boundaries for their child if they were not matched by their own behaviour.I think if you’re not allowing them the freedom to do that, I think if you give them a little bit more freedom, they’re likely to stay within those boundaries, whereas if you give them a really tight boundary, they’re going to smash through it and go to the other extreme. Despite the broad disapproval of adolescent alcohol consumption and awareness of its risks, many participants reported a desire to achieve a balanced and tolerant approach towards adolescent alcohol use. The foundations of such an approach included an acceptance of the inevitability of adolescent alcohol use, an understanding of the factors underpinning alcohol use, and a desire to avoid excessive alcohol use resulting from rebellion against a strict or abstinent approach. As such, a somewhat reluctant acceptance of the behaviour was positioned within a realism around the social, environmental and societal culture for adolescents. Forbidding alcohol use was viewed by many as likely to create a sense of excitement and appeal around alcohol use and thus a greater risk of covert and excessive drinking away from the home, which could lead to greater risk. Parents therefore aimed to foster more moderate or sensible approaches to alcohol use to minimise harm, while supporting their child’s social life and freedom to experiment. For some, such an approach followed a stricter method of managing alcohol use, which was subsequently seen as futile and damaging to the parent–child relationship and thus had been actively changed. For some, a balanced approach was necessary since parents themselves drank alcohol, which prevented them from forbidding alcohol use for their child.Well, I’ve always said to my daughter, “Do you want to taste this? Do you want to taste Prosecco?” New Year’s Eve she tasted Prosecco and was like, “Oh, no, I don’t like it at all.” Um, you can taste wine. So I think not making it taboo is really… is a really good way so they don’t think, “Oh, this is really something really exciting I’m not allowed to do.” Obviously, that’s going to make them want to do it. Many parents sought to introduce alcohol gradually with clear limits to intake. Introductions were often made in the home on special occasions or at social gatherings where the child could sip a drink or try a small drink. Such introductions were driven by an interest in enabling the child to join in and to enable a controlled and supervised introduction to alcohol early in adolescence.Parents also reported mixing drinks for their child to take to parties or providing a fixed amount of beer or cider to be consumed, which was viewed as safer than refusal.I would say the last year, he said they were going to a party and he said, “Can I take some drink?” and I said, “No way, not at all.” He said, “My friend is,” and I said, “Well if your friend’s mum wants to give it to him, that’s up to him but there is no way I am buying alcohol for a 14-year old.” Nevertheless, some did report never providing their child with alcohol (see ‘boundaries’) and others reported not having alcohol in the home for young people to access or take to parties (overtly or covertly). Notably, a minority also described a firmer stance towards alcohol use by their child(ren), focused around abstinence.They’re very, very open with me. As far as I know. Obviously, I think there are some things that they keep. They know I’m not going to freak out if they do tell me what has gone on. “Someone had this,” or, “They tried that.” So, I do think they tell me pretty much most of what they’re up to. Overall, the approach sought by participants appeared to be driven by aspirations of balance between broad disapproval of adolescent alcohol use, protection of the parent–child relationship, support and autonomy for the child, consistency with wider culture and parental behaviour, and a strong protective instinct, which aimed to limit risk and rebellion and thus minimise harm. Instinctive disapproval of adolescent alcohol use was tempered, in part, since an open, communicative and trusting relationship was viewed as critical to create a safer context around alcohol use and to maintain the quality of the parent–child relationship. Open, non-judgemental discussions facilitated awareness of the activities and whereabouts of their child, maintained an approachable stance in case of any problems and enabled parents to communicate safety messages.Yes, and knowing that he could talk to me about stuff. It’s definitely, definitely that. I mean, “I haven't got time!,” and yes. “I’m really tired,” as I open a bottle of wine. Yes, that. So, you know, I make sure that we do have activities that we do together. I’m taking him up to the [event] this year so we can just do stuff The protective role of parents was evident via articulation of the importance of ensuring that they were physically and mentally ‘present’ with their children, taking time away from busy schedules to do things together, provide support, and listen.Always be in control. Make sure that you can get yourself home safely. Stay in groups. Always look after your own drink, don’t leave it unattended. Yes, all of the normal things I would say to them.. Safety messages were communicated in an ongoing and routine manner, often opportunistically using trigger events or news stories, with parents judging when their child was ready. The major concerns expressed by parents included intoxication and loss of control; impaired judgement; vulnerability and a lack of safety; injury, accidents and fights; and health risks; and many expressed particular concern around their daughters and their increased vulnerability, including to sexual assault, being attacked and/or spiking. Thus, most messages were focused around negative consequences, reducing risks and strategies for staying safe , being responsible and social pressures.They don’t drink in the house unless it’s, you know, like with a Sunday meal or something like that, I wouldn’t have them sat around drinking, I wouldn’t allow that. In addition to the messaging, support and focus on the quality of the parent–child relationship, participants described a range of boundaries around alcohol consumption, as well as strategies for managing adolescent alcohol use, used to assure safety. Such boundaries involved age at introduction, offers of alcohol in the home and limits to provision.I am quite strong with it and I think that I have to be with him, because if I gave him the all clear he would be on a right jolly with it because he is quite easily led as well. It is supervised, insofar as I can do it, where I will do the drop-off and the pick-up and that’s at a set time. You know, it’s not go off to a party and come home whatever you feel like it. Boundaries were determined by a pre-existing sense of what was acceptable, the stage of adolescence, the personality of the child and often, some bartering, negotiation and compromise. An approach which was effective for one child did not necessarily apply to another, depending on their nature, desire to fit in with others, friendship group, and the extent of their interest in alcohol. Boundaries were supported by key parental monitoring strategies including communication with parents of young people holding parties to assess risk, providing lifts to and from parties, and having fixed collection times...even with someone that you consider to share some of your views with, even then there’s massive gap here with alcohol. That maybe comes back to the fact that within their family it’s so normalised that they just assumed it's normal for their 12-year-old child to have a beer at their own party. Importantly, however, participants described a clear contrast between their own approach and that of others, with many expressing disapproval and shock around the perceived leniency and low levels of monitoring observed among other parents, while acknowledging their respect for autonomy in individual approaches. For instance, participants described parental absence from parties, the provision of spirits to young people, and a lack of awareness around their child’s activities. For some, this was viewed as being borne out of an assumption that such an approach supported their child, while for others, this reflected the spectrum of norms around alcohol use among different families. Notably, alcohol also appeared to be a subject around which peers who shared similar values and attitudes might differ in their approach.I got a bigger group of mums together and said, “Right. [Name of child] is coming back saying, ‘So-and-so’s mum allows her to have…’ Can we just meet regularly to have a consensus and do some ground rules so we’re all saying the same thing? And we’re all saying the same thing about pick up times from parties and all that kind of stuff.” The distinction between participants’ norms and those in the wider social context of their child presented challenges around boundary-setting and approaches taken, since differences could undermine their own approach. Despite many parents describing an absence of felt pressure resulting from such differences, some reported feeling pressured by others’ approaches and discomfort with the result. Those that had actively built, and communicated with, a close network of parents, were emboldened and strengthened in boundary-setting, since this enabled awareness of others’ limits (e.g. around provision) and a shared agreement of consistent boundaries, while facilitating a greater awareness of the activities of the child.The major influences on young people’s behaviour that participants described were centred around environmental and cultural structures and norms, the influences of friends and peers, and the impacts of wider family members and networks.Alcohol use was described as strongly embedded in attitudes towards fun and socialising across the lifecourse, and was viewed as integral in social activities across the UK, while being widely available, affordable, widely promoted and broadly presented as a norm. Parents noted targeted advertising and marketing, and the promotion of sweeter alcoholic drinks, which had implications in shaping drinking culture among young people. Many also made the distinction between alcohol consumption in the UK and alcohol use in other European countries.Changes over time, from parents’ youth, were seen to have resulted in a shift in alcohol use behaviour to a pursuit or intention of intoxication and excessive drinking. Notably, however, some parents highlighted that their children were more aware of alcohol and its dangers and self-regulated their behaviour more than anticipated.There are people there who get absolutely blotted, but she just thinks it’s quite pathetic. They have a huge influence because it’s all peer pressure and looking good and not standing out from the crowd. They have got the ability to influence it probably the most, peers. Peer influence and peer pressure was viewed as synonymous, and a major influence on young people’s behaviour, with parents accepting the likelihood that many young people would naturally aim to belong in a group, to be like their friends and avoid standing out. Nevertheless, the extent of influence was clearly dependent on a young person’s personality and often minimised by their own strength of character and firm views and attitudes, or the nature of their friendship group.In part, peer influence was experienced via social networking sites (SNS), the extensive engagement with which was viewed as a source of concern for parents. Young people’s use of SNS presented a stark contrast with their own experiences of youth, which were free of the pressures of posts about alcohol and other peers having fun, or threats of being recorded or photographed. Positive portrayals of alcohol on YouTube or SNS was viewed as an influence, as well as a challenge for parents in managing the effects, although the potential for embarrassment or records of activity whilst intoxicated was also viewed as a potential restraint on behaviour. Despite such concerns, the use of social media and technology did not emerge as a major concern in relation to alcohol, in comparison to concerns around safety, vulnerability and boundaries around consumption.Everyone says the peer group is the most important thing, and I think they are really important unless… unless the parents are stronger than… than the peer group, and in terms of being around all the time Views on the comparative importance of peers or family in influencing young people were mixed with some describing peers as having an equal or greater influence, with others noting the critical influence and framework that parents and families provide, for instance in affecting how a child responded to peer pressure.With one I got to the point where I was like, “I don’t want my kids seeing how she drinks, because I don’t want them thinking that’s normal. This is an issue.” As described above, other parents could present challenges to participants, as a result of discordant rules and boundaries. Views on the role of wider family members was mixed. Those who drank frequently or dependently could be negative role models and the focus of discussion about negative consequences of alcohol use; or alternatively, relatives could role model alcohol use in a more positive way. Broadly, such influences formed part of the wider context from which parents felt a protective duty, aiming to manage or protect their child from such effects.This study aimed to explore parental views and attitudes towards alcohol use during adolescence, among offspring and among young people in general. Our findings demonstrate that parents were broadly disapproving about alcohol use and reported concerns around safety and risk, but sought to achieve a balance between their disapproval and anxiety around alcohol use and a view that drinking was inevitable and normative during adolescence. This approach often led to adoption of a more accepting stance than was instinctive, founded upon trust, communication and support, which aimed to maintain quality of the parent–child relationship, while avoiding social sanctions and minimising risk and harm.Our findings support those of related qualitative studies conducted outside of the UK, which report parental disapproval of alcohol consumption during adolescence, but a preference for boundaried alcohol use and the setting of limits around drinking, owing to perceived difficulty in controlling alcohol consumption at this stage , 29. OurThe focus among parents on minimising harm by adopting a more accepting stance than was deemed instinctive or ideal, was, in part, a response to the perception of adolescent alcohol use as normative, and an inherent recognition that alcohol use is deeply embedded in the social structures of society in the UK. We have previously reported how young people internalise and enact peer and cultural behavioural norms and accepting family contexts, generating and sustaining a social world where heavy alcohol use is normative . MoreoveWhile such drinking cultures were or are not unique only to the UK –38, takeMany participants in our study reported a preference for the introduction of alcohol in the home and/or provision of alcohol, to avoid rebellion or excessive drinking outside of the home, and thus viewed parental alcohol provision as a form of harm reduction, as reported in related studies . HoweverThe means of influencing such practices may therefore warrant further investigation to explore how best to ensure effective harm reduction for young people over the short and longer-term. For instance, ways of strengthening awareness of the impacts of alcohol provision, could be incorporated into single and multi-component preventive approaches, as suggested by others , while aInterestingly, our findings suggest an interplay between trusting, communicative parent–child relationships, family closeness  and parental monitoring. The latter involved knowledge of the whereabouts of children, assessments of the settings and perceived risks of individual parties, the active development of parental networks and the provision of lifts to and from parties. Evidence demonstrates that the association between parental and adolescent drinking is mediated, in part, by perceived parental monitoring and discipline , and whiInterestingly, we did not find clear evidence of a perception among parents that there was a downward shift in alcohol use, with many noting concerns around the scale of alcohol use and cultural acceptability. However, the harm reduction and safety messages communicated repeatedly by parents, alongside implementation of a range of parental monitoring techniques and disapproving attitudes, reflect evidence of more restrictive alcohol-related parenting and less tolerant views in the study sample, which supports published evidence. For instance, studies have suggested a shift to more restrictive alcohol-related parenting behaviour and lower tolerance to adolescent drinking; and changes in parental permissiveness and practice has been suggested to be one possible explanation of the decline in adolescent drinking –47. In tRecent studies also highlight that the setting of parental rules concerning alcohol and parental disapproval are associated with lower odds of risky drinking , while iOur study has several strengths, including the sample of parents having been recruited from a range of communities, who reported variable levels of parental alcohol use and family histories. The use of in-depth semi-structured one-to-one interviews also enabled the collection of rich, detailed data regarding individual perspectives and personal experiences, unaffected by social desirability of responses or norm perception in the group. In addition, parents discussed experiences with both sons and daughters from across the course of adolescence. Nevertheless, we note that were able to recruit only two fathers, and the number of participants from low socio-economic groups and Black, Asian and minority ethnic groups was limited. As such, our findings may not be applicable to all areas and groups. In addition, our data were collected in 2018 prior to the COVID-19 pandemic, and there may therefore have been substantial changes in attitudes, behaviours and parenting practices, as well as changes in the determinants of alcohol use, which have not been considered.Our findings suggest that parents navigate a complex interplay of individual, family and environmental factors to protect offspring from risk and harm alongside support for social and peer involvement, parent–child communication and perceived normative alcohol use during adolescence, leading to a balanced approach. Greater awareness of the adverse consequences of early initiation to alcohol and of parental supply, alongside correction of misperceptions around attitudinal and behavioural norms could support parents and caregivers to reduce alcohol-related risk among adolescents. Population-based approaches that lead to a downward shift in general consumption are also needed simultaneously to address role-modelling and the transfer of motivations and behaviours from parent to offspring.


Socioeconomic inequality in health among women is often referred to as smaller than health inequality among men. However, we know less about differences in health between men and women within the same socioeconomic groups. In this article the lack of attention to potential socioeconomic variation in gender health inequality is argued as unfortunate, as it can obscure how mechanisms, such as e.g. working conditions, affect gendered health within specific groups. Drawing on the nationally representative Swedish Level of Living survey (LNU), class/gender interactions as well as class-separate linear probability models are estimated to explore relationships between working conditions and health among men and women with the same occupational class positions. Results show that, although class is not a large explanatory factor for general gender differences in health, there are varying within-class differences between men and women in working conditions, that can contribute to the understanding of within-class gender differences in health. This highlights that, when targeting causes of gender health inequality, it is important to consider not only what class means for women as well as for men, but also what gender means within specific classes. According to previous research, inequality in health based on socioeconomic position (SEP) is larger among men than among women ,2. OtherWorking conditions are potential mechanisms that can have impact on health and class is the SEP-measure most closely connected to working conditions . DemandiThe aim of the present study is explorative, seeking to investigate the potential for class differences in the relationship between gender and health. Do gender differences in health vary by class? And can class-specific gender differences in physical or psychosocial working conditions further our understanding of the relationships between gender and self-rated health problems?job strain refers to a combination of mentally demanding work with low possibility of controlling your work situation ). LNU is a longitudinal survey based on a random sample of 1/1 000 of the Swedish population age 15–75 in 1968 (the age-span was changed to 18–75 in 1991). Refresher samples have been added in each additional wave of the study, making each wave also nationally representative as cross-sectional data . The sample in 2010 consisted of 7 253 individuals, whereof 4 415 answered the survey, giving a 60.9% respondent rate  and all research is carried out on de-personalized data. Consent is obtained from each survey participant at the time of the interview.This study uses the 2010 wave of the Swedish Level of living survey  Age 18–65. Individuals working after the regular retirement age can be expected to be selected both on health and on class, therefore 65 years of age was set as an upper age limit for inclusion, resulting in the exclusion of 636 respondents. ii) To be in employment. Respondents were asked if they were employed full time and if they were employed part time during the week prior to the interview and respondents that answered “No” on both were excluded from the study (n = 1 128). iii) To have available information on work conditions. Employers and those in self-employment (incl. farmers) are not asked about working conditions in the LNU surveys and were therefore not included in the study (n = 14). . further 40 respondents were excluded from the sample due to missing information on independent variables.The final study sample includes 2 597 individuals which represent 68.7% of the respondents in the age group 18–65 (69.8% before exclusion on missing variables). According to official statistics, the share of employed individuals in the Swedish population (age 16–64) in year 2010 was 65% . Given tThe included variables are described below, and the variable distribution can be found in the Appendix (Table A in bad/something in between = 1).Self-rated health (SRH) is a common health measure in surveys. It is a stable measure of individual health, a good predictor of subsequent mortality ,39 and gst Century [otherwise = 0). Different specifications of these variables have been tested and no substantial differences in results or interpretations were drawn.Regarding the more symptom specific health measures included, musculoskeletal pain is a health problem shown to be more common among women than among men ,42 and h Century . The LNUIf the respondent reported both a full time and a part time employment, the working conditions refers to their full-time position and respondents with multiple part time jobs (and no full time) reported working conditions for the position that they defined as their primary employment.more seldom/no = 0). The respondents, furthermore, stated whether their jobs are “otherwise” physically demanding; makes them sweat from physical exertion; forces them into unsuitable work positions; involves many repetitive and monotonous movements, and whether they sit down most of their working time . A factor analysis of these physically strenuous conditions turned out one factor with eigenvalue >1 that included heavy lifting, physically demand, daily sweating, and unsuitable positions . These four items were thus summed to an index of physically strenuous work (0–4) with a Cronbach’s Alpha of 0.73 . To sit down most of the workday loaded in the opposite direction to the other items (-0.61) and was therefore used as a separate dummy variable (yes = 1) in analyses. The question of repetitive movements was also included as a dummy variable (yes = 1) since it did not load highly in the chosen factor.For physically strenuous conditions, respondents were asked if their job requires them to lift > = 60kg and, if so, how often this is required. In order to capture heavy lifting on a regular basis the answers “daily”/ “a few times a week” were here coded = 1  to 5  where “half of the time or more” (> = 3) was coded = 1 for the dummy specification.For emotionally demanding work, the respondents were asked how much working time that consists of such tasks. Answers were on a scale 1 (= no = 1) for non-flexible hours and for being without possibility for private errands.Work flexibility variables were based on yes/no questions about whether the respondent can decide when the workday should start/end, or whether the respondent can leave the workplace for half an hour to go on a private errand “without informing supervisor”. These were coded as dummies (to a very large extent) to 5 , to what extent they can “get support and help from work-mates when needed”. The variable lack of social support at work was coded = 1 for only being able to receive support either “to a small extent” (4) or “not at all” (5).Lastly, respondents were asked, on a scale from 1 (= personnummer). Women were coded = 1 and make up 48.6 percent of the respondents.Information about whether the respondents are male or female comes from the official Swedish personal identification numbers (Socio Ekonomisk Indelning (SEI), which bears close resemblance to the internationally well-known Erikson-Goldthorpe class schema [In this study, SEP was measured as occupational class. There are various measures of SEP, such as education, occupational class or income. These are both interrelated and can have different and independent associations with health . Howevers schema .The categories used were unskilled workers , skilled workers , assistant non-manual employees , intermediate non-manual employees  and higher non-manual employees . Dummy variables for each class category were constructed, and higher non-manual employees was used as reference category in all regression models.Within the classes, there are notable differences in the types of occupations that are held by men and by women  and age squared was included to capture possible acceleration of health deterioration at older ages.All models were controlled for Analyses were estimated with Linear Probability Models (LPM), using Stata 14 software. LPM are similar to OLS-regressions run on a binary outcome, where coefficients are interpreted as percentage point’s change in the probability of the outcome. The results thus give the percentage point’s change in the probability of ill health , given the included variables. Using LPM means assuming linearity on a binary outcome and a common choice for analyses of binary variables has been to use logistic regression. However, this issue has been discussed and it has been shown that when exploring relationships between variables and comparing coefficients between models, a logistic specification is less suitable ,49. LPM The analytical strategy was divided into two steps, which were carried out for each of the three health outcomes. In step one, a baseline relationship between gender and health was estimated (unadjusted model). Then the mutually adjusted relationship between gender, class, and health was then estimated (Model 1) and interaction terms between gender and each class were added, to explore whether gender differences in health differ by class (Model 2). Predicted margins were then estimated based on model 2.In step two, class-separate models were estimated to investigate whether working conditions can account for gender differences in health within each class. In this step, the unadjusted baseline model again included gender. Physically demanding working conditions (Model 1) and psychosocially demanding working conditions (Model 2) were then added stepwise.All models were controlled for age and age^2. Throughout, 95% confidence intervals, based on robust standard errors, are reported.The descriptive results show that, in general, it is more common among men than among women to have jobs that involve heavy lifting, that cause sweat, and that entails sitting down most of the time. Women, on the other hand, have “otherwise” physically demanding work to a larger degree than men, while repetitive movements and unsuitable positions are quite equally distributed between men and women . HoweverPsychosocially demanding work is more common among women than among men and this pattern is found for practically all classes and all conditions . OverallThe share of women in the material, that experienced ill health is larger than the share of men, for all three health outcomes  become small, which has consequences for the statistical power to detect class-specific gender gaps and their mechanisms. Therefore, there is an increased risk of type II error, which could imply, e.g., that there may be even further variation between the classes when it comes to gender differences in health or that working conditions that are relevant for gender health differences are not identified in the class separate analyses . Howeverin to work for men but out of work for women [There is also a possibility of positive selection of healthy individuals into high-ranking positions, which also contain fewer demanding working conditions. The impact of reversed causality on social inequality in health has, however, been found to be small . Selectior women . Women aor women ,54, whilor women . If unheWomen further work part time to a larger extent than men, which may have implications for gender differences in health. Part time work is more common within the working class, and in Sweden this class difference is larger for women than for men . Part tisex as a variable for gender. Respondents in the Level-of-Living survey are identified as men or women by means of information contained in the Swedish personal identification numbers (personnummer) that are issued by the tax authorities to all individuals that are registered in the Swedish population  [A final issue that warrants some reflection, is the practice of using an empirical measure of gration) , thus bagration) –61 and cgration) . To disegeneral female-male disadvantage in SRH, musculoskeletal pain or psychiatric distress, horizontal gender segregation of the labour market is an important aspect for understanding gender differences in health within specific occupational classes. An underlying assumption of class theory is that of shared conditions within classes and differences in conditions between classes. However, due to horizontal gender segregation, men and women have different working conditions also within classes. The present study indicate that work demand can be differently related to gender gaps in health in different classes. Psychosocially demanding conditions, e.g., contributes particularly to the gender gap in health among skilled worker, a class where these conditions are very common among women. Given the exploratory nature of this study, results are tentative and calls for further and more detailed future studies.One conclusion that can be drawn from this study is that the difference between men’s health and women’s health is not uniform; it can vary depending on occupational class. Although class is not a large explanatory factor for the In order to target causes of gender health inequality, it is important to take into account not only what class means for women as well as for men, but also what gender means within specific classes–i.e. the conditions, resources and constraints for men and women within a particular group–and how this can be related to health.S1 Appendix(TIF)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.S4 Appendix(DOCX)Click here for additional data file.


Böger, Gerhard Hindricks, Holger Thiele, Edzard Schwedhelm and Jelena Kornej, was originally published online on 06 June 2020 without open access. With the author(s)’ decision to opt for Open Choice the copyright of the article changed on 27 September 2021 to © The Author(s) 2021 and the article is forthwith distributed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Original article has been corrected.


It is generally assumed that gamblers, and particularly people with gambling problems (PG), are affected by negative perception and stigmatisation. However, a systematic review of empirical studies investigating the perception of gamblers has not yet been carried out. This article therefore summarises empirical evidence on the perception of gamblers and provides directions for future research. A systematic literature review based on the relevant guidelines was carried out searching three databases. The databases Scopus, PubMed and BASE were used to cover social scientific knowledge, medical-psychological knowledge and grey literature. A total of 48 studies from 37 literature references was found. The perspective in these studies varies: Several studies focus on the perception of gamblers by the general population, by subpopulations , or by gamblers on themselves. The perspective on recreational gamblers is hardly an issue. A strong focus on persons with gambling problems is symptomatic of the gambling discourse. The analysis of the studies shows that gambling problems are thought to be rather concealable, whereas the negative effects on the concerned persons‘ lives are rated to be quite substantial. PG are described as “irresponsible” and “greedy” while they perceive themselves as “stupid” or “weak”. Only few examples of open discrimination are mentioned. Several studies however put emphasis on the stereotypical way in which PG are portrayed in the media, thus contributing to stigmatisation. Knowledge gaps include insights from longitudinal studies, the influence of respondents‘ age, culture and sex on their views, the relevance of the type of gambling a person is addicted to, and others. Further studies in these fields are needed. Gambling is increasingly perceived as normal leisure activity in most Western societies. A large part of the adult population participates in some sort of gambling such as lotteries or sports betting. Unlike many other leisure activities, gambling may however cause adverse impacts on the health and wellbeing of an individual and his/her environment. The concept of “gambling harm” summarises a wide spectrum of negative consequences such as financial problems, disruptions to work/study, damage to the health, emotional and/or psychological distress, deterioration in relationships, cultural harms and criminal activities  gambling is to some extent stigmatised stigmatisation  was then linked to one of the following search terms by an AND-condition: “Stigma*”, “public attitude”, “social attitude”, “devaluation", “discrimination”, “labelling”, “prejudice”, “rejection”, “responsibility “, “self-control”, “self-esteem”, “self-worth”, “shame”, “social distance” and “stereotyp*”. A separate search was performed for each of the search term pairs in each database. The literature search was only limited (inclusion criteria) in terms of language (English) and publication date (from 1980 onwards). This year was chosen as a starting point because pathological gambling was first included in the DSM-III in 1980. Any form of scientific knowledge  was allowed.n = 40). 37 of these citations have proved relevant and are included in the qualitative synthesis. The reasons for the exclusion are portrayed in Fig. A total of 5.014 literature references was found. All individual database searches were exported and subsequently integrated, so that duplicates could be easily removed. As a next step, all literature references were screened on the base of title and abstract. Subsequently, 4.874 literature references could be removed, as they were not relevant to the review. Controversial cases were discussed and a joint decision was made. A large number of references could thus be removed as they were obviously off topic. 143 references were then classified as potentially relevant. By taking a closer look at the analysis and results section, more studies were removed. The remaining references were screened for eligibility by the two authors by reading the full text , type of sample , method of analysis  and country of origin of the sample.Second, the content-related aspects were categorised. As a basis, the shared dimensional features of stigma proposed by Jones  were useBeyond Jones’ shared dimensional features of stigma, Hing et al.  have devA total of 37 literature references  was found. Some of these references contained several studies. E. g., an article may describe surveys obtained from different samples . Two publications each worked with the same sample but inquired on different topics  and one corpus-based text analysis. Almost exclusively, cross-sectional surveys were carried out. Only one film analysis  or Canadian samples (n = 10), which might impact the generalisability of the results of the present study. Four studies were carried out with Finnish and four with US samples. One study each was conducted in France, Spain, Sweden, the United Kingdom and Israel. Two studies were based on international mixed samples. Two out of the three film analyses took an international perspective, whereas Chan and Ohtsuka  could be adopted for the gambling field.In general, drug use was more heavily stigmatised than alcohol abuse  would have rendered further results. Due to time restrictions, the quality of the studies was not rated. The consideration of publications in other languages would also have been reasonable. Besides, the lack of formal assessment of intra- and inter-rater reliability can be criticised. Selection of the studies was made as team effort and all relevant decisions were extensively discussed. It would also be worth considering combining parts of the studies using meta-analytical statistical methods in the future.Although a good number of studies focus on the public perception of persons with gambling problems, other aspects have been examined less well. Research on this topic started rather recently. In many countries, therefore, there is a lack of population-representative surveys on the perspective of gamblers. Moreover, it is noticeable that longitudinal studies are not available. These are however necessary to obtain insight into the dynamics of the phenomenon. It would also be interesting to monitor individual persons with gambling problems over a longer period of time with a qualitative research approach. Such a research project could provide important insights into the process of stigmatisation and in particular self-stigmatisation.An interesting line of research is to look into the portrayal of persons with gambling problems on part of the media . Since several studies have already been carried out, complementary research activities could start from a solid basis. The ways in which persons with gambling problems are portrayed in the media of different countries would also make an interesting topic of investigation, especially in countries where this issue has not yet been addressed.Aspects such as the influence of the respondents ‘ sex and age on their attitudes have only been touched on briefly, if at all. Also, the influence of cultural aspects has hardly been taken into focus (Dhillon et al.


The decreasing level of physical activity among female undergraduates is worrying as it is associated with the increased risk of non-communicable diseases. Thus, this study aimed to identify the motivations, barriers and preferences towards exercise among female undergraduates in Malaysia.A non-probability purposive sampling was used for the recruitment process. The inclusion criteria of the participants were registered female undergraduates and aged between 18–30 years old. A semi-structured in-depth interview was used to collect topic-related information from the participants and signed consents were obtained prior to the interview. The interview questions were on respondents’ understanding of exercise, motivation and barriers to exercise, and exercise preferences. The recruitment process was conducted until the data was saturated. All interviews were audio recorded and manually transcribed verbatim. NVivo 11 was used to conduct the inductive analysis of the data to develop themes for motivation and barriers to exercise. For exercise preferences, four predetermined themes were used.A total of 26 respondents participated in this study. Eight themes were found for motivation to exercise, with the most common themes being maintaining or improving appearance, health benefits and togetherness. For barriers of exercising, five themes were found, and the most common ones were disliking exercise and no motivation. For exercise preferences, most respondents preferred a structured exercise program with flexibility in terms of when and where the exercise could be conducted. Light or moderate intensity exercise for 10–30 minutes with a frequency of 1–2 times a week was desired the most among the respondents.In conclusion, personal and environmental factors play important roles in motivating or hampering female undergraduates to exercise, and a structured program was the preferred mode of exercise of these respondents. A new exercise module was designed based on this needs assessment with a 70% acceptance rate among the participants. These findings can help the future development of more exercise modules tailored to female university students. Physical inactivity has been identified as one of the main factors of death globally . PhysicaA previous study reported a decrease in physical activity participation during the transition to higher education , while aA lot of effort has been carried out to combat obesity and its associated risks in Malaysia. One of them is the large allocation of the healthcare budget . However, there is still a growing prevalence of overweight and obesity among Malaysian adults, from 47.7% to 50.1% over the years of 2015 to 2019 . PhysicaThis qualitative study was conducted to explore motivations, barriers, and preferences towards exercise among female undergraduates in Universiti Kebangsaan Malaysia, Malaysia. Based on the recommendation by Dworkin , a samplEthical approval was obtained from the Universiti Kebangsaan Malaysia Human Research Ethic Committee (UKM PPI/111/8/JEP-2017-656). Respondents were briefed about the purpose and the procedures of the study. Informed written consent was obtained from each respondent prior to the interview.The interview protocol used in this study was adapted from Lees et al.  and was Each interview session was recorded using a smartphone recording application and was transcribed verbatim. Both inductive and deductive thematic analysis were employed in this study. For motivation and barriers towards exercise, a qualitative data analysis program, QSR International NVivo version 11 was utilized to analyze the themes , 36. Dat30 female respondents were recruited for this study, but information had reached saturation at the 26th participant. The 26 respondents were between 21 to 27 years old (mean age 23.00±1.17 years old). The respondents consisted of Malays (61.5%), Chinese (15.4%) Indians (7.7%) and other ethnicities (15.4%). The study location was the health campus at University Kebangsaan Malaysia; hence all the respondents were from healthcare related courses: nutrition, environmental and health sciences, biomedical sciences, optometry and dentistry programs. The complete sociodemographic characteristics of the respondents are shown in Multiple factors motivated respondents to start and continue exercising in their daily life. In this study, eight themes emerged as motivation towards exercise, as shown in Over half of the respondents stated that their main motivator to exercise was to maintain or improve their physical appearance (n = 14). When probed further, respondents intended to increase weight (n = 5), reduce body weight (n = 6) and body shape/ muscle tone to increase attractiveness (n = 3). One of the respondents, R25’s  statement is as follows:Actually, the main reason that I want to exercise is to reduce my body weight because of my fat. I have a high fat concentration, so I want to shape some muscles. Because every time I check, it’s always higher than it should be (fat). So that’s the real reason that I want to lose body weight…”.“When there is a change in my lifestyle like when I’m not even tired after going up and down the stairs. My body feels more fit and I will definitely feel more addicted to exercise. To me, I’m hooked. For example, with tae-kwando, my body only hurts for 2 weeks and then we start with movement week, it’s great. Just great”. Other respondents talked about being active previously but were currently living a sedentary lifestyle. Hence, they aspired to be healthy and active again. For example, R5  stated that, “I want to be fit because I used to play handball a lot and back then, my body felt so great. I don’t know how to explain it but it’s great. When I wake up I feel great but now that I don’t play as much, I get tired easily. So, to be fit again would be great”. Some respondents wanted to be fitter than their current state and expressed that they would exercise more often if they had someone to teach them. This was mentioned by respondent, R6 , “Maybe if I could be friends with someone who knew about exercise or somebody else who knows how to exercise, I would”.Health benefits were mentioned by 13 respondents. The respondents desired to improve fitness levels (n = 6), maintain or improve physical health (n = 5) and to know the health benefits of the exercise prior to exercising (n = 2). Some respondents were keen to improve physical health that it outweighed the hindrance to exercise, including pain. An example of such response came from respondent, R6 : “If I know how the exercise activity or the exercise module can benefit me, like what I can get in return, only then am I motivated to do it”. Some respondents wanted dietary advice and energy expenditure estimation in the exercise module that would be developed in the future.Being students, academic performance had become their priority and it had outweighed the perceived health benefits from exercise. Some respondents reported to have busy schedules, hence were selective on how they spent their time. Others wanted to know the specific health benefits of the exercise prior to exercising. For example, respondent R2  said, “Um, for motivation, if someone invites me to exercise then I can follow them but if no one invited me to exercise, I will definitely not exercise by myself”. Another example is R10  who said, “It’s like a support system, I think, when we exercise with friends, we have a gang”. Other respondents preferred joining a group activity. One respondent, R22  remarked, “Because there are many people in a group. The more people there are, the more motivated I feel. When we see other people (become) motivated, we also feel like, oh, we want to do that too but when we are alone, we feel like lazy, do tomorrow and tomorrow. We procrastinate it until we eventually end up not doing it”.The third theme, togetherness (n = 10) was further divided into spending time with friends (n = 6) and joining a group activity (n = 4). Respondents’ motivation was influenced by the presence of their friends. For example, respondent R19  mentioned that “It would be easier if there was someone to teach me to exercise and what to do. If I’m alone, it is much harder to learn how to exercise”.The availability of a coach or a trainer was mentioned by the respondents as a motivating factor for them to exercise (n = 4). One respondent, R13  said, “For me, exercise is like a discipline, we have discipline to keep moving us, to do the exercise regularly. So, and the discipline can be applied in all the other stuff, in our daily life, so I feel like this is my responsibility to do the exercise”. Therefore, exercise is perceived as an activity to develop positive character traits.The best example for the theme discipline or commitment (n = 4) as a motivator to exercise was this response: “If the place to exercise is satisfactory then I am interested to exercise there. That’s what can add motivation for me to exercise”. As for appropriate exercise equipment, one of the respondents, R21  said, “If it was like before this, when I had mood to exercise, maybe I would buy a skipping rope, put it in my room so that I can use it every day. That’s all that I can think of that can increase my mood to exercise. We can buy exercising equipment to help us exercise”.The sixth theme for motivation to exercise is facilities (n = 4). Facilities include convenient place to exercise (n = 3) and appropriate exercise equipment (n = 1). Respondents’ motivation to exercise was dependent on the quality and availability of facilities in the residential college. For example, R10  mentioned, ““Sometimes exercise makes me happy. Feel happy especially when we enjoy the exercise”Enjoyment towards exercise was also a motivating factor for some of the respondents (n = 4). One respondent, R5  said, Because exercise release stress, some more if you stuck in your room for so long you will feel stress facing the four walls”.The final theme associated with motivation to exercise is its stress releasing capability (n = 1). Only one respondent mentioned that exercise can help reduce stress from studying in the room for a prolonged time. The respondent R15  said, “As shown in Because when you exercise, you sweat, then you have to change your clothes and shower…its extra effort, I’m lazy and I don’t like it”.Most of the respondents did not exercise because they disliked exercise or physical activity. This theme is divided into three categories which are general dislike towards exercise (n = 4), dislike being seen exercising (n = 5) and dislike exercising alone (n = 3). For general dislike towards exercise, respondents stated they did not like exercise and that exercise did not make them happy. For example, R21 , “When exercising outdoors, I feel a bit ashamed when exercising with people who are already fit and I, on the other hand, am not”. One accurate example for this theme is described by respondent R22 : “I actually like exercise, but I don’t like it when people watch me exercise. I seriously don’t like it, not at all. Sweating is fine and all it’s just that I don’t like it when people watch me exercise”. For the category dislike exercising alone, one of the respondents, R10  said, “I have no friend to go exercising with. No gang and then if I exercise in my room, I also have no company so it’s not fun”.As for dislike being seen exercising, all the respondents who reported this as a barrier were Muslim respondents. One of the respondents said that she did not have self-confidence. Another respondent R5  said, “I’m lazy, I’d rather waste time watching stories on my laptop than exercise”. Another respondent, R10  said, “Because if I exercise in the morning, um…I’m lazy to wake up in the morning”. One respondent, R11  even said, “These days I rather sit down rather than walk and do exercise”.Another major barrier to exercise is the lack of motivation (n = 11). Respondents were not motivated to join sporting events, exercise by themselves or with friends either indoors or outdoors (n = 10). One respondent said that she did not have the mood to exercise. R21  said, “If the academic work is too heavy or activity or co-curricular is too many then I will skip, I may skip the exercise”.The next theme is time constraint (n = 10). Majority of the respondents depended on the bus provided by the university on weekdays, and public transport such as e-hailing services and city transit buses to commute. Based on the observation and experience of the researchers, students would usually take the bus departing to the faculty early in the morning and return with the campus bus late in the evening. Even though the distance between the faculty and residential college is not far, heavy traffic during peak hours would increase the travel time of the respondents. Apart from that, respondents also tend to spend more time at the college’s cafeteria. This is because there is only one cafeteria operator and the waiting time for food is quite long. In addition, students are also expected to be involved in college activities and most of them are non-exercise related. Many respondents needed to have good time management for academic responsibilities, co-curricular activities and exercising. In many cases, exercising was often the lowest priority. One of the respondents, R14  said, “Sometimes when we exercise in the afternoon, by the time we get back to our room we are tired. So, at night cannot do that much work. Sometimes I even fall asleep”. Respondents said that exhaustion from classes and the travel between faculty and residential college in the evening were the main obstacles that prevented them from exercising. As for pain after exercising, respondent R6  said that, “The thing about exercise that I don’t like is that after exercise, especially when the body is just beginning to adapt to exercising, I’ll get body aches and pain after”.Most of the respondents reported experiencing discomfort or pain during or after exercise (n = 10). This was another deterrent to exercise. Fatigue (n = 7) and body aches after exercise (n = 3) are coded into this category. An example for fatigue was mentioned by respondent R19 , “I used to like going to the gymnasium but now because the equipment and the environment in the gym isn’t good, I don’t go anymore”. Based on the experience and knowledge of our researchers who are also UKM students, the residential colleges in UKM provided sports equipment mainly for sports programs sanctioned by college management, and personal utilization of equipment required written permission. While the college gymnasium is accessible to every resident, its availability to female undergraduate residents was restricted. Female residents are only allowed to use the gym on selected days of the week. To make matter worse, many of the gym’s equipment were defective and the number of equipment was insufficient.The final theme is lack of facilities (n = 1), and respondent R10  clarified this, “Exercise preferences refer to the individually preferred choices and situations that encouraged respondents to exercise. The feedback from respondents was classified according to the FITT principle, a framework used in exercise prescription as suggested by the American College of Sports Medicine . The FITThe exercise preferences by the respondents are shown in Um, to me that isn’t too frequent. It depends on how busy I am as well. If I’m not busy, exercising every 2 days is fine”.In terms of frequency, majority of the respondents (n = 21) chose to exercise once or twice a week while only a minority would exercise three times a week (n = 5). None of the respondents were keen to exercise more than three times a week. Interestingly, one of the respondents, R22 , chose to be flexible in determining the exercise frequency by admitting, “When it comes to going up and down the stairs, confirm I feel so lazy. If there was a lift, I would definitely take the lift. I can’t bear to do high intensity exercise”.In terms of intensity, more than half of the respondents preferred to perform exercise with moderate intensity (n = 15) while the rest chose to do light intensity exercise (n = 11). None of the respondents wanted to do high intensity exercise. For example, respondent R18  mentioned, “Zumba. Some respondents desired exercises that could be done in a confined space like their own room (e.g. Zumba following YouTube® videos) while others preferred to exercise outdoor. One of the respondents, R12  said, “If I had a friend who had similar interests with me, I would rather exercise in a group because we can give each other motivation because we are friends”. Respondents requested the inclusion of interesting exercise activities should an exercise module be produced. For instance, one of the respondents said, “The module has to be interesting. Do Zumba together with music for free”.As for exercise type, most respondents seemed to prefer individual exercise (n = 17) compared to group activity exercise (n = 9). Their favorite exercises were planking, jogging at the park, and Maybe aside daily supervision to check if a person exercises, maybe you can make a schedule. Today, what do you have to do, how many sit-ups do you have to do. The thing has to be organized. How many times do you have to do something, how many minutes do you have to do it, how do you do it, like that. Like, I actually want to exercise but I don’t know how, like for this, should I do this thing first, or that thing first. Should I do sit ups first, or this other thing first. I don’t know the basics of exercise. I do watch videos on YouTube®and others but sometimes I do them and other times I don’t. If we can produce something that’s like organized and okay, God willing, I can follow it”.In short, respondents wanted a simple, easy structured exercise module that was flexible in terms of time and place. Respondent R22  elaborated that, “When it comes to doing exercise, it depends on the timing as well and how it suits with our schedule. In terms of time, maybe I can allocate about 30 minutes to an hour, it depends”.For the preferred duration of a session of exercising, more than half of the respondents chose to exercise within 10–30 minutes per session (n = 14). Some of the respondents (n = 8) wanted to exercise less than 10 minutes at a time while the rest (n = 4) agreed to exercise more than 30 minutes per exercise session. One of the respondents, R1  said, “Majority of the respondents preferred to exercise individually, with low to moderate intensity exercises that last 10–30 minutes per session, with frequencies of 1–2 times a week. However, these preferences do not meet the WHO global recommendation for physical activity, nor the Malaysian Ministry of Health (MOH) exercise guidelines as stated in Malaysian Dietary Guidelines . MOH recFor exercise intensity, the selection of lower intensity exercise compared to high intensity exercise might be caused by the less pleasurable or negative feelings associated with high intensity exercises , 47. PaiOur study identified several themes for motivation to exercise which were maintenance or improvement of physical appearance, health benefits, togetherness, coach or trainer, discipline or commitment, facilities, enjoyment and stress release. Our respondents’ main motivation to exercise was to maintain or improve physical appearance. This was in agreement to other studies which reported that the desire to improve appearance and body image dissatisfaction were associated with practicing physical activities –52. A stHealth benefits is the second most chosen motivator by the respondents for exercising. The desire to maintain or improve their health fitness influenced the respondents to conduct physical activities. Previous studies have reported that good fitness, weight management and perceived health benefits were major motivators for individuals to exercise , 59–62. Another motivator mentioned by some of the respondents was togetherness. Respondents felt more motivated when they exercised with their friends. This was similar to another study which showed that socializing with peers and receiving support or influence from family members could be a motivator for exercising . In addiBased on a research done on university students to discover their motivation towards exercise participation, the top motivations for female students’ participation in exercise were stress management, revitalization, health benefits, weight management and appearance. These were comparable to the findings of our study, where the overlapping motivations were health benefits and weight management . This waAccording to Molanorouzi , there aThe main barrier to exercise in this study was the feeling of apprehension to exercise which included general exercise animosity, dislike being seen exercising, and dislike exercising alone. Sechrist et al.  reportedFindings from this study also showed that time constraint was a major barrier for the respondents to conduct physical activities. University Kebangsaan Malaysia students tend to spend plenty of time travelling between campus to the residential college and to the only canteen operator in the college. They were also involved in a variety of non-exercise related activities in college and had academic responsibilities, hence, lowering the priority for exercising. Van Dyck et al.  reportedAnother major barrier to exercise in this study was lack of motivation. Laziness and lack of interest towards exercise have been reported as some of the major barriers that hindered students  and otheOur findings in exercise barriers of female students were similar to another study which focused on female health care workers. The top two barriers were that they disliked the exercise apparel and they were embarrassed to exercise . AnotherIt is important to fully understand the motivators, barriers and exercise preferences of female undergraduates towards exercise. There is a need for academic institutions to encourage exercise as an integral part of university or college life. Once motivators, barriers and exercise preferences are clearly identified, programs can be designed to maximize motivation factors and minimize barriers to physical activity among students. More importantly, exercise programs can be catered to the needs and wants of these female young adults. The information gathered from this study can help practitioners design effective exercise modules for female undergraduate students in the future.This study had certain identified biases. The first bias was the respondents’ exposure to the benefits of exercise. All respondents were enrolled in health-related degree programmes. They may have higher perceived benefits of exercise compared to non-health related students. Secondly, the living condition of the respondents may have affected the outcome of the research. The respondents’ campus and residential college are located in the city center where traffic congestion often lengthens the commuting time. This may be different from students from campuses outside the city center. Thirdly, although the data reached saturation with 26 respondents, the result of this study cannot be generalized to all Malaysian universities. More studies are needed to ensure the generalizability of these findings.In terms of strength, the one-to-one in-depth interview provided a safe and comfortable environment for the respondents to provide insightful feedback regarding the subject matter, as each respondent had the freedom to express their point of view without being influenced or intimidated by others. To our knowledge, this is the first study to explore the motivation, barriers and preferences toward exercise, specifically among female university students in Malaysia.This study unravels eight themes that were identified as motivating factors and five themes that were barriers to exercise. The motivation themes include maintaining or improving physical appearance, health benefits, togetherness, the availability of coach or trainer, discipline or commitment, facilities, enjoyment and stress release. On the other hand, exercise animosity, lack of motivation to exercise, time constraint, discomfort or pain during or after exercise, and lack of facilities constituted the barriers to exercise. Respondents showed the desire or motivation to exercise but often prioritized other aspects in their daily lives. The lack of drive to exercise can be attributed to the absence of companion (friend) to exercise, a suitable exercise program, convenient place to exercise, or lack of set goals to exercise. This study also found that respondents in this study prefer a structured exercise program that was flexible in terms of time and place of the exercise. Respondents also preferred low and moderate intensity exercise with the frequency of 1–2 times a week, and 10–30 minutes per session. An exercise module was developed based on the results of this needs assessment study and tested among female undergraduates with a 70% acceptance rate . These fS1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.