During a public emergency, which possibly evolves into a major public crisis, it is critical to quickly identify the main risk factors and assess the levels of risk, in order to efficiently manage the risks. In this study, about 40 000 emergencies in China over the past decade are investigated. Then, the five different types of risk factors are identified of these emergencies using the 5W1H methodology, including risk time (When), risk location (Where), risk population (Who), risk psychology (Why) and risk element (What), which lead to a risk matrix that is suitable for China’s national conditions. Based on this risk matrix, combined with expert knowledge, the Borda count and the analytic hierarchy process analysis, risk levels can be precisely assessed, solving ‘how to provide a solution’ (How), which provides decision-making guidance and facilitates prompt risk responses. With the substantial influence and infiltration of the Internet, the online conflicts arising after major public emergencies are becoming increasingly intensified. Because the occurrence of emergencies and the transmission of risks are affected by many complicated factors, one of the key issues in emergency response is to conduct, based on historical emergency data, a systematic analysis and investigation on the risk levels of historical emergencies and to acquire trend patterns in data and text information, thus identifying various risk factors of emergencies. In this study, various risk factors are identified based on 44 274 public emergencies in China over the past decade, which form a ‘risk matrix’ suitable for specific national conditions, providing a foundation for further risk level assessment.The 5W1H  analysis, also called the six Ws, is a complete methodology of problem solving, which was originally proposed by the American political scientist Lasswell in 1932. Through continuous use and improvement in later years, the 5WIH method was developed. The application of the 5W1H methodology to the study of scientific problems, that is, analysing from the six aspects of reason (Why), object (What), location (Where), time (When), person (Who) and method (How), enables researchers to think systematically and scientifically. The 5WIH method should be divided into two levels: ‘5W’ is the first level, corresponding to the fore-analysis, and ‘1H’ is the second level, corresponding to the back-end solutions. In the field of research on risk, the 5W1H methodology has been applied in the risk management of ancient buildings and metadata structure, and metadata is proposed for the risk management of architectural heritage using the 5W1H model in a context-aware application design , risk location (Where), risk population (Who), risk psychology (Why) and risk element (What), based on the contents and characteristics of the online public opinions of a particular public emergency, combined with statistical analysis, text analysis and expert opinions. The second aim is to quantitatively assess the risk level of emergencies, in order to provide decision support for future risk responses, that is solving ‘how to provide a solution (How)’, based on the already identified risk factors, an improved risk matrix, the Borda count and the analytic hierarchy process (AHP).The occurrence of major emergencies will lead to a number of casualties and property losses, as well as negative social impacts. Therefore, research on emergencies such as earthquakes . To assess the risk level, a risk matrix is commonly used for a comprehensive assessment of risk through the probability of risk occurrence and the severity of a hazard. Because of the feasible way to express risk and the easy-to-use feature, a risk matrix is a widely applied tool for semi-quantitative risk assessment  Benzécri  of the ‘The main methods involved are as follows:Correspondence analysis: CA is a method of data visualisation that is an exploratory multivariate technique that converts a data matrix into a particular type of graphical display in which the rows and columns are depicted as points  of the 5W1H method, so ‘risk factors’ contain ‘risk element’.Based on the identified risk factors of various emergencies, combined with expert opinions, a risk matrix is constructed. However, when applying the risk matrix for risk assessment, different risk factors may appear at the same risk level, resulting in a ‘risk tie’. To address this issue, the Borda count is introduced to rank different risk factors according to their importance. Because the value of the Borda count itself is a relative value, generating a pairwise comparison based on the importance of different risk factors, a two-dimensional judgment matrix can be formed, which provides a quantitative basis for further determination of the weight of each risk factor using AHP .The main methods involved are as follows:Risk matrix: Risk matrix is a structured approach to identify the importance of risk in project management. It assessed the potential impact of risk through a simple operation method combined qualitative and quantitative analysis. Traditional risk matrix level is determined by a combination of risk probability of occurrence and severity of the consequences.Borda count: Borda count is a well-known social choice method frequently used for group decision-making problems : According to observation, the emergencies show significant non-equilibrium across time variables and a centrality of times of high occurrence. In addition, emergencies that occur during risk times or sensitive times are more likely to cause public concern and exert a substantial social impact, including the dates of major historic events, of important national conferences or events, and of important holidays and festivals.Risk location (Where): Historical data show that the types and occurrences of emergencies vary from region to region and that high-risk areas of emergencies are risk locations. For example, ethnic areas at the national border are geographically remote. Their natural environment is harsh. In addition, their ethnic, religious and cultural relationships are complex. The eastern part of China exhibits a higher economic development level, higher cognitive capabilities of the locals, and better Internet development technologies than do ethnic areas. Both of the above-mentioned areas have become high-risk areas within the nation.Risk population (Who): The type of stake-holding populations in emergencies exerts a crucial effect on the evolution of public opinion. If an emergency involves a ‘labelled group’, certain emergencies may quickly stir up waves in the public opinion field. For example, in some netizens’ minds, ‘civil servants’ equals corruption, ‘police’ equals illegality and involvement with gangs, ‘urban management officials’ equals violent law enforcement, and ‘the children of the powerful and wealthy’ equals arrogance.Risk psychology (Why): In the process of the development of online public opinion regarding emergencies, public psychology is often the internal momentum for public opinion evolution. Common risk psychology includes bystander effect, victim mentality, anxiety and fear psychology, and habitual suspicion psychology. For example, habitual suspicion would create mistrust between the public and the government, making the public doubt everything the government does and spread rumours.Risk element (What): When an emergency occurs, the involved intrinsic sensitive element can resonate with the online public opinions, thus deriving new risk elements. For example, ‘corruption’ might be derived from an incident involving ‘the death of an official from a fall’ whilst ‘rape’ might be derived from an incident involving ‘the death of a girl from a fall’. Such assumptions may increase the destructive power of the event.The location–event analysis and the time–event analysis are constructed by counting the frequency of different types of emergencies in different spatial and time dimensions. Then, CA is carried out on the two dimensions, respectively, and the relationship is explored from the perspective of ‘location–time–event’ in order to grasp the location–time coupling of certain emergencies, thus labelling the high-risk locations and high-risk times.First, high-risk locations and high-risk times of emergencies are analysed based on data collection and statistics  and 4. IAccording to the type of emergency, the ‘location–event’ two-dimensional matrix and the ‘time–event’ two-dimensional matrix are constructed. With the aid of Statistical Package for Social Sciences (SPSS) software, the corresponding analysis is carried out to identify high-risk locations and high-risk times for different types of emergencies . Public It can be seen from Emergencies are more likely to cause public concern when they involve a certain kind of risk population. The ‘risk population’ may have stigma effects or sympathetic effects. According to the statistics for different groups of people involved in emergencies in the past decade, risk populations can be grouped into the following five categories : governmStatistics on the frequency of the above-mentioned risk populations of event title have revealed the following facts. The ‘children of different ages’ appear the most (1454 occurrences) and draw the most concern, followed by the ‘various students’ population (876 occurrences). The majority of students are minors who are a vulnerable population that is more likely to attract attention. For example, this population includes primary school students, middle school students, schoolgirls, young girls and teenagers. Next are the ‘high-profile occupation’ population (789 occurrences) and the ‘government officials’ population (711 occurrences), primarily involving populations that are prone to conflicts between police and civilians, conflicts between the government and civilians, and conflicts between doctors and patients. For example, this population may include traffic police, urban management officials and doctors. Last is the population with a special identity (789 occurrences), referring mainly to a ‘labelled’ group of people. Examples include the elderly are extortionists by playing the role of a victim; patients are hard to deal with; migrant workers are uncultured and ill-mannered; and children of the powerful and wealthy are arrogant .During emergencies, different populations may have different interests, thus creating different risk drives, with different psychological types and psychological evolution processes. In the same emergent event, a variety of different types of risk psychology may be intertwined, causing the public opinion concerning the matter to worsen or escalate the emergency into a crisis. Through the analysis of the theory of group polarisation, the theory of the spiral of silence  on 18 March with the title ‘Hundreds of millions of yuan’s worth of vaccines spread into 18 provinces without being refrigerated: This is murder, Shangdong issued a letter of investigation’. The word ‘murder’ triggered public attention, and public sentiment quickly spread. However, as early as 23 February, Xinhua News Agency published a news article titled ‘Jinan police cracked the case of illegally operating human vaccines worth 570 million yuan’, which did not stir up huge waves of public opinion.When risk elements (or sensitive words) are involved during the dissemination of public opinion, civilians’ feelings are affected, their attentions drawn, and complaints and negative emotions generated. For example, the vaccine scandal event in March 2016 was published in Through the text analysis of the communication content of public opinion regarding major emergencies in recent years, combined with expert knowledge, the risk elements that can easily cause the outbreak of public opinion are identified and shown in Based on the various types of risk factors identified from the historical emergencies, we first determine the degree of influence and probability of occurrence of different risk factors and construct a risk matrix to evaluate the level of risk factors. Then, we use the Borda count to sort and evaluate the importance of various risk factors, obtaining the sorting results of the importance of various risk factors. Finally, according to quantitative ranking results based on risk factor importance, we establish an AHP judgment matrix, determine the weight of each risk factor and ultimately obtain the comprehensive risk level.In the case of different risk levels and risk occurrence probability, the resulting risk matrix is different. In this article, the influence of different risk factors is divided into five levels, and the risk occurrence probability is also divided into five levels, forming a 5 × 5 risk matrix. Specifically, the five risk influence levels are ‘limited’, ‘slight’, ‘moderate’, ‘serious’ and ‘crucial’. The risk influence is divided into five levels mainly based on the occurrence frequency of different risk factors in the 40 000 emergencies over the past decade in China. For example, the highest frequency words are ‘Die’, ‘Death’ and ‘Kill’ about risk element, so these words belong to the ‘crucial’ level. The five levels of risk occurrence probability are ‘highly unlikely (0% – 10%)’, ‘unlikely (11% – 40%)’, ‘likely (41% – 60%)’, ‘very likely (61% – 90%)’ and ‘extremely likely (91% – 100%)’. Thus, a risk matrix for emergencies is created . To furtTo further illustrate the risk level assessment process, we selected a typical case to show details of the analysis. On 28 June 2018, near a primary school in Shanghai, an unemployed man enacted ‘revenge on society’ by slashing three boys and one female parent. Two of the three injured boys died. Based on the ‘risk matrix of emergencies’ , expertsN is the total number of risk factors to be evaluated, K is the evaluation criterion, M is the number of k, and in this article M = 2. k = 1 indicates the degree of influence of risk factor, k = 2 indicates the probability of occurrence of risk factor and ikR indicates the number of risk factors that are higher than the risk factor i in criterion rik. b represents the Borda value of risk factor i, that is the number of other risk factors that are more important than this risk factor.For risk factors regarding the ‘Shanghai slashing of primary school students’ incident, both the ‘risk population’ and ‘risk psychology’ are ‘relatively high’, resulting in a ‘risk tie’, which means that the same risk level occurs for different risk factors. In this case, the Borda count is used to quantitatively rank the relative effect of the above five risk factors on the overall risk. The Borda count formula is as follows:The above Borda count is used to evaluate the importance of each risk factor of a specific case. The results are shown in rib) (According to the Borda count (bri)  and 2, diRW), that is to determine the contribution rate of different risk factors to the overall risk level, based on which the comprehensive risk level is calculated (ib), the judgment matrix for the risk factors is as follows:As the Borda value itself is a relative value, it is easy to compare the importance of different risk factors amongst pairs and construct a two-dimensional judgement matrix . An AHP lculated . AccordiUsing the above judgment matrix, the weight of each risk factor can be obtained as follows:After the consistency verification, the consistency checking result of the judgment matrix is CR = 0.0265 < 0.1, indicating that the consistency test is met and that the calculation result of the influence weight of each of the above risk factors is valid.Based on the influence weight of the above risk factors and combined with the quantised value of the risk level of each risk factor, the comprehensive risk level of the specific emergency can be obtained:iI) of the three risk factors is at ‘moderate’, one risk factor level (iRL) is at ‘relatively low’ and one risk factor level (iRL) is at ‘medium’. However, the final comprehensive risk level is above ‘relatively high’ (0.7566 > 0.7), which requires decision-makers to monitor and pay closer attention to the evolution of the event , ‘Students killed in Mizhi County’ (04/27/2018) (MZRL), ‘Girl jumped off building in Qingyang City’ (06/20/2018) (QYRL), ‘Shanghai slashing of primary school students’ (06/28/2018) (RL) and ‘Pupil killed in school of Shangrao’ (09/05/2019) (SRRL). Through calculation, the order of these case is MZ > RL > RLSR > RLQY > RLRYBRL. The empirical results above show that ‘Students killed in Mizhi County’ has the highest risk level. Nine students were killed and 12 students wounded in that emergency. The high casualties cause the high-risk level. The risk level of emergencies with no casualties was lower, such as ‘RYB kindergarten child abuse incident’.Based on the same method and procedure, the comprehensive risk level of some emergencies with the same type of the specific case was calculated. The selected cases are as follows: ‘RYB kindergarten child abuse incident’ (11/22/2017) (In this study, we investigated 44 274 public emergencies in China over the past decade, from the perspective of managing the risks from the source and initial causes. The proposed model can help grasp the key risk factors and quantitatively assess the risk level at the early stages of emergencies, providing decision-making guidance to quickly respond to potential risks in the emergencies and to propose coping strategies according to different risk factors and risk levels, thus taking the initiative in the control of public opinion.This research started from the ‘5W1H’ methodology. Based on the historical data of 44 274 public emergencies in China, combined with statistical analysis, correlation analysis, text analysis and expert knowledge, we have identified five major risk factors: risk time, risk location, risk population, risk psychology and risk element. Then, we build a risk matrix that is suitable for China’s national conditions based on these five risk factors. We also made a quantitative assessment of the comprehensive risk level of specific cases through a combination of the risk matrix, the Borda count and an AHP.In the proposed model, the following highlights need to be mentioned. First, in the process of managing or controlling public opinion during an emergency, analysing historical data and summarising the experience of predecessors play a significant role. Based on the accumulated huge amount of historical data, this article identifies five types of risk factors that are then combined with expert knowledge toward the reliable establishment of risk matrix for emergencies. Second, in a traditional risk matrix, the risk level is generally divided into three levels. This article innovatively divides the risk level into five levels, namely ‘low’, ‘relatively low’, ‘medium’, ‘relatively high’ and ‘high’, which makes the assessment of risk in emergencies more accurate and more scientific. Third, through the risk matrix, the risk level of each risk factor is obtained. However, different decision-makers will focus on different risk factors, resulting in different proposals and actions. In addition, the merely mechanical summary of the risk levels for different risk factors may fail to truly reflect the overall risk level. Considering all these factors, the use of multiple quantitative methods to assess the overall risk level in this article is more scientific, objective and comprehensive. This article shows the application in public safety emergency. Further research will focus on other types of emergencies, such as the public health emergency like COVID-19. Since the global outbreak of coronavirus disease pandemic between the end of 2019 and the beginning of 2020, it has attracted extensive attention of scholars from all over the world, which is a typical major public health emergency. The World Health Organization has also announced the outbreak as a Public Health Emergency of International Concern. The ‘5W1H’ methodology and the improved 5 × 5 risk matrix will be used for risk level evaluation of the major global emergency.The quantitative evaluation process of the risk levels in emergencies in this study is highly applicable. With its application value and practical significance, it may well improve the government’s management ability and scientific level of decision-making.


Growing numbers of men, trans/masculine, and non-binary people are becoming gestational parents, yet very little is known about experiences of pregnancy loss among this diverse population.The study employed a cross sectional design. Interviews were undertaken with a convenience sample of 51 trans/masculine and non-binary people who had undertaken at least one pregnancy, living in either Australia, the United States, Canada, or the European Union (including the United Kingdom). Participants were recruited by posts on Facebook and Twitter, via researcher networks, and by community members. 16 (31.2%) of the participants had experienced a pregnancy loss and are the focus of this paper. Thematic analysis was used to analyse interview responses given by these 16 participants to a specific question asking about becoming pregnant and a follow up probe question about pregnancy loss.Thematic analysis of interview responses given by the 16 participants led to the development of 10 themes: (1) pregnancy losses count as children, (2) minimizing pregnancy loss, (3) accounting for causes of pregnancy loss, (4) pregnancy loss as devastating, (5) pregnancy loss as having positive meaning, (6) fears arising from a pregnancy loss, (7) experiences of hospitals enacting inclusion, (8) lack of formal support offered, (9) lack of understanding from family, and (10) importance of friends.The paper concludes by outlining specific recommendations for clinical practice. These include the importance of focusing on the emotions attached to pregnancy loss, the need for targeted support services for men, trans/masculine, and non-binary people who undertake a pregnancy (including for their partners), and the need for ongoing training for hospital staff so as to ensure the provision of trans-affirming medical care. Pregnancy loss affects many people each year. Pregnancy loss encompasses miscarriage, ectopic pregnancy, and stillbirth. Miscarriage occurs in 11–22% of all pregnancies . Yet hetAlthough a growing body of research, summarized briefly above, provides insights as to the specific needs of heterosexual cisgender men who have experienced a pregnancy loss, little is known about how men, trans/masculine, or non-binary people who undertake a pregnancy experience a pregnancy loss. This paper uses the term “men, trans/masculine, and non-binary people” to refer to people who were coercively assigned female at birth, but who report their identity as, for example, male, man, trans, masculine, transmasculine, non-binary, genderqueer, or agender.For men, trans/masculine, and non-binary people in receipt of testosterone, concerns have been raised about its potential impact upon a pregnancy, and specifically in terms of causing a pregnancy loss . This rePrevious research on men, trans/masculine, and non-binary people and pregnancy loss is minimal, and suggests aspects of pregnancy loss unique to this population. Craven’s  study ofGiven the limited body of existing research, the objective of the present paper was to explore experiences of pregnancy loss among a sample of men, trans/masculine, and non-binary people who had undertaken a pregnancy.We are a team of researchers who, over the past decade, have undertaken research with transgender and non-binary people and/or their family members. Our focal areas include but are not limited to family formation, parenting, intimate relationships, and healthcare. As a team we are comprised of cisgender, transgender, and non-binary people, of a diversity of genders and sexualities, one of whom has conceived and carried a pregnancy. Because none of us identify specifically as men, trans/masculine, or non-binary people who have conceived, the research under present consideration was undertaken in collaboration with an advisory board that included men, transgender and non-binary members who have conceived, and whose demographic characteristics reflect greater diversity than those represented solely among the authors of the present work.The broader study was a cross-sectional qualitative study of a convenience sample of 51 trans/masculine and non-binary people. Inclusion criteria were (i) identifying as trans/masculine or non-binary, (ii) having undertaken at least one pregnancy following a gender transition, (iii) living in Australia, the European Union (including the United Kingdom), the United States, or Canada, and (iv) being aged 18 years or older. Participants were recruited via posts on Facebook and Twitter, and flyers circulated both via researcher networks and by men, trans/masculine, and non-binary community members. All recruitment information was circulated in English. Recruitment continued until all participants who responded to the circulated information had been interviewed.Participants in the U.S. and Canada were paid $25-$50 to participate; participants of color were compensated at a higher rate due to targeted recruitment aims for the study and to reflect structural constraints to participation  faced by participants of color. Participants in the European Union and Australia were not compensated for their participation. This reflected research norms at the institutions in these countries; compensation for participation in social research is often understood as a form of potential coercion.Semi-structured interviews were undertaken either in person or remotely via Skype, Whereby or Zoom, by a research associate of the first author , by the second author (for interviews in the European Union including the United Kingdom), or by the third author (for interviews in the United States and Canada). Interviews were undertaken in English between June 2018 and October 2019. In terms of interview questions specific to the present paper, a general question was asked about experiences of undertaking a pregnancy, with specific follow up probe questions about pregnancy loss. Interviews ranged from less than sixty minutes to over three hours, with an average length of 100 min. Interviews were transcribed by a professional service, and participants either chose their own pseudonym, or were allocated a pseudonym if they did not opt to choose their own. Participants were also asked about pronouns, with most participants using either he/him or they/them. These pronouns are used in reporting the findings below.For the purposes of the present paper, responses to the interview questions outlined above where a participant indicated that they had experienced at least one pregnancy loss were extracted for analysis. Importantly, while this question was purposively included in the interview schedule, and then purposively selected for analysis in the present paper, the analysis itself was inductive: it did not begin with a specific hypothesis to test, nor, given the limited previous research, an indicative list of likely topics that would be developed from the data. Of the total sample, 16 participants (31.2%) reported that they had experienced at least one pregnancy loss and were included in the sub-sample for the present paper.Having extracted interview responses in relation to pregnancy and loss from the 16 participants, the first author then coded the data according to the approach to thematic analysis outlined by Braun and Clarke . The firHaving confirmed the codes developed, the first author then developed themes based on the codes. While codes encompass broad salient topics repeated across the data set, themes by comparison organize codes into logical and coherent sets of information. Themes developed are indicative of topics seen as salient by researchers, rather than as being exhaustive of all possible readings of the data set. Codes and themes were not mutually exclusive across participants: some participants gave interview responses that were located within more than one code or theme. For the present paper, ten key themes were identified through a process of repeated readings of the initial coded data, and a process of distilling codes into coherent thematic groupings. The ten themes are outlined in Table The average age (at the time of their interview) for the participants included in the sub-sample was 35 years range 23–49). Of the participants included in the sub-sample, 10 had experienced one pregnancy loss, and 6 had experienced more than one pregnancy loss. Of the 24 pregnancy losses experienced across all 16 participants in the sub-sample, 19 were early term losses (12 weeks or less), and five were late term losses. Of the participants included in the sub-sample, 15 had experienced a live birth either prior to or following a pregnancy loss. Table 3–49. Of For some participants, when asked about their family make-up, there was a clear orientation towards referring to pregnancy losses as indicative of children. In other words, rather than minimizing a pregnancy loss or discounting pregnancy losses by not counting them as children, some of the participants very much included pregnancy losses as part of their description of their family.Charlie, for example, when asked about children, stated “I’ve had two that are here today, and two that aren’t. So I still count them”. Similarly, Luke stated that “I’ve given birth to two living children and we had four miscarriages and six or seven chemical pregnancies, and then my youngest, she was a twin, we lost the twin at ten weeks”. Other participants, whilst not as clearly labeling pregnancy losses as children, made comparisons that facilitated the conceptualization of pregnancy losses as equated with children, such as Moddy, who drew a comparison between their own pregnancy loss, and a relative’s experience of losing a child as a result of sudden infant death syndrome.In contrast to the previous theme, a smaller number of participants appeared to minimise pregnancy losses. This is not to suggest that pregnancy losses had no meaning, but rather that pregnancy losses were not treated as children by these participants. Rather, it would seem that a pregnancy loss was situated primarily as a biological function, separate to broader accounts of family or children.Lewis, for example, when describing a pregnancy loss, noted that “there were some issues before, like what I now sort of see as a miscarriage, but it was like it was just like a really irregular period with a massive clot”. Trent spoke about having had two ultrasounds, one where there was a heartbeat and another where there was no heartbeat, before methodically describing the process of dilation and curettage. In a similar way, Pete shared that “I carried the pregnancy for just six weeks and had a miscarriage. We understood that happens a lot, so we weren’t too worried about it”.In terms of this next theme, it is important to note that participants were not asked to explain the cause of their pregnancy loss(es). Nonetheless, almost half of the participants oriented to the topic of causes naturalistically when speaking about the experience of pregnancy loss. Accounts of potential causes largely involved conjecture on the part of participants, though some participants noted that medical professionals had given an indication of why a pregnancy loss may have occurred.When accounting for causes, some participants normalized pregnancy loss, suggesting that it was for many people a routine and expected aspect of reproduction. An example of this was Pete, who noted that his fertility specialist suggested it was likely just due to his age, or Cole, who suggested that in the immediate months after a person ceases taking testosterone, “our bodies can get pregnant, but they are not [yet] ready to actually carry a baby to term” . Other In terms of emotional responses to experiencing a pregnancy loss, a majority of participants suggested that a pregnancy loss was devastating. Participants typically used strong emotive language when speaking about pregnancy losses, and this was particularly true for participants who did not minimize a pregnancy loss, but rather saw it as a significant life event.Charlie stated that following his pregnancy loss, he went “off the rails, absolutely nuts”. Will described his pregnancy loss as “heartbreaking”, noting that “the first time I had a positive test… I of course was jumping the gun and making all these plans and I was pretty devastated, you know I was devastated and it was horrible”. Ben described his experience of pregnancy loss as “traumatizing”, and went on to suggest that the pregnancy loss felt like the “loss of an option” in terms of having a child. Lewis noted that “I was devastated, even though I didn’t know about it until it happened, and it must have been really early. Then I had a couple more [pregnancy losses] before [I gave birth to child], but really early [losses]. They were quite hard to deal with”.By comparison, a smaller number of participants suggested that a pregnancy loss could be seen as having positive meaning. This specifically related to concerns by some of the participants that having previously been prescribed hormones might have meant they would not be able to conceive. Given the relative lack of certainty that has previously been expressed in research about the impact of testosterone on the capacity to become pregnant , it is nWill, for example, suggested that “It felt like, [the pregnancy loss] felt more positive than negative. It was sad, but more ‘like this can happen’. It felt like we had a bite, like fishing”. Markus noted that they had been aware that, given their age, conception might be difficult, leading them to suggest that “I was just thankful that it worked at all, because it was also like, oh, I didn’t know about my fertility. So it was, it was always, even if it would lead to miscarriage, it was like yeah, but at least I mean my egg and his sperm, yeah it works”. For Gage, a pregnancy loss was positive in two senses: he felt that, at the time, he and his partner “weren’t quite ready” for a child, but that the pregnancy loss really made it clear to his partner in particular that she wanted to have a child.For some participants, there were emotional responses that extended beyond the fact of the pregnancy loss. This typically involved more generalized fears about being a pregnant man, trans/masculine, or non-binary person. Specific to this diverse population, fears related to the possibility that pregnancy might not be a possibility, and also to the potential for the recording of information about a pregnancy loss to force disclosure to other people that a participant was transgender.Trent, for example, was concerned about having a medical record in relation to pregnancy loss, and whether or not that would serve as a marker of his gender history. Similarly, when he was experiencing a pregnancy loss, Pete noted that going to the hospital “was a big decision, considering I was going to have to out myself to a hospital full of strangers. I have never had to go to the emergency room as a trans guy before and it’s always been a huge fear of mine”. Both Markus and Dan noted that in subsequent pregnancies, and especially in the first trimester, that they were particularly worried that they would experience another pregnancy loss. Markus, for example, noted that “The first trimester was kind of difficult for me because one thing was the two miscarriages I had before, so I couldn’t stay calm or whatever. I was always worried a bit”.Less than half of the participants spoke about receiving formal support in relation to pregnancy loss. Interestingly, of those participants in the present study who did receive formal support from a hospital following a pregnancy loss, a majority spoke about having positive experiences with hospitals. Such experiences typically involved hospital staff acting in trans-affirming ways, and providing reassurance that the pregnancy loss was not a trans-specific phenomenon.Noam, for example, shared that the hospital he attended took extra care of him, including that when they were writing up his discharge papers, came to ask specifically about his pronouns. Cole noted that hospital nursing staff had been especially supportive, specifically telling him “’This is super common. One in four pregnancies, especially this early on, do not end up being viable. You did nothing wrong. This is not because you’re trans. There’s no reason why you should believe that this would happen’. I mean, just like they were really, really, really lovely”. Pete spoke about a nurse who refused to accept that the hospital computer had him marked as female, and went to lengths to try and amend this in the system: “The code in the computer for miscarriage would only populate to a female patient. [The staff member doing intake] was like ‘I can’t do this to a female patient. You’re a male patient’… So she called IT and had IT come up to try and override the systems, to get me the right diagnostic code”.A smaller number of participants, however, noted that they received little or no support from hospital staff. This echoes research with both cisgender men and women , 17, whoModdy, for example, stated that “There was no support for miscarriages at that time. I got sent away. There was no offer of counseling, no ‘do you need to talk about it’, none of that. It felt very, very closed off”. Jay stated that they “didn’t feel like there was anything available”, and they further noted that “I feel like what does exist is around supports for the person who was pregnant and there’s very little support for their other person, if there is another person. So I think there needs to be places for trans guys, but there also needs to be places for folks who are partnered to the person who was pregnant”.Half of the participants commented about support (or the lack thereof it) from their family. Given that many participants felt that they did not receive adequate or any support from hospital staff, and that participants identified that ongoing support was often non-existent, a lack of support from families often compounded the sense of loss following a pregnancy loss. Given the broader social context, in which pregnancies by men, trans/masculine, and non-binary people are often marginalized or not recognized, the lack of support from families may also serve to further compound this marginalization.Some participants spoke about unsupportive family members, and particularly mothers. Jay, for example, shared that their mother had told them that they would struggle to conceive, and when they did conceive, she told them “then you’ll probably miscarry”. This meant that when they did indeed miscarry, Jay struggled to turn to their mother for support. Similarly, Pete noted that he and his partner had decided not to tell their family “because we knew or suspected that my family was not gonna take [being pregnant] well”. When Pete experienced a pregnancy loss, he “ended up telling mom and one of my sisters… just because I was upset about it… I think because it was a kind of sad situation they were more supportive than if I had currently been pregnant… So I did have some support through them, but it was limited. I knew they weren’t crazy over the idea of me carrying, but they weren’t vocalizing it as much”.For other participants, however, informal support from friends was received, and experienced as vital. Given the lack of support from family that many participants experienced, support from friends was experienced as essential to coping with, and coming to an understanding of, a pregnancy loss. This was especially true when support was provided by friends who had themselves experienced a pregnancy loss, and who acknowledge it as highly emotive, rather than simply dismissing or minimizing the pregnancy loss.Charlie, for example, noted that “Luckily I had at least two of my friends that were supporting me… It was everything that they were there… and if I didn’t have them I think I would have gone more nuts than I did”. Gage noted that his partner was “amazingly present” and that caring friends who provided “support made a huge difference”, including “one of whom had really struggled to get pregnant herself... showed up when I got home without an agenda and just said ‘Hey, I’m just gonna sit here next to you this evening and you can ignore me or not’”. Jay emphasized the benefits of telling friends, as it meant they could help foster a supportive network, and particularly people who had themselves experienced a pregnancy loss. As they noted, “the outpouring of other people was super helpful. It felt like just about anyone I’d known who tried to get pregnant… said ‘Oh yes, this happened to me as well’”.The findings reported in this paper provide some support for previous research, both in terms of previous research on cisgender heterosexual men and pregnancy loss, and in terms of the limited literature on gestational parents who are men, trans/masculine, or non-binary. In terms of the former, participants in the present study commonly reported strong emotional responses to a pregnancy loss, and like cisgender men, similar to those experienced by cisgender women . DiffereIn terms of the limited literature on gestational parents who are men, trans/masculine, or non-binary, and similar to research by Craven , particiThese points about ‘wrong body’ and ‘betrayed’ or ‘failed’ bodies have implications for clinical practice. Specifically, the findings presented in this paper suggest that whilst a pregnancy loss can be deeply distressing for many men, trans/masculine, and non-binary people, it can also be a sign that the body is working. Clinicians will best meet the needs of trans/masculine and non-binary people who have experienced a pregnancy loss by focusing on the emotions attached both to the loss and to the possible desire to attempt another pregnancy, rather than focusing on pregnancy loss as a means to infer that trans/masculine, non-binary and men’s bodies should not be pregnant. The findings reported in this paper also suggest that clinicians will best meet the needs of men, trans/masculine, and non-binary people by acknowledging that, at least for some people, a pregnancy loss may be experienced as a child lost, signaling the need for supportive counseling for both gestational parents and their partners. Such counseling may support men, trans/masculine, and non-binary people and their partners to access further support through informal channels , as well as addressing potential barriers to support in regard to family. This may include involving family members in counseling so as to facilitate their understanding of the needs and experiences of men, trans/masculine, and non-binary people following a pregnancy loss.These implications for practice highlight that whilst there may be some similarities to other people’s experiences of pregnancy loss , trans/masculine, non-binary, and men’s experiences as highlighted in this paper demonstrate unique points of difference. These include the importance of inclusive healthcare , the specific meanings that trans/masculine and non-binary people may bring to the experience of pregnancy loss , and the ways in which marginalisation may negatively impact on available support .experiences of pregnancy loss. Additionally, it is important to note that the interviews did not uniformly enquire about the relationship between conception, pregnancy loss, and receipt of hormones. Whilst research suggests that testosterone levels are unrelated to pregnancy loss for cisgender women [In terms of limitations, participants experienced pregnancy losses at a diversity of gestational ages. Future research will benefit from examining more closely whether gestational age differentially impacts upon experiences of grief in terms of pregnancy loss for men, trans/masculine, and non-binary people, though research on cisgender men’s experiences suggests that gestational age is not a determining factor in terms of grief following a pregnancy loss . Furtherer women , this isIn conclusion, this paper makes an important contribution to the literature through its focused and detailed examination of trans/masculine, non-binary, and men’s experiences of pregnancy loss. The findings suggest that ongoing attention to trans/masculine, non-binary, and men’s experiences and needs in terms of pregnancy loss is warranted. This includes in terms of the clinical encounter directly following pregnancy loss, ongoing support , and the importance of providing and creating spaces for and with men, trans/masculine, and non-binary people for their feelings, both positive and negative, to be explored, in order to ensure that experiences of pregnancy loss are acknowledged and heard.Specifically, and in order to ensure a trans-affirming space for men, trans/masculine, and non-binary people, both hospital staff and staff providing grief counselling specific to pregnancy loss will benefit from training specific to working with this population. This should include a focus on the importance of asking about pronouns, advocating for system change in terms of ensuring that names, pronouns and gender can be correctly recorded, and ensuring that medical experiences following a pregnancy loss do not further compound the potential grief experienced by men, trans/masculine, and non-binary people and their partners.


Entertainment-education (EE) is a communication strategy that uses popular media to engage with audiences on prosocial topics such as health, social tolerance and sustainability. The purpose of EE serials on radio, television or the internet is to introduce new ideas, norms and practices by means of storytelling, as well as to offer points of engagement for audiences to talk about the themes raised by the intervention. However, in today’s media landscape, it has become increasingly difficult to captivate audiences as they have fragmented across channels and have started to create and circulate content themselves. The concept of spreadable media allows us to deal with fragmentation and user-generated content in productive ways, as it recognizes the role of autonomous audience members in shaping the flows of media content in the online networks that underlie today’s media landscape. In this article, we introduce spreadable EE: an innovative approach that builds on transmedia storytelling strategies to reach and captivate target audiences for a longer period of time, and that entails collaboration with online platforms, communities and social influencers to stimulate meaningful conversations. We enhance EE's theoretical, empirical and practical traditions with insights about how today’s audiences have come to engage with media and propose strategic approaches to create and evaluate spreadable EE. In his lush garden, on a cloudy summer day, we see Bill Gates behind a laptop watching a video of Mark Zuckerberg. Zuckerberg stands next to a bucket of ice-cold water and says some last words before unleashing it onto his head: ‘I'm going to challenge Bill Gates, my partner at Facebook Sheryl Sandberg, and Netflix' founder and CEO Reed Hastings. You have 24 hours to do this, or you have to donate one hundred dollars’.—Splash!Gates, arms folded, looks up from his laptop. ‘Well, I am glad to accept this challenge, but I want to do it better…’A bit later, we see Gates on his pier, under a gantry, holding a rope connected to a big bucket of cold water. ‘I’m going to challenge three more people. Elon Musk, Ryan Seacrest, and Chris Anderson of TED, consider yourself challenged!’—Splash! In 2014, the ALS Ice Bucket Challenge  was amonOver the last decade, health- and social change organizations have experimented with interventions similar to the ALS Ice Bucket Challenge, often with a view to ‘go viral’. But is it right to assume that the ALS Ice Bucket Challenge went ‘viral’? Not according to Jenkins, Ford and Green , 2013, wFrom this perspective, the ALS Ice Bucket Challenge did not simply ‘go viral’. Instead, it managed to ‘spread’ because it was well-attuned to the dynamics of the new media landscape. It activated social processes by inviting audiences to participate through a nomination mechanism, gained social momentum by involving a diverse range of celebrities, and translated momentum into real-world contributions through a playful moral imperative . As suchspreadable EE.In this article, we seek to combine lessons learned from a phenomenon like the ALS Ice Bucket Challenge with the entertainment-education (EE) strategy—a communication strategy that uses popular media to spread prosocial ideas. EE typically leverages the appeal of popular media to educate and motivate viewers to improve their health, safety, or equality—mostly using dramatic radio, television and internet serials that allow to engage with a story over a longer period of time . As suchThe EE strategy is characterized by an affective approach, using the appeal of popular media on radio or TV to reach target audiences and introduce new knowledge, norms and practices . With thnarrative processing  , 2004. Cceptives .The advantages of persuasive storytelling are apparent, however, not all stories are equally entertaining. Some stories simply stick, whereas other stories are unable to captivate audiences. High-quality storytelling—being in written form, on the radio, or on the screen—is more of an art than a formula . The creThe media landscape has changed radically since the early nineties, presenting challenges and opportunities for the EE strategy.First, the media landscapes in Western societies have increasingly saturated through a multiplication of media outlets and options, offering audiences alternative ways to gratify their media-related needs . Audiencbroadcasting schedule, where audiences adapt to broadcasting schedules to see their favorite shows, to the age of the stream, where audiences choose from a continuous stream of media content at any time they like , several beauty experts asked their followers for their opinions and, after lively conversations in the comments, summarized them and shared their own opinions. Thereby, SAFN and the social influencers provoked the online communities to challenge the norm from bottom-up, criticizing the idea and ultimately introducing an alternative norm: having condoms with you is smart, not slutty. Eventually, the intervention did not only include influencers sharing SAFN’s message but also invited audiences to reinforce or reappropriate SAFN’s message, ultimately rippling through the social networks around them. As such, SAFN leveraged the dynamics of social influence in these different communities to stimulate meaningful conversations about the topic. An intervention by the STD/AIDS Foundation in the Netherlands (SAFN) provides an example of how EE professionals can approach online communities as points of engagement. SAFN found that many young Dutch women intend to use condoms, but do not always carry condoms with them because they are afraid to be seen as a ‘slut’. To challenge this norm, SAFN collaborated with social influencers to reach out to online beauty and fashion communities. In a series of YouTube videos cultures is more likely to be shared, be imitated, or inspire the creation of new content , the social media team of Population Foundation India (PFI) set up story circles around key issues following a four-step cycle: inspire, enable, activate, and aggregate. Seeking to promote gender equality, the TV series depicted families celebrating their daughters rather than only their sons (inspire). Online, this practice was coined as celebrating Laadli Din—a witty combination of the words ‘best’, ‘girl’ and ‘day’—providing a label for a practice that can be easily adopted (enable). On the show’s Facebook page, audiences were asked to share pictures of their daughters and sisters to celebrate their Laadli’s (activate), that were combined into new Facebook posts by the community managers to amplify the support for this practice among the audience (aggregate). This led to a series of posts with audiences sharing their interpretations of Laadli Din and comments about the role of girls and women in the family challenging existing gender regressive norms.In practice, the key messages of an EE intervention can be layered into a communication strategy to stimulate Laadli Din’ provides audiences with a new and uniquely labeled behavior that can be easily adopted. In EE, such a specific word or practice is also known as a marker. Markers are unique identifiable elements of messages such as new words, phrases or novel behaviors that ideally model new realities to break oppressive power structures in society (The word ‘ society . The goaLaadli Din), a visual lexicon of markers may shape the course a conversation takes. Similarly, East Los High provided easily sharable content such as healthy recipes and dance routines drawn from the TV show, promoting conversations about healthy food and exercise.In the digital age, markers do not necessarily have to be words: we can also think of other forms and modalities that are easily replicable in text, photos or videos such as symbols, gestures or dance moves. Markers can even include digital stickers, animations or augmented reality via Facebook Filters, Frames or Snapchat Effects, appealing to the playfulness of the target audiences. By including stickers, GIFS and visual effects that only refer to particular scenes, characters and events .


Background: Climate change influences patterns of human mobility and health outcomes. While much of the climate change and migration discourse is invested in quantitative predictions and debates about whether migration is adaptive or maladaptive, less attention has been paid to the voices of the people moving in the context of climate change with a focus on their health and wellbeing. This qualitative research aims to amplify the voices of migrants themselves to add nuance to dominant migration narratives and to shed light on the real-life challenges migrants face in meeting their health needs in the context of climate change. Methods: We conducted 58 semi-structured in-depth interviews with migrants purposefully selected for having moved from rural Bhola, southern Bangladesh to an urban slum in Dhaka, Bangladesh. Transcripts were analysed using thematic analysis under the philosophical underpinnings of phenomenology. Coding was conducted using NVivo Pro 12. Findings: We identified two overarching themes in the thematic analysis: Firstly, we identified the theme “A risk exchange: Exchanging climate change and health risks at origin and destination”. Rather than describing a “net positive” or “net negative” outcome in terms of migration in the context of climate change, migrants described an exchange of hazards, exposures, and vulnerabilities at origin with those at destination, which challenged their capacity to adapt. This theme included several sub-themes—income and employment factors, changing food environment, shelter and water sanitation and hygiene (WaSH) conditions, and social capital. The second overarching theme was “A changing health and healthcare environment”. This theme also included several sub-themes—changing physical and mental health status and a changing healthcare environment encompassing quality of care and barriers to accessing healthcare. Migrants described physical and mental health concerns and connected these experiences with their new environment. These two overarching themes were prevalent across the dataset, although each participant experienced and expressed them uniquely. Conclusion: Migrants who move in the context of climate change face a range of diverse health risks at the origin, en route, and at the destination. Migrating individuals, households, and communities undertake a risk exchange when they decide to move, which has diverse positive and negative consequences for their health and wellbeing. Along with changing health determinants is a changing healthcare environment where migrants face different choices, barriers, and quality of care. A more migrant-centric perspective as described in this paper could strengthen migration, climate, and health governance. Policymakers, urban planners, city corporations, and health practitioners should integrate the risk exchange into practice and policies. Under pessimistic and realistic scenarios of sustained high emissions and unequal development, climate change will represent an increasingly important factor contributing to internal migration ,2. In 20Human mobility in the context of climate change refers to a range of responses from individuals, households, and communities, including migration, displacement, and planned relocation ,6. In BaMigration is considered an important determinant of health, and broadly speaking, migrants are considered a vulnerable group from a health perspective, because displacement can compromise other important determinants of health such as shelter, food, and water security and inclusion in labour markets, education, and healthcare services . Our recWhile there has been extensive research into the “dyad” research fields of climate change and migration and climate change and health, less is known about the climate change, migration, and health nexus ,9,10. ThThis paper focuses on the concept of climate risk, including specific risks for health due to climate change known as climate change and health risks. Climate risk is determined by the interaction between slow and sudden-onset hazards, exposure, and vulnerability and is depicted in Bangladesh is one of the most climate-vulnerable countries in the world, due to the high population density with high levels of poverty in combination with a high reliance on natural resources and vast coastal areas ,16. BangThis study aims to contribute to a deeper understanding of the role that socio-cultural factors play in the migration experience. We aim to contribute recommendations about how barriers to accessing healthcare may be reduced (downstream) and how the determinants of health might be optimized (upstream) to protect and promote migrant health and strengthen migration governance. Due to the complex and interacting drivers of migration, we do not seek to make causal inferences between climate change and health outcomes. Using qualitative methods, we sought to amplify the voices of migrants themselves to add nuance to dominant migration narratives and to shed light on the real-life challenges migrants face in meeting their health needs in the context of climate change.In 2019, Bangladeshi researchers based at the University of Arts Bangladesh in partnership with researchers at Heidelberg University, Germany undertook a series of interviews with migrants living in Bhola slum in Dhaka, Bangladesh to explore their experiences of migration and health in the context of climate change. The research was interrupted by slum fires. Data collection was completed just before the COVID-19 pandemic reached Bangladesh and lockdowns were enforced, which led to significant migration back to origin.Bangladesh is a low-lying country in South Asia with an estimated population of 165 million , represe2 [This study was conducted in Dhaka city where approximately 6,970,105 people live within 1353 km2 ,26,27. M2 . Freshwa2 .In Bangladesh, the health system and the underlying healthcare infrastructure are considerably underdeveloped and neglected . The heaIn November 2019, four  Bangladeshi research assistants (RAs) were trained to collect qualitative data using standardized instruments, available in both Bangla and English. We piloted and revised instruments to refine translation, improve acceptability, and ensure cultural appropriateness. We employed purposeful sampling, using a screening tool to select participants whose migration decision was at least in part influenced by a sudden or slow-onset climate hazard. We obtained written informed consent from all study participants and audio-recorded one-on-one interviews in Bangla.Socio-demographic data collected included sex, age, employment status, marital status, and religion. The interview guide used open questioning and used probing to follow up on issues that seemed relevant to participants or identified as important through the debriefing process. The questions sought to capture “what” migrants experienced concerning climate change, migration, and health and “how” they experienced it . RAs alsWe simultaneously translated, transcribed, and checked interview transcripts for data accuracy by an external party. We anonymized identifying participant information and maintained confidentiality. We interviewed 60 adults (>18 years) men and women from migrant communities in Dhaka, Bangladesh, and 58 interview transcripts were included in this analysis. We excluded two interviews because one participant was determined not to be a migrant, and another interview was not audio recorded. The study received ethical approval from the Ethics Committee of the Medical School of Heidelberg University (S-928/2019) and the Ethics Committee of the University of Liberal Arts Bangladesh (OFR009).Thematic analysis tenets guided the data analysis, which is a systematic approach to identifying themes through an inductive analysis of qualitative data . We begaWe interviewed 58 migrants whose decision to migrate to Dhaka was, at least in part, influenced by sudden or slow-onset climate hazards are included in this analysis. We identified two overarching themes from the thematic analysis. Firstly, we identified “a risk exchange of climate and health risk”. Migrants describe a changing environment in terms of threats and needs and requirement to adapt. Sub-themes under this theme include income and employment factors, changing food environment, shelter and water and hygiene sanitation (WaSH) conditions, social capital, and environmental determinants of health.The second overarching theme is the “changing health and healthcare environment”. Migrants described how their physical and psychosocial health changed over time with reference to their migration experience. This theme encompasses the following subthemes—physical and mental health status, healthcare as a business, navigating the health system, and the quality of healthcare. These two overarching themes were prevalent across the dataset, although each participant experienced and expressed them uniquely. We describe the themes and subthemes in detail below with quotes to substantiate the analysis .Extreme weather events and mortality: “When the river erodes the homes they make this sound, like the sound of cattle dying as the water rushes against the house. The noise wakes up the residents and that is when they know the river is about to destroy their homes. They do not get much time to save their belongings” .Extreme weather and trauma: “The children have to stay at home whole day, they do not get outside the home, we go out because we need to work, so they stay at home in hot whole day and they fall sick in extreme hotness. They got fever, diarrhoea or cough one or another disease they get” .Extreme heat: “Multiple drivers contributed to the migration decisions with different degrees of choice involved leading to different mobility responses including planned voluntary migration and forced displacement of individuals, households, and whole communities. Many migrants expressed a preference and inability to remain at origin (home).Some migrants took loans to cover bad harvests and expressed a need to go to Dhaka to repay their debts after which time, most migrants intended to return home. However, many migrants seemed jarred by the very high cost of living in Dhaka and described livelihoods that were equally, if not more, fragile and insecure as those they experienced back home, where illness or injury could be devastating. Whilst many migrants described exhausting and hazardous working conditions at origin, many described high-risk working conditions and exploitation at the destination too (Dhaka).It was really good there (origin). You cannot earn there. You can earn here (Dhaka) but you cannot eat here” .Exchanging income insecurity: “(I wake up). around 4 to 5 am in the morning. After my morning prayer, I used to go to field. Several nights I could not even sleep because of the workload. Work, work, and work. (I go to sleep at) 3 am at 2 am. There was no fit time. I used to sleep 2–3 h. Like today I have to finish a particular … cultivation process but the labour cost is too high” .Difficult working conditions at the origin: “I wake up in the morning and go out to with rickshaw and come back within afternoon. I used to drive twice a day-morning and afternoon. But now I cannot, I pull it once in a day. My body does not support me to do that” .Difficult working conditions at destination: “Migrants described a changing food environment including improved food security where food was accessible, diverse, and nutritious, whilst others described a significant decline in food security with shortage and poor quality and safety. Concepts used by participants to describe a changing food environment included affordability, quantity, quality, accessibility, acceptability, taste, and safety.The situation with the food was bad back in the village (origin). People would not ever be able to buy fish and here (destination) the market is close and we can buy the food and eat it” .Quality and accessibility improved: “Harmful..! There is not a single good food in Dhaka (destination). Frozen fish or ice-covered fish are available here. There is no such thing as fresh fish brought from the river at any time. Everything here is stale. In the village (origin), fish in rivers and vegetables can be found fresh or cultivated in the fields themselves” .Quality and safety worsened: “Back in our hometown (origin), we ate well. There we used to cultivate vegetables in our house compound but here in Dhaka (destination), we have to buy everything. Here we do not have the space to do these. We can’t even buy meat because of its high price” .Affordability worse: “A key source of concern for migrants was insecure shelter expressed as concerns about paying rent and the continual fear of expulsion, abusive landlords, property destruction, and the high cost of living. A fire in the slums interrupted data collection and resulted in the secondary displacement of some migrant households.I am fine with them (authorities) destroying our homes, it being a government area, but give us a month to move. But they didn’t give us any warning, not even a second” .Property destruction by authorities: “Authority demolishes that slum, so we relocate here…No, it’s not (life is not secure here). But we don’t have any other place to go. Everywhere is the same situation” .Secondary displacement: “What to say! I have no peace from Dhaka city. The difference between Dhaka and one’s own village is like day and night. If the date crosses from 10th to 15th of the month, the landlord starts screaming and asks for house rent. If we are 2 days late, tell me to leave the house. If I have rented for 20 years, the landlords will say the same. And when I am in own home, there is no one to talk to like this” .Insecure shelter: “No participants described an improved water and sanitation environment post-migration. Key concerns included intermittent access to water, water scarcity, poor water quality, and the need to boil water in an environment where power was limited and expensive. Migrants also described competitive access to limited toilets with very poor hygiene.The environment is polluted in Dhaka (destination). However, things were better in Bhola (origin). Here the water quality is really poor. It contains iron, sometimes smells bad, quite undrinkable. We have to refine it by boiling to drink it” .Poor water quality: “This is a slum area, too many people live here, that’s why we have to stand in a line to go to the toilet” .Limited sanitation facilities: “Social ties acted as a pull factor towards Dhaka and also kept people connected to their origin whilst working in Dhaka. Some participants described fragmentation of social ties and isolation in Dhaka, whilst those who migrated with other households or a bigger community described the maintenance or re-establishment of social ties that seemed to be linked with a more positive migration experience with possible implications for mental health and wellbeing.I feel better here (destination) to be honest and here I have many friends and mates with whom I can share my problems or spend quality times” .Social capital maintained/re-established at destination: “There is freedom in the village (origin). One could be known as someone in their own village but in Dhaka (destination) nobody knows you. We had no worries back in the village, but here we have a lot of worries” .Social capital decreases at destination: “Participants discussed their mental health and wellbeing in terms of a lack of peace and overwhelming loss. They also described a changing healthcare environment with a range of services and models that seemed to require a high level of health literacy to navigate. Migrants experienced numerous barriers to accessing healthcare including financial and geographical barriers. Migrants contrasted the quality of care at origin with that at the destination and provided some valuable insights into what they considered quality healthcare to be.Migrants gave accounts of a range of health problems they struggled to manage with the limitations of the health system at both origin and destination. Migrants described their health as deteriorating or remaining unchanged post-migration and often connected this assessment with environmental determinants of health such as air and water quality and working conditions. It  was good in the village (origin). In this place people are sicker, loud words, screaming, and slum’s disturbance, waste-garbage, uncountable mosquitoes” .Health status deteriorating at destination: “Diseases are always there, fever and body aches are always there. A constant. We have to take pills to work and live” .Health status unchanged through migration: “Several participants subtly expressed mental health and wellbeing issues, speaking of a lack of peace often combined with a sense of loss that extended beyond material loss to social and cultural loss and damage. Loss was also expressed as a loss of identity, loss of family trade and inherited livelihood, loss of social ties, and a loss of connection to homelands.When we lived in the village we lived so peacefully. Even if we do not eat one time we were in peace. Coming here we work, we eat but there is no peace. I keep thinking of the house rent, keep thinking how I will feed my children and do treatment” .A lack of peace: “When we left our house, we broke down into tears... I thought if I pull rickshaw at least I would get money to feed my family. Our poor life is only for that. What I had lost it is unbearable. We are facing troubles while paying borrowed money” .Loss of land and connection to homeland: “So the people in the village (origin) and in here (destination) are very different, the village area and town area very different. So we are people of village, when we come to the town, we become somebody else. That is why we go back to village to get well” .Loss of identity: “Although some migrants periodically returned home to visit relatives, seek healthcare, or recover from illnesses, others described a willingness but inability to return for a visit. When discussing loss and mental health and wellbeing, some migrants talked about feeling trapped at their destination.Living in Dhaka is like living in a jail. But I still have to live here...It’s like taking poison. I have no other way that’s why I am here” .Trapped at destination: “The village (origin) is a place for enjoyment. I used to enjoy myself there (origin). Even if I did not get food, I would be at peace. There is no peace here (destination). Here I am carrying out a sentence” .“Participants described a pervasive desire to return to origin, even though they admitted in the same interviews to not having a home, family, nor livelihood to return to. This desire seemed to be grounded in a connection to country/birth place. In other cases, the desire to return was conditional and depended on available housing and employment, and repayment of debt.After all, hometown (Bhola) is special. It is said that in a Bengali son, you cannot find such a homeland somewhere else, own homeland is the queen of all countries/places, it is own homeland. Hometown has no comparison” .Connection to country: “Migrants describe scarcity in terms of health services at origin, and difficulties in interacting with the health system at destination (Dhaka), experiencing mainly financial and geographical barriers to accessing healthcare. Some migrants described having to choose between eating and paying for medicine and that illness and injury can be bankrupting. It cost 5000 taka to operate Caesar (caesarean section). Yet, Caesar was not done finely, there was problem with sewing. Then, we went to doctor for a solution, he asked for 2000 taka to do Caesar again. Don’t have to pay after that? We paid 1500 rupees after a lot of requests. Two stitches were opened, after paying he sewed finely again” .Financial barriers: “Problems arrived one after another, my wife got sick. I spent around 3, 4 lacs for her surgeries, with my own earnings. After that I met the accident, again on my leg I spent around 2.5 lacs. However, I couldn’t buy medicine for myself, I wandered around asking for money from people. Not everyone could help, but some did and this is how I bought my medicines although I couldn’t cure my leg. It still hurts and I cannot move it” .Illness can be devastating: “Many migrants used pharmacists as a first point of call for primary healthcare needs. Pharmacists also acted as a point of referral. Other health services, such as clinics and hospitals, were largely used for serious matters and emergencies. There were no accounts of using health services reactively, rather only preventatively. Similarly, migrants accessed health services for physical complaints—there were no accounts of migrants using health services for mental health issues. Linking to financial barriers to accessing care, some migrants described healthcare as just another business. When describing different levels of quality care at origin and destination, migrants referred to concepts of accessibility, affordability, and patient satisfaction.They even ask for money for a normal vaccine. Fifty taka for a single one. No free medicine. They do not even talk without any money. What kind of healthcare is this?” .Healthcare as a business: “Yes, I take medicines they prescribe to me. They give out medicine depending on the money, the more money you have the more medicine they give you” .“I would say Bhola’s  because Bhola’s doctor didn’t give us several tests which cost us around 3–4 thousand. He simply gave us 2–3 medicines and that would do. Dhaka’s doctors do business more than treatment. I have pain in my back, my leg hurts and a part of my head hurts every now and then. But I do not visit the doctor in fear of tests and costly medicines” .Quality of care: “The doctors here (Dhaka) do not understand. The doctors back home (Bhola) understand. They (Drs in Dhaka) will not listen to us at all. They only prescribe some random pill and tell us to pay them an absurd amount of money. They will tell us what we have before we explain it and make us visit again after we have taken the pills. The follow-up also costs a lot of money” .“People who move in the context of climate change make complex decisions by weighing up changing vulnerabilities, exposures, and capacities where health is both a factor and an outcome of the migration decision and experience. The migrants in our study undertook a “risk exchange” concerning climate and health risks without a clear net gain or a net loss. Migrants moving in the context of climate change also enter a different healthcare environment where various barriers present themselves, to which they adapt and have views regarding the quality of healthcare.Our findings support existing literature in three main ways. First, our findings variably depict migration as adaptive, a form of climate risk management that can reduce health risks , and as Second, our findings support claims that climate-related migration can lead to the disruption of social ties with potentially adverse consequences for mental health and wellbeing. At the same time, our findings also show that existing social ties can inform migration decisions and provide material and social resources that can benefit migrants’ health and wellbeing and may reduce mental health stressors associated with climate impacts and migration . Third, our findings reveal that climate-related migration is associated with social and cultural loss and damage. Internal migrants are ultimately the responsibility of the state, yet from a broader perspective, developing countries have contributed least to the emissions their citizens are now paying severely for. Therefore, this social and cultural loss should be taken into account in the global loss and damage discourse and include non-economic damage in the form of health and wellbeing impacts .Our findings differ in important ways from the current literature of migrant health in the context of climate change. First, it is challenging if not impossible to determine the primary driver for complex migration decisions that are multi-causal and dynamic ,39. ThisSecond, a subset of the existing literature depicts climate mobilities as adaptation or maladaptation, implying a net gain or net loss scenario. Studies have sought to determine whether climate mobilities were successful or not, are cross-sectional, and overlook time scales  ,39,42. OThird, existing literature focuses on health-seeking behaviour and barriers and enablers to healthcare access, yet less attention has been paid to the quality of healthcare from a migrant perspective ,6,39. A Recognising changing health risks and the diverse health outcomes for migrants in the context of climate change, the main implications of this research for practice are to consider this complexity when planning health services and public health responses. Further research could appraise the association and degree to which some factors act protectively and thereby improve health outcomes  and how others act deleteriously . Cost–benefit analytic studies could illuminate the best investments to improve migrant health taking into account the benefits migrants offer host communities (such as labour services) and the benefits they offer sending communities (such as the mobilization of remittances). This research reveals how migrants use formal health services for physical complaints, for emergencies and reactively (rather than preventatively), reinforcing the need to strengthen health systems, reduce barriers, reorientate towards prevention, and more broadly ensure health services are migrant-inclusive and climate-resilient . FurtherOur findings highlight that migrants suffer from mental health and psychosocial issues, yet do not seem to utilise health services for non-physical complaints. Considering this when developing healthcare services could increase health service utilisation, cultural appropriateness and, potentially, improve health outcomes. Community-based mental health services have consistently demonstrated improvements in migrant mental health outcomes  and may Our findings detail a complex health system that seems to require a relatively high level of health literacy to navigate. Further research could explore health literacy as a barrier to utilising health service access and utilisation and find practical ways (such as developing activities and tools) to either reduce the level of health literacy required to access services or increase the health literacy of migrants, or both. Further research could take a patient-rights approach to migrant health services and explore the components of quality of care from both a provider and patient perspective. This highlights how patient and practitioner rights and responsibilities may be clarified and aligned to both reduce barriers to accessing care and to improve the quality of care. Extending on this, there is a need to promote tenant and employee rights too to avoid internal migrant exploitation. Our research raises concern about protection gaps for internal climate migrants in terms of health but also in terms of land rights, tenant rights, and employment rights with evidence of exploitation surfacing in many interviews. This raises a point of concern for diverse stakeholders, given that all migrants have rights to the underlying social, political, economic, and cultural determinants of physical and mental health such as clean air and water and non-discriminatory treatment . GovernmOne novel finding of this research that we have not seen published elsewhere is the concept of trapped at destination. The literature documents “trapped populations”, who lack the resources, assets, or networks to enable migration, and also voluntarily “immobile populations”, who choose to remain for reasons of place attachment, sociocultural continuity, and values ,39. BothOur work has several limitations. First, the participants are unlikely to represent all migrants in Dhaka, and the experiences of migrants who move in the context of climate change may differ from those moving because of a different constellation of drivers and pull factors. Second, the selection process was imperfect. Given contested definitions of climate migrants, we simply sought to select migrants whose mobility was at least in part related to climate change from their own perspective. We do not seek to demonstrate causal attribution between climate related migration and health outcomes in this qualitative study. Third, the themes may over-represent male views, given our sample was not gender balanced and men preferred to represent the households’ views. Fourth, our cross-sectional approach depicts the memory of the experience at one point in time and could not take into account how this experience and perceptions may change over time.Our results demonstrate how Bangladeshis engaging in internal climate mobilities in the context of climate change can undertake a “risk exchange” at origin and destination, whereby they exchange a range of hazards, exposures, and vulnerabilities at origin for a different set at their destination, requiring continual adaptation to reduce climate-related health risks. The experience of climate-related migration can also be understood as multi-staged and sometimes cyclical, rather than linear, whereby people can be trapped or immobile at their destination, as we already know they can be trapped or immobile at their origin. Social ties can be fractured by migration yet can also serve a protective role for migrant health and wellbeing.Along with changing environmental and social health determinants is a changing healthcare environment where migrants face different choices and barriers, requiring a high level of health literacy to navigate an unfamiliar health system. We illuminate migrant views regarding the quality of care that could provide useful insights when developing health and migration policy, designing health services, and effective public health responses. This may involve building more climate-resilient and migrant-inclusive services, improving the cultural competency of health workers, and incorporating preventative and mental health activities into models of care. Further, our results highlight a need to look beyond environmental threats to social threats migrants face such as tenant and employee exploitation, which calls for a rights-based approach. Policymakers, city corporations, health practitioners, and urban planners should integrate the complexities of the risk exchange into their discourse and decision making and approach policy, practice, and further research with a migrant-centric and climate-aware perspective. Internal migrants are ultimately the responsibility of the state and should be incorporated into public protection and insurance schemes to, at a minimum, prevent catastrophic health expenditure and, ideally, achieve universal healthcare. Our findings add depth to the collective understanding of climate-related migration and health in that, from a migrant perspective, the experience is more complex than a “net gain” or “net loss” in terms of health and wellbeing. The experience and health outcomes depend on the circumstances migrants find themselves in with respect to health determinants. This may serve as a useful entry point for practice and policy decisions.