Explicit and implicit attitudes have been studied extensively, but there is less attention to reducing dissonance between them. This is relevant because this dissonance (IED) results in distress and has inconsistent effects on behavior, e.g. less physical activity but more smoking. Mindfulness decreases dissonance between self-related explicit and implicit constructs. This study investigates if, and which, specific mindfulness subskills are associated with decreased dissonance between explicit and implicit attitudes, and whether mindfulness subskills moderate the relationship between IED and intention/behavior.N = 1476) explicit attitudes, implicit attitudes, red meat consumption (RMC), intention to reduce RMC as well as levels of trait mindfulness were assessed.At baseline and one and three months thereafter, participants’ (Mindfulness subskills were not associated with decreased IED. IED was associated with lower RMC and a higher intention to reduce RMC. The mindfulness subskill acceptance buffered the effect of IED on intention, seemingly offering a skill to deal with dissonant attitudes, which was unidentified until now.The mindfulness subskill accepting without judgment functions as a way to deal with dissonance. Future research should use this novel finding and investigate whether mindfulness can be used as a buffer in contexts where dissonance results in maladaptive behaviors. Dual-process models suggest that individuals have two sources for their evaluative tendencies –5. The fDissonance between these two types of evaluations has mainly been explored for self-related topics such as self-esteem or affective experiences –12. ThisOne factor that has been shown to enhance congruence between dissonant implicit and explicit evaluations is mindfulness , 12. MinAlso Brown and Ryan  concludeAs far as we know, only Hyde and colleagues  performeAttitudes are a key construct in social psychology and are regarded as important determinants across various  behaviors. Both implicit and explicit attitudes can predict the same  behavior , 27 and The aforementioned studies demonstrate that the effects of implicit-explicit discrepancy (IED) on behavior are inconsistent . Therefore, the question arises whether the effect of IED on behavior could be moderated by a third variable. Goldstein et al.  demonstrIn sum, the aim of the study is twofold. First, we investigated whether mindfulness is related to more congruent implicit and explicit attitudes and, if so, we explored which subskills are associated with that (RQ 1). Second, we assessed whether the mindfulness subskills moderate the relationship between IED and behavior (RQ 2a). Dual-process models, which postulate direct influences of implicit attitudes and explicit attitudes on behavior served as starting point for these two research questions. Socio-cognitive models, such as the Reasoned-Action Approach  or the IThe behavior chosen for this study is red meat consumption (RMC). RMC has been defined as a threat for people’s health (e.g. ) as wellhttps://osf.io/7enj9/?view_only=d1afaf26fdbe4f13a9feb0d857c89db0. IED and mindfulness were not part of the previous study. In the study at hand, emphasis lies on the relationships between mindfulness, IED, behavior, and intention.The current study is a follow-up study of a larger study, in which different predictive models of implicit attitudes and explicit cognitions regarding (the intention to reduce) red meat consumption (RMC) were tested. The study protocol of the original study was preregistered at The FHMLRec, the ethical committee of a Dutch University, provided ethical approval for this study .To determine the sample size, we conducted a power analysis by means of G*Power. Small effect sizes were anticipated for main and interaction effects (f2 = 0.03) and the test power was set at 0.80 with a type I error rate of α = 0.05 for two-sided testing. The calculation revealed that a minimum sample of 488 is required. Based on former experiences of the internet research agencies that were collaborated with in this study, a drop-out of 60% between the baseline and the second follow-up (T2) was expected. Therefore, the aim was to have data of 1220 participants available at the first measurement (after having implemented various exclusions), in order to have data of 488 participants available at the second follow-up.We conducted a three-wave longitudinal study with a baseline measurement (T0), a follow-up after one month (T1) and another follow-up after three months (T2). The whole study was conducted online among a sample of the Dutch population , which was recruited among members of two independent Internet panels that operate in line with the ISO standards , 49. AllWhen willing to participate, information was provided explaining that the study aims to gain insight into the relationship between determinants related to eating behavior and that there would be three measurements, that one measurement would take 15–20 min to complete, that each measurement was comprised of a reaction time task and a questionnaire, that participation was free of risks, that all data would be gathered and analyzed anonymously, and that they would receive a monetary reward. To begin with the study, participants needed to read and agree upon an electronic informed consent. If participants did not do so, they were excluded from further participation. At the beginning of the study, we included a question to double-check whether only people who consumed red meat at least once a month participated. People who answered the question with “no” were excluded. One and three months after baseline, a new invitation was sent to those participants who had participated previously to complete the follow-up. Depending on the standards for payment used in the two different Internet panels, participants received €2.50 or €4.75 for participation in the baseline, €2.50 or €3.00 for participation in T1, and €4.00 or €5.00 for participation in T2.love, friend, freedom, humor, joy; translated from Dutch). Words with the lowest scores on positivity, highest scores of familiarity and similar evaluations of arousal were selected as negative stimuli . To represent red meat, pictures were derived from the study of De Houwer and De Bruycker ; item 2: B = −.23, p = .02, 95%CI ; item 3: B = −.50, p = .06, 95%CI )   and moderate , but not when it was high   and moderate , but not when it was high   and moderate , but not when it was high  .The same pattern was revealed for VIFs < 1.65) and can, therefore, be ruled out as a possible reason for nonsignificant findings.For intention items after three months, no significant interactions between IED and the mindfulness subskills were found. All regression coefficients are depicted in Table We did not find any mindfulness subskill to be associated with the level of congruence between implicit and explicit attitudes, which is contrary to our expectation. This finding is, however, partly in line with the findings of Hyde et al.  and HofmWe did not find any mindfulness subskill to moderate the relationship between IED and RMC. These null-findings could be due to different reasons. Firstly, RMC was assessed by means of self-reports. It is possible that reporting errors lead to bias in terms of the amount of consumption, thereby also leading to a distorted illustration of the relationship between IED, RMC, and the moderating role of the mindfulness subskills. A second reason could be that the mindfulness subskills simply do not moderate the relationship between IED and RMC . Whether this is the case should however be investigated by future research making use of a more objective measure of consumption. Furthermore, it would be worthwhile investigating whether these findings also apply to other types of behavior. Thereby it could be investigated whether other  behaviors are also positively or negatively affected by IED and whether mindfulness could function as an “antidote” in case the effect is negative.An additional finding of the present study was that IED was related to behavior at all three measurement points, which was also the case in former studies –34, 69. Our results regarding the relationship between IED and intention suggest that there exists an additional way to deal with dissonance, which has, to our knowledge, not been identified before in the literature. The mindfulness subskill acceptance without judgment moderated the relationship between IED and intention. For people with a low and only moderate ability to accept their thoughts and feelings without judging them (including possible negative feelings resulting from IED), higher IED increased the intention to reduce RMC. For people with a strong ability to accept their inner processes as they are, IED was not associated with intention, hence no reaction was linked to IED. This finding fits nicely with the assumption that mindful people are better able to control their reactions as they have a greater acceptance of their own ‘errors’ and associated conflicts  as well In the present study, the non-acceptance of dissonance had a positive and thereby desirable effect on the intention to reduce RMC. Future studies should investigate in which contexts dissonance results in healthy behaviors, as it was the case in the present study, and in which contexts dissonance results in rather unhealthy behaviors, as demonstrated in former studies –34. ShedSeveral possible limitations of this study should be taken into account. First, RMC was measured by self-report. Although based on the Food Frequency Questionnaire, a validated tool also for the assessment of meat intake , self-reThird, the study was conducted online, thus participants were at home in an uncontrolled environment. This appears to be an environment more prone for distractions, which, one might expect, could especially affect the SC-IAT and its outcomes. However, Houben and Wiers (2008) investigated whether an Internet-delivered IAT would yield different results compared to an IAT performed in a lab and detected no significant differences. Importantly, they even found that the IAT performed at home was more strongly related to other explicitly assessed measures as well as to the target behavior (drinking behavior) than the lab-based IAT. This supported our choice to apply this method to our sample and setting as well. Additionally, we asked participants directly after having performed the SC-IAT whether they were distracted during the task. If this was the case, their data were excluded from the analyses.Fourth, the SC-IAT showed low test-retest stability, which is a general issue faced by researchers using implicit measures. This might be due to sensitive systematic error  or Fifth, acceptance of dissonance was not measured but rather inferred. Whether people who scored higher on acceptance were indeed able to better accept dissonance is unclear. Specific questions about the ability to accept dissonance could be added in future research to draw even stronger conclusions.Sixth, the study made use of an observational design. Although its longitudinal nature is definitely a pro, an experimental approach, in which dissonance would have been induced or the level of mindfulness would have been manipulated, would allow to draw stronger conclusions in terms of causation. We are convinced, however, that the present study offers a first step and ground for this topic leading to the next logical step - a replication in an experimental setting.Mindfulness subskills are unassociated with the level of congruence between implicit and explicit attitudes toward red meat consumption. Instead, the mindfulness subskill accepting without judgment functions as a way to deal with dissonance. Future research should use this novel finding and investigate whether mindfulness can be used as a buffer in contexts where dissonance results in maladaptive behaviors. The exact relationship between attitude, attitude discrepancy, behavior, and intention appears to be complex and dependent on other variables, such as the type of behavior. To draw more generalizable conclusions, more research is needed to identify these behaviors and factors.


The COVID-19 pandemic draws attention to many things, including our global connectedness, the role of ‘big government’, marginalisation, solidarity, and the ‘unsung heroes’ who keep essential systems running. For all of us, it tests our resilience, our ability to cope with turbulence, with the unpredictable developments in the wake of the extraordinary measures taken by governments to ‘flatten the curve’.In Austria, in mid-March 2020 radical measures were implemented that affected almost all aspects of daily life. Although the supermarket shelves were well stocked with food, Austrians turned their attention to local farms, and farmers responded quickly. Like never before, on-line platforms were used to build new relations, connecting farmers and citizens; farmers engaged in direct marketing offered to deliver orders, as farmer markets were closed; farmers asked for support as farm workers from Eastern Europe were not allowed to enter the country, and citizens responded by volunteering to help on the fields. These are a few circumstantial observations, but they indicate how disruptive change also opens up new possibilities, and how quickly (some) farmers can adapt, demonstrating their resilience.Studies of farm resilience focus on what enables farms to adapt to changing conditions, both on- and off-farm. They have shown that farm resilience may be influenced by available resources, workload, knowledge, power in the agro-food system, and broader societal structures. Many studies take a structuralist approach to farm resilience. They often strive to identify a ‘type’ of farm that ‘is’ resilient. So far, this has remained elusive: farms that enact resilience are rather diverse, as are the combination of challenges they face.Taking a relational approach to farm resilience allows for different insights and may be better suited to address the unpredictable dynamics farmers have to cope with. It shifts attention from structures to relations—which may be material, social, mental—and how these are constructed, maintained, broken, adapted. Indeed, farm resilience may draw less on structural factors, and more on creativity, mental agility, possibilities explored, options kept open, honing diverse skills, bricolage, resources that can be repurposed and reallocated. In a world that is assumed predictable and is driven by efficiency, creativity and exploring possibilities may seem like daydreaming and a waste of time. Honing skills that are not currently needed or keeping unused resources may seem unproductive, but it may well be crucial to build resilience.The question guiding research on farm resilience thus shifts from what ‘is’, to what enables an open ‘becoming’. Indeed, while crop production and animal rearing are constrained by bio-physical processes, farming might be even more constrained by what is thinkable. Yet, if there is one thing that the current COVID-19 pandemic has shown, it is that much of what was unthinkable may suddenly become a reality.For farms, the current crisis might well highlight that a strategy which focuses on specialisation, on optimizing processes, on increasing efficiency, and on reducing production costs has its limits in a VUCA world, i.e. one that is volatile, uncertain, complex, ambiguous. Indeed, this strategy tends to reduce both the number and the diversity of relations to those few that are ‘optimal’ under specific conditions, with the implicit assumption that these conditions are controllable and will remain broadly the same. But they do not. Change is not just marginal and gradual. Surprises are inevitable. Resilience thinking teaches us to ‘expect the unexpected’.Clearly, the current emergency measures are not here to stay. But maybe we should not rush to get back to ‘normal’. Maybe now is a good time to think what kind of agro-food system we want, and how we can transition to it. Indeed, even if the neoliberal rhetoric emphasizes that ‘there is no alternative’, the global COVID-19 pandemic clearly shows that policy makers and citizens can implement radical change. May be we should act just as decisively to address the climate crisis and the various ills in our agro-food system. May be resilience thinking can help guide this transition, as it points to the systemic benefits of encouraging diversity between and within farms; strengthening relations between farms and their local agroecosystem; and making social relations in farming more just and fair.


Industrial agriculture and food corporations have produced an abundance of food that is highly processed, nutritionally poor, and environmentally burdensome. As part of a healthy campus initiative, generated to address these and other food production and consumption dilemmas, a student-run “local and sustainable” food establishment called Food Next Door (FND) was created. This intrinsic case study evaluated food literacy in health science students, faculty, and staff first as a pilot to build the case for FND and further explicated customers’, volunteers’, and leads’ experiences with FND, identifying potential pathways from food literacy to citizenship. Ten returning customers, eight recurring nutrition student volunteers, and three graduate student leads participated in interviews that were analyzed for themes and subthemes. The findings show a progression in themes. Customers’ experiences highlight FND’s fresh, flavorful food, smiling and supportive staff, and personal transformation. Volunteers’ themes identified greater awareness of new foods and plant-based eating, acquiring new knowledge and skills in commercial kitchens, and deepening their connection to food, each other, and to where food comes from. Leads’ themes show opportunities to gain managerial skills, a deeper understanding of food and skills from being immersed in value-based food systems, and confidence in peer teaching. Experiencing and becoming part of the food value chain through FND built food literacy, shifted values, and transformed students into food citizens.  In the last decade, attention to integrate sustainability in nutrition has increased. A sustainable diet was first defined by the Food and Agriculture Organization based on a trans-disciplinary workshop among professionals in environmental and nutritional sciences . SubsequSeveral practice and concept papers have also been published recently to raise awareness in nutrition practitioners and organizations for curricular and practice integration of sustainable food systems topics and experiences around the globe ,11,12,13Food literacy ,17,18,19It is generally accepted that food literacy is focused on increasing food and nutrition knowledge and practical skills in food selection, planning, and preparation that lead to healthful eating behaviors. Food literacy also focuses on the interactions among individuals and sharing of information and actions with regard to food and eating, for example from expert to client. However, food literacy also encompasses a broader perspective with critical reflection and integration of food’s social and environmental contexts, including the sustainability of food production ,18,19. IMost recently, Vettori et al. evaluated food (and nutrition) literacy in terms of antecedents, components, and consequences . One of Food value chains are alternative arrangements most often known as regional or local food systems. Value chains transform the traditional competitive seller/buyer relationships into a collaborative approach. Transparency, working together, and providing fair shares to all partners under unified environmental or social values are characteristics of food value chains . Food vaOne of the caveats regarding the integration of sustainability into the curriculum for dietitians is that the field of sustainability sciences and practices, including food systems work, is very broad and complex, and thus, it easily gets marginalized in an already packed science-focused nutrition and dietetics curriculum. This is in contrast to the urgency for action to promote sustainable, healthy food systems, where the nutrition professional sits at the center of this work  to promoUniversities, and specifically dining halls, have been recognized as possible living learning labs for food literacy for students . Campus Thus, more needs to be known about educational opportunities that promote learning engagements in sustainable foods systems, especially in cyclic, value-based food systems where students, and in this case, nutrition majors, partake in all aspects from food production to consumption. Positioning such experiences for students and future professionals as food literacy and citizenship also remains unexplored. Therefore, the aim of this study was to describe experiences in university customers eating at, and students volunteering for and leading Food Next Door (FND)—a student-run, local food establishment—on a university campus. A secondary aim was to identify potential pathways from food literacy to citizenship through experiences with FND.www.uccs.edu/swell) was launched to promote wellness through hands-on learning and skill—building in sustainability practices to regenerate human health, cultivate a mindful society, and protect the environment.When the University of Colorado Colorado Springs (UCCS) foodservice transitioned to self-operation away from a corporate management company, one of the main reasons was to create academic connections through food systems-based, living–learning lab opportunities on and off campus. At this time, a program called SWELL  called FND. Sourcing local, sustainable food from Colorado family farmers, complemented with food grown on campus, was one of the goals of FND. FND produced the so-called SWELL meals, which were mostly plant-based, with a protein flip option —the “SWEapproach  and circapproach .FND was supervised by faculty, directed by graduate assistant leads (SWELL students), and supported by undergraduate volunteers (mainly nutrition students). SWELL meals and burgers were served first as a pilot in to-go containers in 2015/2016, second in a market-style retail dining operation in 2016/2017, and finally in residential locations 2017/2018, two to three times per week. FND customers were campus and community-based patrons. Further, volunteering for, and leading FND was expected to boost food literacy and help rebuild campus culture and a sense of place through the creation of a different food experience on campus. Graduate students were engaged in FND as leads. FND required them to handle heavy workloads, with a focus on food supply issues, bridging gaps from on-campus to rural agriculture and academics to auxiliary services, to name a few. FND was also tasked with refreshing the messaging around healthy food, engaging eaters with the ideas of digital-free community lunches at designated tables, and instilling the values of locally grown food. Volunteer students were primarily in their last year before graduation and signed up in practicum rotations with the goal to deepen their learning through various self-selected dietetics rotations. Ethnographically, FND’s culture is best described as a student-led, multi-disciplinary, experiential process that is embedded in academics, implemented through the collaboration with dining services, and enabled and elevated through the local and regional food system and its farmers.FND was not the first food systems initiative integrating nutrition undergraduate and graduate students at UCCS. Our work started in 2009 with the first students involved in food and farm field trips as part of community nutrition coursework in dietetics. This developed relationships with local farmers, food hubs, and chefs. In the following years, community funding led to graduate student assistantships on farms with the vision to create mutual benefits between the dietitian and the farmer working together: the farmer teaches the dietitian where food comes from, how it is grown and from which seeds, when it is harvested, how it is priced and sold, and its history and cultural significance. At the same time, the dietitian educates the farmer in nutrition literacy and establishes the connection to the consumer as a health professional promoting fresh, locally grown food using gained knowledge and skills in food literacy from the farmer. This collaboration led to the Flying Carrot Food Literacy project with graduate students working on farms and becoming the link to consumers at a local farmers market. As a result of its transformative significance, this work also initiated the first course in sustainable food systems within nursing and health sciences departments. The course “Food, Culture, Community, and Health” became a core course for graduate students in sport nutrition and a sustainability-flagged course for the UCCS’ Compass Curriculum. These past occurrences are mentioned here to position FND, since FND grew out of the work with the Flying Carrot Food Literacy project, which focused on the community. UCCS’ foodservice transition to self-operation in 2014, the campus farm and farmhouse, and the built relationships with the urban and rural farming community, including food hubs, enabled FND. Finally, FND gave rise to other academic and community programs, one of which became the UCCS Grain School—an academic and community course with a focus on heritage grains and the grain value chain with the goal of re-establishing a heritage grain economy in Colorado. For a summary of the UCCS food journey, see . Diffusion of innovation (DOI) theory focuses on how new ideas and practices are adopted over time ,37. DOI In qualitative research (QLR), the use of theory varies extensively . For thiThis intrinsic case was conducted over the course of three academic years, including the pilot study. An intrinsic case study design was appropriate for our purpose, as this method focuses on a situation or a program and produces knowledge that is non-deterministic in nature—knowledge where “reality is constructed by individuals interacting with their social worlds”  (p.6). APurposeful, criterion-based, convenience samples of participants from four sources were selected for this study. Participants for the pilot study were selected from a pool of students, faculty, and staff from our university’s Nursing and Health Sciences departments; customers were selected if they purchased five FND meals or more , and student volunteers were selected if they attended at least three FND meal preparation sessions to earn academic credit. Leads were sports nutrition graduate students funded to run FND. Purposeful sampling was deemed appropriate for this study because our aim was to engage participants who had experience with FND and could provide rich descriptions of their experiences .Data were collected from academic years 2015/2016 to 2017/2018. Primary data sources were a survey, individual interviews, field notes, observations, materials, documents, and reports. It is recommended that multiple data sources be used to create the context surrounding participants’ lived experiences . Our resThe pilot included a questionnaire with a validated food literacy survey administered at baseline before FND, which included an initial meals-to-go program in a small café setting before it moved to the center of campus in retail and residential dining.The food literacy survey included questions related to planning, managing, selecting, preparing, and eating topics according to Vidgen and Gallegos  and topiThe food literacy survey included 33 true/false/don’t know and multiple-choice items, with a maximum correct score of 33. The survey was subjected to content and criterion validity comprised of experts and a farm and food literate sample, respectively, and test/retest reliability according to the Flying Carrot Market Study, which was presented at the 2016 Sports Cardiovascular and Wellness (SCAN) Symposium . For theFor the current pilot study, we used a convenience sample. Additional data collection during the pilot study included other demographic questions, questions pertaining to more sustainably and locally sourced food, participation in taste education, purchasing behavior, and willingness to pay more for local food. For the pilot study, we also quantified semester sales at a nearby campus café, as this was critical to bridge the gap between academic program goals and the fiscal responsibilities of self-operated dining services. Piloting whether a program makes economic sense is also important for DOI, as dining services are commonly categorized as revenue-generating services on college campuses and are more likely to adopt new ideas if they do not lose money. The purpose of the pilot study was to build the case for FND. In this sense, the pilot study was a needs assessment.Year two and three included three different cohorts of participants with the main goal of exploring the overall experience with FND. We first focused on consistently  returning costumers (n = 10) in year two and on consistently returning (more than three sessions) undergraduate nutrition student volunteers (n = 8) and graduate student leads (n = 3) in year three. Graduate student leads were graduate students in sport nutrition and graduate assistants with SWELL who were paid through DHS. Participants in these three cohorts were interviewed based on the questions outlined in The three graduate student authors on this paper collected the pilot data and data from customers and student volunteers, while the lead researcher interviewed the leads. Interviews were audio-recorded and transcribed. Care was taken to make these inquires nonthreatening and easy to understand to allow participants to freely share their thoughts and opinions. Interviews were intentionally short and direct, although clarification and elaboration of meaning were sought when needed.t-tests (p < 0.05).Survey data were analyzed by counting each correct answer and deriving a total score. As there were no statistical differences among participant groups, except for sex, data were pooled and expressed descriptively overall and by sex , FND awards (3), SWELL annual reports (3), national presentations (3), internal white papers (3), and published articles referring to FND (2)). This analysis illustrated how food literacy was generated and disseminated. Then, interview and material and document data were triangulated. Distinct from triangulation as a form of mixed-method research , the process we used, called data triangulation, helped us identify different but complementary data on the same topic from the multiple sources of data we collected ,41.Finally, we engaged in the inductive process that Stake calls “propositional” or “naturalistic” generalization  (p. 86).Since the credibility and trustworthiness of data are critical to demonstrate rigorous QLR research, strategies recommended by Guba and Lincoln  and CresThe pilot study was conducted in fall semester 2015 of the 2015/2016 academic year before FND was launched in fall 2016. A total of N = 75 (age 30 p < 0.05). Food literacy scores were not related to participation in taste education (visited taste education: 22.2 ± 4.7 vs. 20.9 ± 3.9) but those who participated in taste education were more likely to purchase SWELL meals-to-go (p < 0.001). When evaluating purchasing behavior and food literacy, those who were purchasing SWELL meals-to-go had higher scores (23.8 ± 3.9) compared to those not purchasing meals . Food literacy scores were also higher in those willing to pay more for more local and sustainable food (23.2 ± 4.1) compared to those not willing to pay more . Food literacy scores were lower in males (18.6 + 3.6) than females  scored below a score of 75%. The range from lowest to highest score was 8–31 (24–94%). When asked about the interest in more locally grown and sustainable food served on campus, 64% responded positively, while 8% responded no, with the rest responding with “don’t know”. Over the course of the pilot study , there was an 18% increase in sales presumably from the increase in sales of SWELL meals-to-go.quotation marks”. At the conclusion of this section, word clouds were developed to help summarize the experience for each of the three data sources. We conclude with a description of the essence of FND’s experience, leading to pathways from food literacy to citizenship  fresh, flavorful food; (2) smiling, supportive staff; and (3) personal transformation. farmers market look”. Customers commented that the station with local produce displayed and recipes to take was “beautifully set up” and looked “just so fresh”. The FND station also included announcements of Farmhouse Fridays (cooking) and other events and the menu itself. The menu changed weekly, with no rotation, and featured mostly regionally procured food except for olive oil and some spices. Customers were simply amazed by the variety and creativity, expressing this by saying “this is delicious”, “prepared in a way that brings out different flavors”, and “(I) appreciate you do something different every week”, even though some also acknowledged the “taste difference”. One customer mentioned that FND was “the one healthy place on campus I can eat”. FND meals were priced lower than other less healthful foods in the retail space, as an incentive; thus, customers mentioned the “great price” for such high-quality, locally sourced, healthy food.Theme 1 reflected customers’ comments about fresh, flavorful food, which pointed to the look and feel of FND. It was not difficult to spot FND in retail and residential dining, as the red-white checkered decor had a ““helpful and knowledgeable and friendly” the students were, that “they always had a huge smile on their face” and were visibly excited to being there, serving and supporting customers in eating more healthfully.Theme 2 focused on the smiling and supportive staff. One customer mentioned how “I always feel really successful in my personal eating after I have finished my FND lunch”. After students designed the menu, procured and harvested the food, prepared it, and served it, the verbal delivery was not only filled with information on sourcing, flavor, nutrition, and sustainability but also rich in passion and joy to serve food on campus that was truly from “next door” with the farmer’s story attached to it. One customer mentioned “I like the way you describe the content of each meal” and another said, “You really get the impression that everyone helping out is really excited to be there and to serve food”. In retail, FND was serving two meals or a total of 150 servings per week to customers. Eating at FND seemed to help people eat better at home, as expressed by the following quote: “expanding my horizons”, shopping with more consciousness, and trialing new things “with ideas for doing stuff at home”. Most importantly, SWELL meals were delivered with education, which was highlighted by a customer saying, “Everybody needs to know what healthy eating is all about” and another adding, “I didn’t know [healthy eating] could be as good as this is”.Theme 3 highlighted personal transformation. FND led to personal transformation in shopping and cooking practices, partially because of exploring unfamiliar ingredients, as one customer put it For year three, eight volunteers were also interviewed regarding their experiences when working in FND. Three major themes emerged: (1) awareness; (2) knowledge and skills; and (3) connection. Theme 1 highlighted awareness to foods volunteers had not seen before. One volunteer said, “There were many vegetables that I didn’t know the names of, had never tried, [and] didn’t see in the grocery store before, and now I do.” Volunteers at FND were exposed to a variety of fresh, local, and seasonal ingredients and were taught by FND leads how to be creative in the kitchen and use these “new” foods to prepare delicious, healthy meals. Volunteers also got one meal at FND free of charge per week in appreciation for their work, which offered them an opportunity to see and live the experience full circle, witnessing their hard labor brought to fruition during service. Many of the recipes prepared by FND were plant-based, and this emphasis on plant-based eating influenced the volunteers’ own food choices, shifting some toward reducing their meat intake and incorporating more plants into their diets. One volunteer commented that FND “pushed me more toward a plant-based diet. I am Cuban so there’s meat in every single meal every day, and I don’t do that anymore. FND has definitely changed my habits and thoughts of what healthy eating is”.“many students had never worked in foodservice before and just being in the kitchen, being around equipment was huge”. They were exposed to a variety of local grains, beans, and produce, and when they volunteered, the FND leads would make sure the volunteers knew how to hold a knife properly as well as chop the produce, cook different grains, soak and cook dry beans, and navigate large commercial kitchens. Volunteers expressed gaining a deeper understanding of where the foods they prepared came from, for example saying, “I did not know we grew a lot of stuff here at our farmhouse” and “I learned a lot about different foods and from where these foods were sourced”. For example, the statements “just being able to see where it comes from” and “knowing that everything is locally sourced” related to FND’s procurement commitment, which was always a critical topic, along with food safety skills, when the menu preparation with volunteers started. Furthermore, volunteering with FND gave individuals exposure to and the skills necessary to educate on topics of local food and cooking, such that this newly acquired knowledge could transfer into their future professions. This was summarized by the following: “FND added another aspect of nutrition to my knowledge and to my practical use when I become a registered dietitian” and “It’s something that I can utilize, even with athletes that I know could benefit from it”.Theme 2 focused on knowledge and skills pertaining to food and cooking. Volunteers articulated that they gained invaluable skills in the kitchen. One volunteer mentioned “I love this program… FND creates community. It brings us all together”. FND not only connected individuals, but it also helped them connect with food and build a better relationship with food. “Through FND, I learned more about food and got a better relationship with food.” “It was good to see a different side of foodservice that’s more appreciative and more exciting to work with.” As a result of the freshly picked produce, the kitchen smelled not of grease or sugary bakery items but of irresistible flavors and food that looked like it came straight out of the soil, vibrant in color and life, rather than pale and out of a plastic bag. This surprisingly new connection with food also led individuals to become more mindful. “Healthy eating is more than just eating a fruit and vegetable with each meal. I think it has more to do with where it comes from, how it was grown, and the people involved in that process.” Synthesizing the experience of FND for volunteers was probably best expressed by the chosen title for the graduate project reporting on the experience of volunteers with the statement “the future dietitian cooks”!Theme 3 is related to personal and inter-personal connections. Food preparation was at the same time each week when students would come together to work toward a common goal: preparing delicious local food for the campus community. One volunteer said, For year three, three leads were interviewed regarding their experiences when working in FND. Three major themes emerged: (1) becoming a leader; (2) peer teaching and learning; and (3) food systems knowledge, skills, and advocacy. As a leader, you just have to always put that face on and make decisions. People are counting on you. At the beginning, it was overwhelming, juggling so many roles in the kitchen. Sometimes, I just wanted to be in a corner with a cutting board and cut the beets”. Handling large quantities of farm-fresh food, harvested just hours before preparation, teaching concepts and skills such as food safety and knife skills to volunteers while also delegating tasks, dealing with challenges such as seasonal supply or cooking with unknown ingredients, and creatively adjusting the recipe based on familiar customer expectation was a big responsibility that required full effort and commitment. Leads expressed needing to consistently “stay(ing) engaged, focused, and fully committed to the work”. There were so many challenges to manage. “There was so much food in the fall to prepare, it would take three hours just to wash the food and we had not even started cooking it", “cooking with unknown ingredients” or “odd balls like the tomatillo and how do we make that part of the meal”. In commercial kitchens on this scale, it is usually the menu and recipe that guides the cooking. In FND, this was somewhat flipped, where the ingredients, especially if unexpected or unknown, lead the menu and required recipe adjustments. While this was a challenge, it also offered opportunities for creativity. FND leads were expressing their excitement even if they were under pressure. “To be put in that leadership and management role as a graduate assistant was a lot of pressure, but it also made me rise to the occasion. And you do things that you did not think you could do. The commitment, I think, was really amazing. And you get out of it what you put into it and I cared a whole lot about it. I would stay awake at night and think about it. I would draw diagrams of how I was going to set up the bay at FND the next day. I would stay up at night and do that. I loved it.”Theme 1 was focused on becoming a leader, with leaders having to hold a lot of moving parts including planning and procurement, harvesting, cooking food, serving meals, marketing the menu, and educational messaging. One lead expressed it by saying, ““Running a foodservice operation with orders, money, procurement, catering … brought about necessary collaboration” as one lead expressed in preparation for the weekly action plan, which required “a lot of thinking”, “including our own ideas” not just “flipping cookbooks or pulling recipes” off the internet. “It had an impact on me, so I like(d) shar(ing) that.”Theme 2, peer teaching and learning, was especially informed by the lead students’ steep learning curve, feeling inspired, and yearning to pass it on to others. While in the kitchen with volunteers, FND leads exercised the highest order of command as leaders and managers, following their action plans and ensuring safe practices, while also teaching what they had just learned to their student peers. bins and boxes with food straight from the earth”. This new learning was often overwhelmingly challenging. Yet, FND’s cyclic experience enabled a continuous, reciprocal dialogue from teacher to learner about farming and gardening, opportunities for creativity through all the senses, and a platform for students to “learn from mistakes” without significant consequences due to the academic environment. All leads expressed similarly how “working on the farm” and “farming and gardening” meant they were “able to teach skills in the kitchen”.The kitchen work was not comparable with handling culinary work in a conventional supply chain. There were ““opening eyes to food, cooking, and gardening”, understanding “seasonality”, and becoming more aware that nutritiousness depends, at least to some degree, on “trying to learn where food comes from”—the food’s origin and when and how it was grown. Comments such as “I never tied local food together with nutrition” reflect significant curricular gaps in nutrition and dietetics. Secondarily, building relationships and shifting values through the newly developed relationships with farmers were also important. Leads identified new relational values of food, associating food with “planetary health” and expanding definitions of healthy eating from calories and nutrients, such as protein, to food, the food system, and sustainability. Participating on farms, experiencing the sweat from harvesting and what goes into food production, both in urban gardens and on rural farms, provided a deeper level of understanding of the food system and food value chain, in one lead’s words, “why it is important that we use these foods”, in the support of the regional community, food security, and conservation of open lands for agriculture.Theme 3, food systems knowledge, skills, and advocacy, emphasized the enhanced understanding and navigation within the food value chain. First, common among all leads was that FND built food literacy To summarize the findings from year three, FND leads learned to align their thinking, planning, and procurement with the constraints of food availability in a regional context. What used to be common sense in seasonality had to be relearned. The interaction with local farmers and soiling their own hands weekly while physically harvesting what was fresh taught them so many aspects about food that started with soil, water, climate, biodiversity, and seeds. Environmental challenges, such as drought in the West or elevation and the length of the growing season were topics that brought more understanding to the limited availability or the type of food, its flavor, culinary use, and nutritional benefits along with its origin—sometimes being indigenous or ancient. For FND volunteers, food preparation led by their graduate peers increased their awareness to the foods grown in Colorado and the climate-friendly, healthy SWELL meals and introduced some level of environmental awareness and food production while increasing practical knowledge and skills in institutional foodservice settings. FND also brought them a renewed sense of community and food connections. They too learned about the food system they were working in, its interdependence, and collaborative spirit while working together in the kitchen, of course, distracted by smells, sights, and flavors from this fresh food. What was tough for the leaders to juggle seemed to be softened by the joy of cooking together, which was so well reflected by the consistent return of volunteers.The quote below sums up the experience by one of the most experienced student leads, indicating a deeper understanding through immersion in FND.“Being able to have my hands in the garden, there was something very special that I was able to transfer into the kitchen. Coming with bins and bins and bins of fresh produce from the garden, much of them I never had true exposure to. You hear about leeks, tomatillos, many kinds of peppers. But to be able to harvest, then take it in an electric cart over to campus and learn how to cook with it, which part of it you eat and which part you don’t eat. Can you eat the seeds? Do you take them out? Are they spicy? Sweet? What about the skin? How do you cook it? And it was so fresh. I had never dealt with such fresh produce before. Never in my life had I taken all the food from the garden and then cooked it. That was brand new. Being able to have experience with food and also learning about the local farms and identify(ing) which farms have what food and at what time. Learning the seasonal calendar was a learning curve for me. But the food aspect of it is amazing. Learning to cook with different herbs, how the fresh food can really make a dish. You don’t have to do a lot to it when the produce is so fresh and flavorful. You don’t need to add a ton of spices or salt and you don’t need to cook it in any special way to make it taste great. And I think that was something that really was amazing that both the customers and I were able to recognize quickly. The customers would express how flavorful and amazing the food was, and we would tell them, it’s just five ingredients all tossed together. A light bulb went off for them and for me. I started to know food differently, despite my previous culinary and sustainability training. It just goes to show that learning it in the classroom is one thing, and hearing about it is one thing, but actually being fully submerged in doing it is another thing.”“how much work goes into food production is a humbling experience. I have more respect for food and want to do it justice”.The peer teaching and learning from leads to volunteers touched on all components of food literacy, including critical food literacy. The recipe development process followed by the ambitious action plan from harvest to service required trans-disciplinary thinking and action. The menu included both environmental and health objectives, but it was additionally confined by the availability of products and taught the students lessons of restraint, flexibility, creativity, and ignited forgotten skills in home economics to extend the seasons of food . It also involved the transport of harvested food for “mise en place” in commercial kitchens and unpacking, combining, and bulking up recipes, costing the menu based on purchases, while keeping track of farmer names and locations. The educational portion often asked for interaction with the farmer or food hub, learning about their stories, the history and culture of their crops, experiencing a small piece of the lives of American family farmers, and their hardship of staying afloat. Society’s romanticism of farming or gardening was replaced by sober knowledge, empathy, and arising commitment to participate in and contribute to a thriving food system. As one lead put it The themes from our data sources showed a progression  from fooThis intrinsic case study described experiences in customers eating at and students volunteering and leading FND, a local food establishment on a college campus. FND involved a cyclic process from farm to kitchen and table with a fully student-led program, producing environmentally responsible meals, balancing carefully flavor and nutrition in menus and recipes, while discovering the foods of Colorado, the seasonal and variable supply of produce, the cross walk from campus farm to kitchen, and the infinite dialogue among student peers—teaching, learning from challenges, and rising to the opportunities of bringing this food to campus eaters. From customers to volunteers and leads, themes we identified highlight experiences from FND as life-changing.In addition to a vigorous science and didactic curriculum, nutrition and dietetics programs cover many, if not all, aspects of nutrition and food literacy, but the field is especially focused on functional and interactive components. For example, nutrition students research and learn the scientific and inter-personal dimensions of nutrition in health and disease and how to work with patients to improve eating habits and promote health or treat disease using medical nutrition therapy and the nutrition care process . CriticaThere is a recognized progression from food literacy to food citizenship. Critical food literacy is conceptualized as a kind of food citizenship where work with food extends beyond oneself and expands to societal dynamics ,48,49. MFood literacy is desperately needed in university students, including those students preparing for health professions . From ouWhile FND required campus resources and full commitment of their leads with many challenges to overcome, such establishments can live on college campuses and make dining experiences unique. Our pilot data were needed to launch FND, as we were able to show the need for food literacy in students, faculty, and staff using our survey data. Those purchasing meals-to-go were interested in and willing to pay more for healthier and more sustainable food options, which demonstrated higher food literacy scores. We were also able to show an almost 20% increase in sales with meals-to-go, all of which persuaded DHS to start FND. Unfortunately, socio-economic status is often predictive of healthy eating, also in college students , and fooFND experiences taught volunteers and leads, who were nutrition students, new strategies for healthy eating from sustainable food systems according to what we believed was meant, at least in part, with a call to action by the EAT-Lancet Commission on Food, Planet, and Health . DevelopExperiential learning opportunities are well-recognized pedagogical strategies to deepen students’ understanding of classroom materials ,55,56. IAgriculture has a significant impact on climate change. Food production and consumption are responsible for 26% of all greenhouse gas emissions , decreasEspecially the FND leads seemed to have gained a deeper understanding of the current food system and learned how to engage in and help build an alternative value chain alongside the institution’s mainstream suppliers. Based on interview questions such as “How did FND change the way you think about and act around food?” and “What was most important to you about FND?”, leads expressed the pressure and challenges of FND but also the profound learning opportunities being fully submerged in the food value chain. Their daily interaction with DHS brought many challenges and opportunities for student leads to apply critical thinking, problem solving, and decision making. For example, students had to solve logistical issues, learn about procurement policies, collaborate, and effectively communicate with each other and DHS. They also saw the hard and often less fulfilling work of foodservice personnel and began to understand the uneven distribution of the food dollar along the supply chain all the way to the farmer. They recognized the current disconnect of foodservice workers from the food source. Discerning differences in supply vs. value chains , recogniChange agents are now needed to address food systems complexity. However, health and nutrition professionals will not simply be able to opt into specialized practice in sustainable food systems . These p“One must begin in one’s own life the private solutions that can only in turn become public solutions.”Wendell Berry This three-year qualitative analysis of FND has limitations. First, our sample sizes for the pilot study and the interviews were small. The main researcher was the faculty advisor of FND and directed UCCS’ food journeys since 2009 . FND hadAnother limitation of this study is the food literacy survey. This survey was developed for another project and not FND and college students specifically. Nevertheless, the survey we developed captured what we needed to build the case for FND.That health and nutrition professionals are part of the future food systems workforce is in the hands of those writing curriculum and competencies and in innovations for post-graduate training that are multi-disciplinary in nature and use systems thinking, as illustrated recently by Ingram and colleagues . On the “changing RD curriculum to integrate agriculture”. Our research, describing the experiences from FND, provides a start. Unique to QLR is that categories of meaning, here expressed as themes and subthemes, may be used in developing assessments or competencies for the purpose of developing nutrition curricula to include sustainable food systems experiences.While there is good momentum currently in expanding the sustainability competencies of dietitians in North America ,6,7,8,9,Further research is needed on the long-term impacts of food systems courses and co-curricular activities such as FND in students and beyond the early adopters we studied. It is of interest to better understand what experiences lead to all aspects of food literacy and transformation to food citizenship, especially in nutrition students. Finally, more needs to be known about how these experiences in nutrition students in college transfer to food systems work in dietitians in the future.This intrinsic case study focused on a student-run, farm-to-table dining operation, called FND, on a college campus and experiences of early adopters, including customers eating at and nutrition students volunteering for and leading the operation. Our pilot data set the stage for this FND as food literacy was low, but interest in and purchases of alternative food options high. Interview themes in customers related to fresh and flavorful food, smiling and supportive staff, and personal food transformation. Volunteer themes highlighted greater awareness of new foods and plant-based approaches, cooking skills, and connection. Lead themes focused on leadership, peer teaching and learning, and food systems knowledge and advocacy. Through this case study’s inductive process, pathways from food literacy to citizenship emerged. Experiencing and becoming part of the food value chain through FND built food literacy, shifted values, and transformed participants into food citizens.


This paper surveys measures of economic openness, the latter being understood as the degree to which non-domestic actors can or do participate in a domestic economy. Based on the existing literature, the authors introduce a typology of openness indicators, which distinguishes between ‘real’ and ‘financial’ openness as well as ‘de-facto’ and ‘de-jure’ measures of openness. They use data collected on these indicators to analyze trends in openness over time and to conduct a correlation analysis across indicators. Finally, they illustrate the potential consequences of employing different openness measures in a growth regression framework.The online version of this article (10.1007/s10290-020-00391-1) contains supplementary material, which is available to authorized users. The impact of economic openness on domestic economies has been a prime area of interest within both the scientific community as well as the wider public. The relevant debates, however, use a great diversity of concepts to describe the extent of international economic integration: terms like ‘trade openness’, ‘economic integration’, ‘trade liberalization’ and ‘globalization’ are widely used when the general increase in economic openness during the last decades is addressed. The same observation holds true for the financial dimension, where terms like ‘financial openness’, ‘financial integration’ and ‘financial globalization’ are used regularly and often interchangeably  or assessments of the institutional foundations of economic openness, i.e. the legally established barriers to trade and financial transactions (de-jure measures).In addition, ‘hybrid’ measures aim to incorporate information on both, real and financial aspects, while “combined” measures also strive to integrate information on de-facto as well as de-jure aspects of economic openness , information on non-tariff trade barriers (such as licensing rules and quotas) or tax revenues emerging from trade activities relative to GDP. Financial de-jure measures indicate the extent to which a country imposes legal restrictions on its cross-border capital transactions. As de-jure indicators evaluate a country’s regulatory environment, it is important to keep in mind that this environment is influenced not only by national policies; they are also shaped by the impact of supranational institutions like the European Union or the World Trade Organization.The above construction and interpretation of the two main types of indicators, de-facto and de-jure, reveals that these types do indeed measure different facets of openness, which need not be consistent for a given country. For instance, a country could have a defensive legal stance in terms of openness, but still play an important role in the world trading system e.g. due to its special position as a trade hub (e.g. China) or as a financial hub . At the same time, a country may be open to trade in terms of institutions and policy, but nonetheless lag behind in terms of its real integration in international trade due its geographic remoteness (e.g. Canada) or technological inferiority (e.g. Uganda).3total impact of a series of different factors, such as the level of technology, geographical location, the existence of natural resources, legal regulations and tax policies, political and historical relationships, multi- and bilateral agreements or the quality of institutions. Therefore, de-facto measures can be seen as capturing the overall impact of all relevant factors without any ambition to delineate their relative contribution to the chosen outcome dimension. It is for these reasons that any “combined measure”  or a more ‘inward’ sense (Imports), or restrictions of what enters the numerator, such as variants considering solely trade in goods or excluding exports in primary sectors.However, despite its popularity Trade/GDP and its variants have to be used with caution for a number of reasons, most of them relating to the normalization by GDP.First, by taking GDP as a reference point, Trade/GDP incorporates a specific size bias as small economies typically show higher trade volumes relative to GDP than large economies—a fact well-known from the estimation of gravity equations (e.g. Feenstra 2015). As a consequence, strong domestic economies, which also happen to be major players in international trade , find themselves at the lower end of any country-ranking composed out of Trade/GDP.trade dependency ratio, trade openness index, trade share or trade ratio, have been suggested. More recently, Fuji  free market agenda: the Aiming to complement the available data-sources, we developed an additional alternative indicator that closely follows the methodological approach of the tariff-based measures of Jaumotte et al. , but is financial openness index” and defined as the volume of a country’s foreign assets and liabilities relative to GDP  has been widely used in the literature on the impacts of financial openness. It focuses on regulatory restrictions of capital account transactions, is publicly available and covers 181 countries over the period 1970–2017.9economic globalization  are comparably rare. To derive such more specific measures of economic globalization requires researchers to first isolate the relevant economic dimensions and then identify suitable variables for measuring these dimensions. Among those globalization indicators that could serve as a starting point for assessing the economic dimension of globalization—such as the DHL Connectedness index  measure similar aspects of economic openness and, therefore, are strongly correlated with each other. To corroborate this hypothesis and to study the relationship between indicators belonging to different types, we now conduct a comprehensive correlation analysis of all available openness indicators (as well as their specific sub-components and variants) presented so far, which are technically suitable for such an analysis.Since many papers use the first difference of these indicators, we pay attention to both, correlations of the variables in levels as well as in first differences.When inspecting Figs. Across the four major types of openness, the cluster relating to de-facto financial openness measures is the least visible cluster, which indicates that this dimension exhibits the greatest diversity in terms of indicators with different conceptual underpinnings. Notably, we find that the KOF economic globalization index is correlated with almost all other indices, which illustrates its ability to integrate different aspects of economic openness.In sum, the correlation analysis suggests that the concept of ‘economic openness’ has many facets, and various measures capture quite different aspects of this ‘openness’.We continue by posing a question that is of particular interest to empirical researchers: what do the findings from the correlation analysis in the previous section imply for the choice of openness variables in regression specifications? For illustration purposes, we run growth regressions based on a data set for 65 countries over the time period 1995–2014. The choice of this data sample was driven by data restrictions: we only included observations when data for all the different economic openness indicators were available. If we would allow for differences in the data sample used for estimating models with various openness indicators, we would be unable to provide a clear interpretation about whether using different openness measures has an impact on the reported results. Our choice of the data sample, on which we provide more detailed information in the appendix, therefore, facilitates comparative interpretations.There exists a large literature on the determinants of economic growth  are positively correlated with growth, but only the first two variables are statistically significant. The results for the FD-specifications show that the Tariff_WIT and the FTI index coefficients switch signs, although they also remain statistically insignificant.The conclusion for measures of de-facto financial openness is also ambiguous: in case of the 5-year averages, three of the four de-facto measures suggest a positive relationship , with two of them being statistically significant, while one LMF openness indicator (LMF_EQ) has a negative sign. The results are more straightforward when the FD estimator is used: here all indicators suggest a negative relationship and all these correlations, except for the FDI outflows, are considered as statistically significant at the 5% or 1% percent level.Finally, we also observe ambiguous patterns for the financial de-jure measures with KAOPEN and CAPITAL being positively, and HF_fin being negatively associated with growth, for both the estimations based on first differences and 5-year averages. However, only the CAPITAL coefficient in the FD-case shows statistical significance.These exercises reveal that there is not only considerable variation in outcomes when different types of economic openness are considered, but that results may also vary within a certain conceptual dimension as different indicators are constructed in different ways. To arrive at a fuller picture of the empirical assessment of economic openness, we estimate a more complete regression equation in the next step. In doing so, we augment the baseline specification by explicitly including measures for different types of economic openness in each single model.The results regarding the determinants of GDP per capita growth obtained from these estimations are again sensitive to both the dimensions of economic openness actually considered as well as to the set of openness indicators chosen to represent different dimensions of openness  and a ‘de-jure’ dimension , respectively. The data set consists of 216 countries over the time period 1965–2019, although there is wide variation in the coverage of the country and time dimension across different openness variables.We have used this data set to analyze the correlation across indicators, both in levels and in first differences. We find that indicators that belong to the same category of openness measures indeed tend to be correlated more strongly. Correlations among openness indicators are, however, in general much weaker in the case of first differences. By using a standard growth regression framework, we have shown how different types of economic openness as well as different indicators capture the impact of openness on economic growth in different ways. From this finding, it follows that applied researchers are well advised to motivate their choice of openness indicator rigorously, since different research questions might also entail different conceptions of economic openness. At the same time, it can be argued that the identification of reasons for why different measures of economic openness yield different results is an important and rewarding research activity.Supplementary material 1 (PDF 476 kb)The data and code files required to replicate the results presented in this paper are available on GitHub: https://github.com/graebnerc/econ-openness. The R package for downloading the data on all the economic openness variables used in this paper is also available on GitHub: https://github.com/graebnerc/OpennessDataR. Below is the link to the electronic supplementary material.


Objective: This study’s principal aim was to describe the lived reality for people with cardiovascular disease (CVD) and other chronic health conditions, who live in economically deprived neighbourhoods in a city in North West England.Methodology: This is a qualitative, exploratory study based on in-depth, semi-structured interviews with participants experiencing compromised cardiovascular health, conducted in August 2017. The study sample comprised 14 adults  aged 54 to 76. Thematic analysis was used for data analysis, and the biographical disruption concept was used as theoretical reference to explore the results. Wider health inequalities literature supplemented the individual experiences of chronic illness.Results: Four main themes were developed from the data: (1) chronic illness as a disruptive experience; (2) struggling for money; (3) lifestyle and health risks; and (4) reflections on current inequalities. The varied nature of participants’ narratives about their chronic illness indicated that the experience of biographical disruption depends on the wider socioeconomic and cultural factors of the individual.Discussion: This study suggests that biographical disruption theory combined with health inequalities contexts highlights the role of hidden suffering and enhances the understanding of chronic illness experiences and thus informs clinical management, service and public health planning. Bury  establisHowever, biographical disruption is not sufficient to explain the diversity of experiences of chronic illness, as its focus on the illness may mask and reduce the impact of the wider socioeconomic and cultural factors on the chronic condition of the individual Lawton, . It is eHealth inequalities are defined as differences in health status or in the distribution of health determinants between different population groups  chronic illness and its management; 2) dietary choices and food bank utilization; and 3) trade-off decision making regarding basic needs, including food, medications, and other necessities. Participants gave informed consent for the interviews, which were audio recorded. A short questionnaire on general demographic information was also completed.Ethics approval was obtained (reference number 1815 University of Liverpool). All data were pseudo-anonymized, with removal of identifiers.Participants were recruited from a deprived North West England inner-city neighbourhood. All participants were living in a low-income area, and they self-reported at least one major risk factor for or the existence of cardiovascular disease (CVD).Fourteen qualitative interviews were conducted, at which point the research team agreed that thematic saturation had been achieved. Thematic analysis was used as a tool of data analysis to understand and reflect people’s everyday reality  chronic illness as a disruptive experience (2) struggling for money, (3) lifestyle and health risks, and (4) reflections on current inequalities. Theme 1 was framed by biographical disruption theory Bury, , 1991. Tbefore the stroke I had a future” (Derek)—by interrupting future plans. Others described their chronic illness experiences as a “slow deterioration” (Diana), which gives the idea of continuity rather than a disruption Our findings describe biographically disruptive experiences of chronic illness Bury, . Howeverthe most annoying thing is that I can’t do what I used to do”. He engaged in sports, photography and music concerts but he was limited because of neck spondylosis and arthritis. Some participants also highlighted restricted social components of life as disruptive experiences leading to isolation.Participants with arthritis recognized their chronic illness as painful. The experience of physical pain drew the attention of the participants to their bodies. Awareness of bodily stages facilitated their recall of all the body parts that were damaged or painful. Participants frequently described their limitations in activities as well as their inhability to work as a result of their physical impairment. Liam pointed out “I can walk up and down stairs and they think that’s fine” (James). Participants found it hard to deal with and improve their mental state, and so were unable to sort out issues and seek help on their own. Indeed, some participants pointed out the necessity of being guided through the day. Participants were also conscious of how their mental state affected their personal life.Well, without beating about the bush, I am depressed, and I’m aware that the way I am maybe affects other people. I mean, I said to you I was living in Area A when I had the stroke and now living in Area B. I mean, when I had the stroke I was living with my partner and she asked me to leave, and I’m sure that it’s because I couldn’t cope with having had a stroke and I was and am depressed. (James)In this study the “what is happening?” Bury,  went beymy name is William and I had a stroke”. When asked to say something about himself and to describe a normal day for him, William replied with the following words (note the times that he repeated “I had my stroke”). William’s narrative also reveals the process of re-thinking his life by emphasizing the “before” and “after-now” A new personal identity was acquired related to participants’ chronic health condition, suggesting that their sense of self had changed. Chronic illness prompted a new identity, revealed by participants identifying themselves with their chronic illness. For instance, “w” Bury, .Well beI was too young to have a stroke”. They had to re-evaluate the meaning of chronic illness as related to the ageing process. Lastly, the participants in this sample illustrate a wide range of responses and adaptations to chronic illness Participants faced tough financial situations. Diana, living in a little detached bungalow, explained “a roof over the head” (Stuart). The tough financial situation made it difficult to save or have spare money. As Diana said, “a pound will help”. The majority of the participants were living day to day, economizing whenever possible, and developing money-saving strategies. Diana, whose only entertainment was the television, had frequently phoned the company to try to get the price reduced. Stuart had to sell some of his belongings to friends or second-hand shops to financially survive. James’s desperate strategy is exemplified in an email that he sent to the researcher (SEQ) some days after the interview.I didn’t say this the other day as it is slightly indelicate/embarrassing. After my stroke when I got home I only used one piece of toilet paper at a time. It was a pointless attempt to try and save money. (James)As a consequence of financial hardship, participants had to control and prioritize expenses, carefully and consciously selecting their choices. Priorities varied among participants. James, the only participant who had to pay for prescriptions, said that medicines and food were top of his list. By contrast, others’ priorities were bills, mortage, and “second nature” (Derek) for most participants. The stress and worry produced by the threatening financial situation had harmful effects on participants’ chronic health condition. Derek and James admitted that money could make a difference mentally.It’s a constant stress. Most of the people in there will tell you when you walk in the door, every day you’re looking for the white envelope or the brown envelope to call you in, so it’s a constant, it’s constantly on your mind. […] You later learn that things like stress, it’s the worst thing in the world, stress. That’s one of the things you’ve got to learn to control, and you can only control that with this [money]. (Derek)Worrying constantly about money became a way of life or “These feelings were shared by those around them. Relatives worried about participants’ health, and checked on them often. Participants’ families and neighbours were concerned about their delicate health condition which, indirectly, might have a negative impact on them. In order to relieve participants’ worries, their families did the finances for them.being needy”, affecting his sense of self-pride. Although he did not ask, church, friends, and neighbours often gave him meals.But sort of like I hide away from them  in the end because I don’t want to feel as though like I’m some sort of like I don’t know, for want of a better word like some sort of basket case like, let’s all help Stuart type thing. (Stuart)Support came from family, neighbours, friends, churches, associations, and foodbanks; and it could be both material things such as food, money, and furniture, and less tangible things such as emotional support, phone calls on their behalf, and decorating and gardening. While some participants appreciated the help and support, material things and money made others feel embarrassed. Stuart felt ashamed for “unhealthy habits” and how these could harm their health; in particular, smoking, unhealthy eating and insufficient physical activity. After his third stroke, Terry was restricted to a wheelchair, limiting exercise, so he put on a lot of weight. He felt unhealthy and noticed breathing problems from smoking and excess weight. Participants were, however, aware of ways to improve their health. Whilst some expressed intentions or actions to change these unhealthy behaviours, others reported not knowing how to improve their lifestyle or not being ready to change.To eat healthy and be a non-smoker is the ideal thing, but … […] I can’t see me, at 54 years old I can’t see me changing that much now. […] I think I’m set in my ways now. As long as I can stay healthy and clot less. (Robert)Several participants talked of “I never thought I was at risk of having a stroke. I mean, it’s not like they can tell me to lose weight, stop smoking, stop drinking. I don’t drink, I don’t smoke … […] I won the wrong lottery. They can’t tell me why I had the stroke. (James)However, many of the stroke survivors reported a healthy lifestyle before the event. They expressed anger, disappointment and surprise, and they could not understand why it had happened to them. James’s narrative reveals the “why me?” question Bury, .I neverputting the brake” (Diana) or “cutting down” (Clare). Nevertheless, the convenience of ready-prepared meals and the easily accessed take-away food were barriers to nutritious food choices. Diet was not always a matter of choice. On the one hand, participants had to rely on others’ cooking skills or decisions when living in a family or in a residential care home; on the other hand, they were prevented from cooking for themselves . Diana and Andrew declared that their diet was better when they had got a carer, but it seemed to be frustrating for Andrew since he could not feed himself due to his paralysis.Participants were aware that their diet had undesirable effects on their chronic health condition. Despite their willingness to change and make healthy choices, some said that they could not afford the recommended diet. Losing weight was a common concern among those who identified themselves as obese, and recognized that healthier eating could make a difference and improve diabetes, blood pressure, and mobility. Participants tried to eat healthily by controlling unhealthy food intake, that is, “people should never be in the position to use one”. Jacob lost his job when he had his stroke. With no income for over two months, he was given a food voucher by the council. Although he found the food bank staff very welcoming and helpful, he found that going there was “very degrading after working for so long”. He felt embarrassed and went just once, and then not to the closest. Robert never went to a food bank because he was “too proud to go”. Experiences of hunger were expressed by the same participants. Jacob went hungry after his stroke. After his benefits finally came through he still panicked when “the cupboards were empty” four days before getting paid. Stuart had to carefully control his limited budget, resisting his desire for occasional take-aways. Buying the desired and required food previously taken for granted was not always straightforward anymore. Stuart described not getting many hot meals and missing some meals, necessitating strategies to feel full.A lot of the time I do eat a lot of cereal to keep myself going rather than having meals. I will have cereal and a cup of tea and that, that’s what … […] You can get cereal really cheap and that so … […] I like the one from Aldi you can get that’s pretty cheap obviously, it’s the cheapest or what. I will eat anything, whatever I get given. But if I was going to buy I would just get the erm … it’s like the rice flakes with like bits of fruit in for 79p, Aldi’s own. […] Or try and get a cheap loaf and just try and get beans and toast and things. (Stuart)Poverty influenced food choices. Buying the cheapest food and seeking special offers were frequent money-saving strategies, in addition to receiving food from family or friends. Although the participants were grateful and showed appreciation, they also felt embarrassed. Food banks also played an important role. Stuart and Jacob described the nice atmosphere and great treatment, but pointed out that “Maybe the NHS, if we use the NHS, or the government, needs to be more proactive. Because when I had my stroke, I can’t be proactive. Maybe now I can be a little bit reactive, but then this is what I was saying, three and a half years ago I couldn’t even react. (James)Participants expressed both dissatisfaction and contentment with the health and care systems. While some received welfare advice and rehabilitation support, others did not get any of these services. Access to care services seemed to be associated with the individual’s capability to seek them. Participants’ mental health problems were barriers to strategically managing their chronic illness and seeking out care services. Whilst the National Health Service (NHS) was theoretically there to provide help, participants often had to request or seek support to receive it, rather than it being offered.Information about accessing care was lacking. Derek complained that he did not get any help when seeking information about care services. Terry was confused and disorientated when asking about cholesterol results. Another frequent complaint was delays for GP appointments, surgical procedures or other healthcare services. Several participants characterized the government and NHS as institutions that were not helping them manage their illness. Derek believed that there were not enough social policies, and James voiced disappointment and scepticism about health policies, highlighting that although prevention can save money and is more desirable than cure, it is chronically underfunded.It’s just the people who are running the country at the minute, they just don’t care. That is the whole problem with the country. […] The way I’m feeling it’s just like a class thing all the while like. That’s the whole problem with anything to do with this country from my opinion and my visions from where I come from in the North, it’s just a class divide, and everything is a class divide, down to sports, down to looking at people. People don’t live in the real world from the South and that, everything is taken for granted up there because they’ve got everything, jobs, everything all up there. All the money seems to go up there, but it’s not easy up North and that. (Stuart)Participants often asserted themselves, highlighting missing rights, and dissatisfaction about the way they felt within wider society. These reflections about wider socioeconomic contexts shaped and influenced their experiences of managing their chronic illness as individuals living in a developed country. The majority of participants lived within the most deprived areas of a city in North West England. Shops were scarce, and there were few green spaces or community centres. The North-South divide emerged from Stuart’s interview. He seemed to feel he was being treated as a second-class citizen or dismissed in comparison with people from the South. Some inequalities were identified.Our findings describe the everyday realities for people with CVD and other chronic illnesses living in economically deprived neighbourhoods and experiencing economic hardship. These experiences are discussed within their contexts of relative poverty and social disadvantage in a developed country, using biographical disruption as a theoretical framework Bury, , 1991.slow deterioration” indicates that the individual’s life was not disrupted by the onset of the chronic illness but rather the chronic illness was part of individual’s life story  in low-income populations  and socio-economic realities (macro-context) interactions. This study adds the concept of “non-visible disease” to indicate the psychological components of chronic illness which is a promising area for further model development.Our study has some limitations. Twelve out of 14 participants were recruited via the Stroke Association. Therefore, the findings may not be applicable to other deprived groups not represented in our sample, including people with other CVD and more severe impairments, and those who do not join similar healthcare associations. Gendered experiences of chronic illness management within individuals living in a deprived area were not explored due to the small number of females in this sample. Further research using biographical disruption theory should explore gender differences.This study evidences the need for reviewing some concepts of the biographical disruption theory. We found that co-morbidity and the psychological features of a long term condition shaped participants’ experiences of ill health. This study identified that the nature and extent of disruption varied among participants as well as their responses and pathways to overcome the chronic illness. Future research should develop “narrative analysis tools” to identify different narrative chronic illness patterns (Edwards & Gabbay, This study showed that the mental health of the chronically ill participants was compromised. Mental health problems shaped ability to seek help, and this suggests that people living in disadvantaged areas managing a chronic illness might be in a cycle where the change depends more on the actions taken by the NHS or policymakers than their own. Health care providers should actively engage in helping chronically ill individuals living in deprived areas. Further actions should support these individuals by helping and advising with finances, offering emotional assistance, providing regular medical checks, and informing, and advocating healthy choices. In addition, health policies stressing responsibility for lifestyle choices should be replaced with “upstream” interventions empowering communities and avoiding potential stigmatization, so the health gap may narrow across the UK.Biographical disruption theory linked with health inequalities evidence may be a powerful combination to explore how experiences of chronic illness are underpinned by economic, lifestyle, and environmental factors and how they impact on individuals’ health status. The varied nature of participants’ narratives about their chronic illness indicates that the experience of biographical disruption is context-specific (Faircloth et al.,