In the field of consciousness science, there is a tradition to categorize certain states such as slow-wave non-REM sleep and deep general anesthesia as “unconscious”. While this categorization seems reasonable at first glance, careful investigations have revealed that it is not so simple. Given that (1) behavioral signs of (un-)consciousness can be unreliable, (2) subjective reports of (un-)consciousness can be unreliable, and, (3) states presumed to be unconscious are not always devoid of reported experience, there are reasons to reexamine our traditional assumptions about “states of unconsciousness”. While these issues are not novel, and may be partly semantic, they have implications both for scientific progress and clinical practice. We suggest that focusing on approaches that provide a more pragmatic and nuanced characterization of different experimental conditions may promote clarity in the field going forward, and help us build stronger foundations for future studies. Studying consciousness, i.e., subjective experience, or “what it is like to be…” , is a sp studies . Essentiudies  implies complete unconsciousness. Other states such as deep sleep, dreaming, anesthesia, and different disorders of consciousness (DOC), are considered to exist on some continuum between these two extremes , have been studied extensively using a wide range of measurement techniques  certain brain states, particularly coma, deep slow-wave sleep, and deep general anesthesia, are genuinely unconscious, or that they have significantly reduced level/degree of consciousness e.g., . These e1)Behavioral signs of (un-)consciousness can be unreliable: It is of course well known that any behavioral assessment of the degree of (un-)consciousness based on responsiveness to sensory stimuli  or sleepwalking Subjective reports of (un-)consciousness can be unreliable: Subjective retrospective reports States presumed to be unconscious are not always devoid of experience: Careful studies have provided evidence that dreaming occurs surprisingly often in deep non-REM slow-wave sleep stages  and retrospective reports of some kinds of experience (sometimes even vivid and complex) can be obtained from certain conditions more often than our assumptions about the state of consciousness in these conditions would dictate. However, since retrospective reports following anesthesia or sleep can be unreliable due to recall failure and confabulation, it is uncertain to what extent such reports can be trusted. While we do not argue that consciousness never disappears or that there are no brain states that are most correctly described as unconscious , we do argue that the terminology used when describing various states has implications for clinical practice and basic research.8 Thus, assuming that deep slow-wave sleep, general anesthesia, and certain DOCs, are unconscious states, might lead theoretical development astray. Finally, if we consider as “fully unconscious” states that actually contain frequent dreaming or “other kinds” of experiences, we may miss opportunities to study such “other kinds” of conscious experience  has clinical consequences. For example, the question of whether a DOC patient is conscious or not has direct relevance for ongoing and future treatment, and is important for the patient’s caretakers and next of kin. Moving away from the term “unconscious” might then weaken the support for clinical tools developed to help diagnose DOC patients. Therefore, criticisms of current use of the concept and term “unconsciousness” should avoid hasty conclusions, else risking “throwing the baby out with the bathwater.”The primary purpose of this perspective is to suggest that, given the evidence of disconnected or covert experiences occurring surprisingly often in states commonly labeled as “unconscious” (and the multiple confounds in inferring the absence of consciousness), one should be more cautious in how one uses the concept and term “unconsciousness”, primarily, in basic consciousness research.However, if states like general anesthesia, slow-wave sleep, and certain DOCs, are no longer valid as contrastive paradigm cases of unconsciousness in consciousness science, it seems hard to identify mechanisms necessary and sufficient for consciousness. We believe that current approaches that focus more on “degree of similarity” to normal wakefulness, or on how confident we can be that there is some conscious experience (and perhaps of what), can avoid the issues discussed above. Here we outline three such approaches.1.Pragmatic approach: Rather than working from prior assumptions, we can classify states based on how they differ from normal wakefulness, or based on the confidence we have that they might support any form of consciousness. Most studies following a “state-based” approach  already do this when using wakefulness in healthy subjects as a reference (control) condition. Accordingly, several measures used in the clinic are more appropriately described as “positive markers,” that is, markers capturing the “degree of similarity” to wakefulness in healthy subjects  in more operational terms  large scale contrasting and comparison of the outcome of various neurological measures between different states (e.g., as in Finally, the specific characterizations of various states, as exemplified above, can then be updated accordingly in a more iterative fashion as new knowledge is acquired.3.Predictive approach: In order to support a more pragmatic and descriptive approach, one may focus on predicting what contents are experienced by subjects in specific situations based on their neural activity, i.e., developing and applying “mind-readers.” This approach may help build confidence in the validity of subjective reports of phenomenological experience in wakefulness. From there, one can gradually approach states and conditions in which we have reason to doubt subjective reports. Although the field is still in its infancy, there have been several advances in this regard, for example decoding dreams (per se (g dreams , movie wg dreams , speech g dreams , and othg dreams . This apg dreams . Howeverg dreams  in that  (per se . On the For more generalized forms of “mind-readers,” one might identify basic dimensions of conscious experience (e.g., as in In sum, we argue that there are strong reasons to take a step back and critically re-examine our “traditional” assumptions about different states of consciousness. Although such issues have been discussed for some time, there seems to remain a tendency to still use outdated assumptions and terminology, e.g., that general anesthesia and slow-wave sleep entail full or nearly full unconsciousness. We suggest that focusing on approaches that provide a more pragmatic and nuanced characterization of different states and conditions might be less controversial, promote clarity, and can help build a stronger foundation for future studies.The original contributions presented in this study are included in the article/ASN wrote the first draft and did most of the work on the manuscript. All authors contributed to the ideas and arguments, writing, and revision of the manuscript.


This study used a mixed methods approach to understand the ways in which religion and quality of life (QoL) are associated in later life in Ireland. Longitudinal quantitative data from 2112 Christian women aged 57 and over at baseline (2009–10) participating in the Irish Longitudinal Study on Ageing (TILDA), as well as qualitative data from semi-structured interviews from 11 Christian women aged 65 and over in 2018, were used. The quantitative data showed an association between lower religiosity and lower QoL. Qualitative data supported an effect of religious involvement on QoL although certain aspects of being religious in Ireland were accompanied by distress. The data suggested that the relationship between religious attendance and higher QoL could be driven by multifactorial pathways, including psychological, social, and practical benefits.The online version contains supplementary material available at 10.1007/s10943-022-01519-3. A majority of studies on the relationship between religion and well-being, positive emotions and happiness have reported positive associations, while a smaller number have presented mixed findings, often varying depending on the measure of religion or religiosity used , QoL is measured using the CASP-19 scale and, in recent waves, the shorter CASP-12 scale , as well as a pen and paper self-completion questionnaire (SCQ). Ethical approval for each wave of TILDA was granted by the Trinity College Dublin Faculty of Health Sciences Research Ethics Committee, and informed consent was obtained. Detailed descriptions of the TILDA methodology are given elsewhere  ; religious importance ; and religious comfort and strength . We chose to use the responses denoting the ‘most’ religious as our reference categories: those who attended religious services more than once a week, those who said religion was very important to them, and those who derived comfort and strength from religion.2 to assess whether CASP-12 score trajectories varied over time by religiosity. Fitted predicted scores were plotted for each model by religiosity to aid the interpretation of results. Model fit and collinearity were assessed.We analysed the first five waves of TILDA by fitting linear mixed effects models of the trajectories of CASP-12 over time. Random slopes were allowed for age, and models were adjusted for covariates. We used unstructured random effects covariance which allows for variances and covariances between all variables and does not assume a covariance structure  were contacted seeking permission to advertise to the congregation. Seven of these churches ran recruiting advertisements for the study, through notices in church newsletters or recruitment posters on church noticeboards. Nine participants were recruited from five churches. Two of these participants were friends and contacted the study together but were interviewed individually. A further two participants were recruited into the study by friends who were congregants of the targeted churches. The final sample of 11 women were aged between 67 and 89 and lived in Dublin, except for one respondent who travelled from another Irish city to participate. Details of participant age, marital status and religious affiliation are given in Supplemental Table A. All participants gave informed consent to participate in the study, and the study received ethical approval from the Trinity College Dublin School of Medicine Research Ethics Committee.Each participant completed an individual semi-structured interview with the same researcher. The interview schedule used is presented in Supplemental Table B. Interviews lasted between 50 min and two hours and were conducted in Trinity College Dublin, apart from one which was conducted in the participant’s home. The interview instrument was developed to explore the women’s experiences of health, ageing, and religion in Ireland, but was also flexible enough to allow for further themes to emerge. Predetermined themes included trajectories of religious engagement, religious practices, personal beliefs, community participation, family/networks, and health and well-being. All interviews were conducted, recorded, and subsequently transcribed by the same interviewer.Thematic analysis was used; this generally consists of five interconnected and nonlinear phases: compiling, disassembling, assembling, interpreting and concluding  mentioned ways in which religious practice or belief helped them or others cope with adverse life circumstances, which included physical health crises, death or illness of loved ones, and mental health difficulties.“I was 50 years of age and I went back [to the church] in earnest. I had a big operation. And I had problems breathing […] And then I started praying to God, and telling God that I’d be back for sure, and I’d never miss again. That’s when I was 50, that was 30 years ago. So, I really made up for it, then.”Margaret, 80Margaret’s experience of returning to her faith later in life was an example of turning to religious practice when confronted with difficult circumstances.“It’s peaceful and it flows over me. It’s like music. It flows over you and you absorb some but not others, you know? Suddenly mass would be over and I’d think oh my God I didn’t say a prayer all through that mass. But those things happen.”Geraldine, 81Three respondents also discussed spiritual and religious feelings and practice which led to inner peace, calm and tranquillity. These feelings were for the most part associated with religious attendance, although they were also related to attributing religious feeling to other events in their lives.“I would think that my religious beliefs have given me a better quality of life, than I would have if I didn’t believe. Because, as I said to you earlier, they have given me, my beliefs give me a purpose and a meaning.”Kathleen, 69Only one respondent explicitly mentioned religion as a source of meaning and purpose in her life. However, this was a strong theme for this respondent, and she mentioned it as both important for her own well-being, and that of others.n = 9) spoke about the role of religion in maintaining engagement and activity as part of the community, in particular for older people. Some, like Anne, acknowledged that religion was an important source of mental and spiritual well-being for others, but believed it impacted on her personally through more active and social mechanisms. This passage from Anne highlights that, even though some may not experience feelings of religious or spiritual well-being, there are other ways in which they gain from religion. Anne’s religion manifested through active participation in her community, instead of meditation, prayer, or other forms of individual religious practice.“Now, I’m useless at meditation, I know this, I have tried it a few times, not for me […] Again, my version of religion is to be helping people, doing things. Not sitting in a church on your own, pretending to have a conversation with God. […] I mean there are people who are very devout, and I don’t knock that, you know, and they get tremendous, erm, kind of, self-fulfilment from it…”Anne, 71Most of the women , religious practices became a point of contention with younger generations. Anne struggled with her daughter’s decision not to have her son receive his first communion, an important sacrament for Catholic children.“Catholics are definitely discriminated against in the media. […] Now, I think were actually being discriminated against, for being Catholics.”Teresa, 89The very normative nature of religiosity during the women’s early years made societal changes in religiosity more difficult. For some, there was a feeling of losing a majority place in society.“Ah, yes, you say a prayer at all, you’re a holy Joe. Ah yeah, yeah. No laugh, no fun at all, holy Joe.”Patricia, 82Teresa’s feelings of being discriminated against reflect the perceived shift from having a majority position in society to a less privileged one. Others expressed feelings of exclusion:“ was very angry with the Church about, you know, I have five children. My husband just said, God, he got told to increase and multiply, but he didn’t say by how many. He thought the ideal family would be two children. But anyhow, we ended up with [more]. Now I wouldn’t give any of them back, but, it just was, it made life very difficult. And you know, then it’s not fair to the children either.”Geraldine, 81.Although many would comment on the change in religious practice and belief in the country, and frame it as a negative, this did not appear to have a substantial impact on the well-being of the majority. However, the Church’s influence over women’s reproductive and family choices was felt by one respondent to have been an intrusion on her life.“And that, that… all those happy [memories]… I wouldn’t, even if my husband was alive and in very good health, I wouldn’t have told him. He wouldn’t know, you know, he wouldn’t know about it. But, being terrible disappointment and upset for me. […] So they’re the kind of things, it dents your faith you see, when you see things gone on.”Brigid, 74Finally, one respondent was affected by Church abuse scandals personally, and the effect on her self-esteem and happiness was profound. Brigid discussed finding out that a priest who she had been close with and greatly admired had been implicated in sexual abuse.Quantitative data from TILDA showed that women aged 57 and over in Ireland had good QoL on average and were likely to be regular Church attenders, as well as considering religion to be important and finding comfort and strength in religion. Mixed effects models showed that higher religious attendance, importance and comfort were associated with higher QoL scores, but that these effects were small and diminished substantially after adjustment for covariates. There were also no interactions between religious measures and age, suggesting any association between QoL and religiosity was already established at the baseline observation at age 57 and over.Qualitative data illustrated some of the ways in which religious practice, belief and belonging may impact well-being, and that this association was not always entirely positive. The women described religious practice, in particular, as being conducive to well-being. Meditative and calming effects were associated with church attendance and religious practice for many in the sample. For others, belonging to a religious community provided opportunities to develop and strengthen community ties, as well as access to community resources and activities. However, inter-generational conflict also emerged as a theme, where many of the women felt that their religious beliefs put them at odds with younger family members, as well as modern Ireland.The integration of quantitative findings, showing slightly higher QoL in the more religious, and qualitative findings, showing the ways in which religion can be supportive of well-being, strengthens the validity of both results. In particular, our findings suggest that religious attendance has the most consistent effect on QoL, and that the differences between high and low attenders observed in the quantitative analysis arise from religious practice as a source of inner peace and tranquillity, as well as the way habitual religious behaviour can be a source of opportunities, all of which are conducive to health. The fact that religious practice does not seem to influence the change in CASP-12 scores over time suggests that the level of well-being afforded by religious practice is already set earlier in the life course. If there is a protective effect of religious practice, it may be established and practiced from an early age.The qualitative data also add a new dimension to the quantitative results; we see that the change in the role of the Catholic church in Ireland in the women’s lifetimes has been difficult for many of them. The feeling that the religious context was changing around them was evident in many narratives, in particular when discussing relationships with younger family members, or the religious change in modern Ireland. There was also evidence of an internal conflict with the Church for some of the respondents; Church abuse had direct and indirect impacts on their feelings about the Catholic Church. For some, like Brigid, the impact was strong and direct. But for others, the influence of the Church on family-formation decisions was a point of resentment many years later.Evidence from other studies supports some of our findings. Previous research has shown that religious attendance is associated with lower depressive symptoms in older Irish adults Below is the link to the electronic supplementary material.


The opioid antagonist extended-release naltrexone (XR-NTX) in the treatment of opioid use disorder (OUD) is effective in terms of safety, abstinence from opioid use and retention in treatment. However, it is unclear how patients experience and adjust to losing the possibility of achieving an opioid effect. This qualitative study is the first to explore how people with opioid dependence experience XR-NTX treatment, focusing on the process of treatment over time.Using a purposive sampling strategy, semi-structured interviews were undertaken with 19 persons with opioid use disorder  participating in a clinical trial of XR-NTX in Norway. The interviewees had received at least three XR-NTX injections. Qualitative content analysis with an inductive approach was used.Participants described that XR-NTX treatment had many advantages. However they still faced multiple challenges, some of which they were not prepared for. Having to find a new foothold and adapt to no longer gaining an effect from opioids due to the antagonist medication was challenging. This was especially true for those struggling emotionally and transitioning into the harmful use of non-opioid substances. Additional support was considered crucial. Even so, the treatment led to an opportunity to participate in society and reclaim identity. Participants had strong goals for the future and described that XR-NTX enabled a more meaningful life. Expectations of a better life could however turn into broken hopes. Although participants were largely optimistic about the future, thinking about the end of treatment could cause apprehension.XR-NTX treatment offers freedom from opioids and can facilitate the recovery process for people with OUD. However, our findings also highlight several challenges associated with XR-NTX treatment, emphasizing the importance of monitoring emotional difficulties and increase of non-opioid substances during treatment. As opioid abstinence in itself does not necessarily equal recovery, our findings underscore the importance of seeing XR-NTX as part of a comprehensive, individualized treatment approach.Trial registration: Clinicaltrials.gov # NCT03647774, first Registered: Aug 28, 2018. The opioid antagonist extended-release naltrexone (XR-NTX) blocks the effects of opioids and is a promising, safe and effective , treatmeTraditionally, recovery from OUD has been understood as abstinence , but likall opioids, including opioid agonist medication, is the treatment goal …” .After these initial challenges, quitting opioids involved positive changes, e.g., in physical- and cognitive functioning or a general sense of improved mental health, including feeling stable and more in touch with one’s emotions. Yet, although most participants experienced improved psychological functioning, some described struggles to deal with mental challenges or underlying issues that reappeared. One participant explained that he had experienced traumatic events and reported having Adjusting to a new reality.Even though you start naltrexone you are not finished, the road continues.” .““Seventy to eighty percent [of the time] I have felt safe (…), that no matter how things are in the future, you can’t use heroin, you’re blocked, you just have to deal with it (…). At other times (…), I feel imprisoned, like what the hell am I supposed to do?!” The commencement of XR-NTX treatment did not indicate a problem-free life. Adjusting to an existence without opioids could be encouraging, but no longer having the safety of the OTP system could be challenging. On the one hand, “being blocked” could be wholly unproblematic and mean diminished craving; as opioids “would not work anyway,” participants felt they no longer had to use any energy thinking about them. On the other hand, XR-NTX could feel like a prison. For some participants, opioids—especially heroin—had been an escape from reality, and XR-NTX represented losing this.Some participants reported trying heroin, mainly to see if XR-NTX really blocked its action and experienced that it did. Several described hearing of ways to break the blockade, and although one participant described succeeding in this, most did not welcome this information as it could induce cravings.heroin addict”, not a “drug addict”, and the use of other (unfamiliar) drugs was a complete surprise.It hadn’t crossed my mind that I would do it. And maybe that was naïve of me. Because I know I like to escape from myself. Yeah, I thought maybe I would get drunk from time to time or something like that.”“Participants described generally using fewer non-opioid substances after inclusion in the NaltRec study. Some participants reported using no substances, and some described a limited non-opioid use that was typically less problematic than their previous opioid use had been. A few participants however, found being without opioids to be unmanageable; feeling desperate for the opioid effect, resulting in serious and harmful non-opioid use. As Gunhild explained, she had previously identified as a “However, suddenly again “struggling with myself”, Gunhild, who was well acquainted with fluctuating, long-term psychological difficulties, found it unbearable to manage without anything (i.e. opioids) dulling the emotional pain, thus lapsing into a serious and harmful use of non-opioids.If I didn’t have a job, and got naltrexone, then it wouldn’t matter, if I just sat at home and watched TV. Because half of what I did when I didn’t have a job, to make time go by, was to use drugs.” “Finding a way to manage an opioid-free life was significant. Participants voiced the need for something more than “just the injections”, such as support or some activity.Most think, “I’m sober now, [I must get a job].” Then you’re starting too high up on the ladder, right, and then you’re bound to fall.” “Still, not expecting too much too fast was emphasized; just getting used to being sober could be enough.Although some clearly wanted to manage on their own, participants generally saw the value of some kind of support from external services, which many already had. The first months, in particular, were underlined as a period where extra support was needed.I needed [help], to understand how I was supposed to cope without looking for somethingthat could dull everything. (…) There should be more follow-up, especially in the first two months. I really think so, because I felt so very alone.” “The discontinuation of opioids could also highlight the need for additional help, and the handling of underlying mental issues was emphasized as important, as these could stand in the way of fully utilizing the potential of the XR-NTX-treatment and of further recovery. In addition to various services, some also voiced a wish for peer support groups with other patients receiving XR-NTX. Several participants found the monthly visits of the NaltRec study useful as an opportunity to reflect on the previous month.Mum doesn’t know I use amphetamine now (…). It’s hell not being able to tell mum I’m struggling.” “The feeling of support from friends and family—having someone to reach out to if things got difficult—was important. However, having made the decision to quit opioids also involved expectations of continuing to “do good,” which was described as a possible barrier to actually utilizing the potential support system.Participants generally did not want to involve family in the treatment, not wanting to overtax relatives or feeling that it was nobody’s business but their own. However, for some, support from family had “always” been in place, and choosing to start naltrexone was thus a way of “giving back;” showing that a step forward had been taken.I wanted to] establish a group for those of us using naltrexone, (…) so we can meet and have a coffee and discuss things. NA [narcotics anonymous] says something about it; share strength, hope and experience. Because if you don’t, you are horribly alone with your problems.” “ takes a piece of your soul, a piece of your identity.” .An important aspect of XR-NTX treatment was that it offered the opportunity to be “normal”; leaving stigma behind, participating in society, and reclaiming the self.What has surprised me most after starting up is that I have found myself again, got to know myself, but at the same time it’s been quite an insecure process.” “Quitting opioids allowed for the rediscovery of oneself, which could be both liberating and unpredictable.Who am I today?” Some expressed feelings of having changed, in preferences or interests, or lost parts of themselves they previously valued. Still, most felt they were moving towards who they wanted to be. No longer being dependent of opioids, and belonging to “the normal group” contributed to a sense of dignity as it also meant escaping the stigma of being an “OTP patient” or “drug addict”, a distrusted outsider. Feeling useful and being able to take responsibility meant growing as a person. The accomplishment of quitting opioids or the OTP further contributed to a sense of pride and increased self-esteem.The need for opioids had previously overshadowed everything, and as Jon explained, having used opioids for a long time could mean uncertainty about one’s present identity: “I’ve always had my family. Before, I was just there, now I am with them.” .Belonging and being able to participate in society was considered important. However, functioning in the world with little or no experience of operating in a “normal society” was also challenging. Still, several participants described suddenly feeling like part of something when they had a job, had more time and energy to participate, or experienced strengthened relationships; “Before I couldn’t… Or, I probably could have if I planned it, but then it had to be part of that plan.” “An increase in social needs could be challenging, as it could involve going out more, and disregarding the previous structure in their life. Nevertheless it could also be beneficial, signifying freedom from an almost compulsive routine and the freedom to participate in social events, and society.It has changed my life; it’s a whole new world.” .“Although the exact reasons for starting treatment and future goals varied, hope for a better life was shared. Dissatisfaction with the regulations of the OTP or the medication itself was common and combined with the desire for an opioid-free life was a strong motivator for attempting XR-NTX.Many participants described having felt there was little hope, and not feeling free as long as they were using opioids. Being on XR-NTX offered a new perspective; it allowed for a future for the first time in a while. XR-NTX could also be the endpoint in a long process, providing the means to finalize the hope and ambition of a “normal life.”“Yes, there is meaning to life. There are many things I want to do now, that I had stopped more or less, like fishing, being outdoors, and getting in shape. Everything feels more meaningful.” The positive changes taking place during treatment seemed to fuel hope and contribute to optimism about the future. Although various difficulties could make hope waiver, it was not lost, and the decision to continue treatment seemed strong. Many participants felt they led a more meaningful life.Maybe I should just give up and accept that I’m an addict, and that’s what I’ll be for the rest of my life.” “However, maintaining hope could prove difficult if things did not turn out as imagined. Having previously seen XR-NTX as a miracle, expectations turned into broken hopes when reality turned out differently.It remains to be seen when I’m actually done, after the 13 injections. That’s another task to overcome, right?” “The time limitation of XR-NTX treatment felt frightening for some, as the trial was limited to one year, and there was no possibility of continuing treatment after the end of the trial. Although achievements had been made, for some, thinking about “being back on my own” created uncertainty about the risk of relapsing to opioids and further destroying what had been achieved. Others felt that the distance from opioids, attained during treatment, was vital. Although they initially had feared relapse and the end of the treatment, having dealt with life without opioids for nearly a year, they felt these were no longer of concern. Yet, even though much had been accomplished, there was sometimes still a sense of uncertainty about the future, with participants not being sure if the progress would continue once nothing was “holding them back”.What will happen if I’m still caught up in drugs and relapse to heroin? What will happen to me then? Is it back to the OTP, and Subutex, and all that? I don’t want that. (...) If that happens, I might as well shoot myself, because I don’t want to go back.” “There were also some worries about not being able to achieve abstinence from all substances during treatment, which gave rise to distressing thoughts:For patients struggling with a harmful use of substances, the question of whether a return to heroin would be less harmful than the use of various other substances was raised. However, beyond this, participants in the present study did not voice any doubt as to whether or not to continue XR-NTX during the trial.To our knowledge, this is the first study exploring in-depth the experiences of people with opioid dependence successfully inducted and choosing to stay in treatment with XR-NTX over time. This qualitative study offers five major findings. First, the induction to treatment held considerable challenges for patients. This was mainly related to the difficulty of handling the emerging emotions when discontinuing opioids. Second, XR-NTX was experienced as an effective treatment, signifying freedom from both illegal opioids and from the “OPT system”, and involving substantial benefits for patients, such as improved health, or the opportunity to participate in society. Third, for a few patients, extensive use of non-opioid illegal substances could indicate considerable challenges dealing with opioid blockade and be a substantial barrier to continued XR-NTX treatment and further recovery. Fourth, mental health problems could also be a considerable barrier to the treatment process, patients not being able to use opioids for symptom relief. Fifth, our results underscore the need for individualized and tailored support and follow-up during XR-NTX treatment.Our findings are in line with qualitative studies showing that patients consider XR-NTX a relapse-preventing option reducing cravings , 49, as external barriers to treatment retention and heroin abstinence were mentioned by participants, such as economic insecurity or social factors. This is contrary to previous findings [Interestingly, few, if any, findings , and mayfindings . Thus thIn line with a biopsychosocial model of addiction , our finOne size does however not fit all, illustrated by the variability in participants’ experiences and diverse needs for support during treatment. While some participants were undeniably in need of increased enforcement, others clearly desired the autonomy XR-NTX offered, preferring no service involvement. Regardless, the induction and early weeks of treatment will probably be a period where enforced support will be beneficial for most patients. It is also important to note that for some patients, measures beyond basic support will initially be excessive, as merely adjusting to an opioid-free everyday life poses sufficient challenges to overcome.For many participants clearing up and experiencing the outside world and inside emotional states more intensely felt liberating, yet this freedom could also come at a cost, in the form of increased emotional vulnerability and an increased need for additional support. The various areas requiring strengthened efforts ranged widely, which needs to be taken into consideration when planning XR-NTX treatment course. While some participants expressed a need for health services, such as mental health treatment or addiction and motivational counselling, others just wanted to have something to do, a job, someone to chat with, or to give or receive support from peers with experience of XR-NTX treatment. Interestingly, patients were hesitant to involve family or friends in the treatment, and although their support was valued, the importance of reinforcement from health- or social services was emphasized. Not surprisingly, our results emphasize that additional measures are more important than ever. Although XR-NTX addresses the physiological basis of addiction, the sole blocking of opioids is insufficient alone.Consistent with other studies of XR-NTX, participants overall reported a reduced use of illicit opioids , 4, 40. Our participants also described an overall reduction in non-opioid substance use, however, a few reported an increase. Many patients with OUD have polysubstance-use disorders , 64. TheSome patients, when unable to handle life without opioids and desperate for an escape, may turn to “anything” (i.e. other substances) if there is no prospect of an opioid effect. For our participants, an extensive use of non-opioid substances carried the likelihood of harmful effects on health and functioning and could raise the question whether continued XR-NTX treatment would be sustainable over time if unable to get this use under control. Even though XR-NTX meant avoiding the detrimental effects of opioid dependence, the effects of increased non-opioid use carried disadvantages which could be as great as, or even greater than when previously using opioids. In addition, further recovery and the building of a new life seemed difficult with such a use. Interestingly, participants still preferred to continue XR-NTX treatment, which likely points to the strength of the hopes tied to XR-NTX treatment.A pronounced desperation for an escape and the turning to other substances will likely be a warning sign that for the patient opioid antagonism is very challenging to handle, and that additional measures are needed to continue to benefit from continued treatment. Non-opioid use is an important outcome measure of XR-NTX treatment, and clinicians should remember that XR-NTX treatment does not automatically mean overall abstinence. An extensive use of non-opioids will in many cases complicate further recovery and raises the question of how to achieve “freedom from opioids” without the cost of introducing or increasing use of harmful substitute drugs.For many, the struggle of “not being able to escape into opioids,” an unnerving prospect initially, was not an issue after having passed the early phases of treatment. This might in part be a form of defense mechanism, making it psychologically easier to write off and accept not using opioids when there is no conceivable possibility of intoxication by opioids, which in turn in itself might diminish craving. In addition, the majority of our participants, having previously been in OTPs had probably not used the opioid agonist medication as a means of escape. Thus XR-NTX, instead of feeling like an obstacle to escape, felt mainly as a safety net, guarding against relapse. Others, however, struggled visibly. This may to some extent be understood from a developmental-learning perspective, which also underlines the importance of support when learning and implementing new habits . “QuittiBased on our findings, mental health difficulties are of importance for how well opioid blockade is handled, coinciding with findings that addressing mental problems in patients with OUD likely enhances the odds of a stable recovery . ComorbiHow being blocked was experienced did however not seem to be wholly explained by factors like the amount of support offered or received, or the individual’s mental health, and was not constant, but could vary within the same person, from “ok” to “like a prison.” Likely, differences in social or psychological factors, like personality traits or coping skills are at play, as well as varying life conditions or circumstances. This again highlights the complexity of opioid dependence and the challenges people with OUD face, underscoring the need for diverse approaches and varied professional expertise to help meet these challenges. Still, a more systematic exploration of both external and internal factors associated with how being blocked is experienced and tolerated, and the connection with e.g. treatment outcome and success is needed to conclude further.XR-NTX-treatment is not intended to be lifelong and there is no recommended standard treatment-length . The limFor many, opioid abstinence sustained by XR-NTX enabled a new, more meaningful life. This might be particularly important as SUDs impair many aspects of a person’s life, and might especially restrict the ability to experience meaning in life. Finding meaning is important to recovery in general , and hasAs XR-NTX offers a unique opportunity to avoid the effects of opioids over time, we suggest that it is what is achieved during treatment in terms of rehabilitation and recovery, rather than treatment duration or opioid abstinence in itself that is significant. Specifically, it seemed that the positive changes taking place during treatment were of more importance for participants than the abstinence from opioids per se, even though abstinence enabled these advances. This is in line with findings  showing This study’s explorative design offers important in-depth insights into XR-NTX as a treatment option for OUD. Participants were recruited from an open-label naturalistic treatment study, ensuring real-world relevance. Although this qualitative study included a limited sample, the material was rich in content, and presents detailed variations in experience. Both participants highly satisfied, as well as those disappointed with XR-NTX treatment participated, and gave voice to the nuances of the experience of treatment. Although our sample has a gender imbalance, this imbalance is in line with that of the overall study and that of treatment seeking persons with OUD in Europe, and we did not seek to address or explore gender differences explicitly.Participants were interviewed at different times during the 12-month treatment period, which might influence what was emphasized or recalled. However, the themes presented were independent of the point in time at which the participants were interviewed. Still, the present study does not examine whether participants chose to stay in treatment beyond the time of the interview. Thus we do not know if some of the challenges mentioned were overcome, or if they better represent the narratives of patients choosing to discontinue treatment . In addiParticipants might have been particularly motivated for the new treatment approach that XR-NTX represents in Norway, or have had a particular dissatisfaction with agonist treatment. Caution should be taken regarding the generalizability of our findings; nevertheless, they are transferable to similar settings, as a detailed description of the study’s context has been given, and patients freely choosing XR-NTX will likely share the same motivation. A detailed description of the research process has been given, ensuring transparency. It is also worth emphasizing that retaining patients in XR-NTX treatment over time can involve considerable challenges . The patXR-NTX treatment, although potentially life-changing, can also involve serious challenges for patients. This means individuals receiving XR-NTX treatment will need additional services and support, especially in the beginning of treatment, but also when it comes to difficulties handling emerging thoughts, feelings and experiences when blocked from the effects of opioids. A strengthening of health- and social services, and emotional support whether from such services or from the patient’s network seems essential. Further, the monitoring of and assistance with arising emotional difficulties, as well as the possible subsequent harmful use of non-opioids is vital to help patients cope, and stay in treatment over time. Nevertheless, patients need for help will vary between people, at different times and with varying circumstances, which highlights the importance of seeing XR-NTX as part of a comprehensive, individualized treatment approach.


Recent research has consistently related the production and consumption of meat with environmental degradation, health problems, and damage to animal welfare. However, meat consumption represents a well-established eating behavior among many consumers. After all, meat is a central food in many cultures, and changing eating habits can be very challenging. Nevertheless, there is a group of consumers who have reduced the consumption of meat in their diet. Understanding the facilitators and barriers that influence these behavioral changes in different cultures and contexts can help to promote future collective reductions in meat consumption. This article investigates the main facilitators of and barriers to the reduction of consumption in the largest meat-consuming market in the world to contribute to the advancement of knowledge on meat-reduced diets. In order to achieve this objective, semi-structured interviews were conducted with consumers who reduced their meat consumption. In this context, a content analysis was conducted to identify 22 facilitators and 15 barriers classified according to the COM-B system. This system conceptualizes Behavior, which can be influenced by Capability, Opportunity, and Motivation. The results of this research corroborate previous discoveries or confirm the presence of a set of facilitators of and barriers to the reduction of meat consumption previously suggested in the literature. Consumer behavior concerning the consumption of food products has attracted the attention of the academic community and companies , especiaRegarding the eating behavior of meat consumption, recent research has pointed out some problems associated with environmental degradation , health Promoting the global reduction of meat consumption will undoubtedly be challenging, as it is necessary and urgent . On the Research related to the frequency of meat consumption and determinants of meat intake ,10,12 isDespite the importance of the theme, research on changing the behavior of consumers who reduce meat consumption or adhere to flexitarianism  is limitThe change in consumer behavior identified in the literature shows that the cultural domain of meat consumption may be less evident . Review This is a qualitative and in-depth study using semi-structured interviews. In this respect, it is also relevant to show that the current research is part of a (recent) line of qualitative studies in meat reduction and meat substitutes  capabilities can be physical or psychological and are related to the knowledge and skills needed to engage in a specific behavior. An (ii) opportunity, in turn, is represented by social or environmental factors that are outside the individual and drive behavior. Finally, (iii) motivation represents the mental processes (reflective or automatic) that drive behaviors .The COM-B Model was selected to identify the facilitators and barriers that could be presented according to the dimensions in light of this theory. This model has been used and validated by several studies in the literature, such as that of Graça et al. . The litThis study was performed using a questionnaire and semi-structured interviews. The semi-structured interviews were conducted according to a script based on previous literature and the main barriers and facilitators for reducing meat consumption, presented in The study sample consisted of 18 people who were reducing their meat consumption. This target audience is still small in Brazil. Although previous studies have investigated the intention to reduce meat consumption , this doSnowball sampling was employed in this work, using the researchers’ contact network, disseminating on social media, and sending invitations to universities in Brazil. Regarding ethical issues, all the participants received information about the research through an informed consent form and voluntarily agreed to participate. The interviews took place virtually through web conferencing tools and were recorded, transcribed, and exported to ATLAS. ti web content analysis software.The collected content was subjected to content analysis in six steps to identify patterns , as detaEighteen in-depth interviews were conducted between 4 July and 4 September 2021. As suggested by the ethics council, each participant received a fictitious name to preserve their identity. The duration of the interviews varied, with the average interview lasting between 21 and 46 min. In the descriptive statistics analysis, it was observed that 14 participants identified themselves as women, and 4 identified themselves as men. Their ages ranged from 19 to 53 years. As for their places of residence in Brazil, 9 participants lived in the South region, 3 in the Southeast region, 3 in the North region, 2 in the Northeast region, and 1 in the Midwest region. Regarding education, 12 participants had completed higher education, and 6 had incomplete higher education. At the time of the interviews, the participants’ meat consumption varied from occasional consumption  to daily consumption (with reduced portions of meat compared to previous consumption levels). The conscious reduction in meat consumption duration ranged from 3 months to 12 years. An overview of all the facilitators and barriers identified in the study can be found in Twenty-two facilitators for reducing meat consumption were identified, of which eight had not been described in the previous literature, which is an essential contribution of this study: (i) health problems or dietary restrictions (C.F.); (ii) acquisition of new knowledge, skills, and information (C.R.); (iii) cooking or buying their own food (O.F.); (iv) access to restaurants and fairs (O.F.); (v) access to a nutritionist (O.F.); (vi) feeling of flexibility in the diet (M.R.); (vii) dislike of cooking meat (M.A.), and (viii) habit of eating little meat (M.A.). Additionally, four barriers identified in this study were also not previously described in the literature: (i) health problems or dietary restrictions (C.F.); (ii) price of substitutes (O.F.); (iii) meat availability (O.F.); and (iv) social interaction (O.S.)The facilitators and barriers for reducing meat consumption in Brazil identified in the study were classified as (i) physical capability, (ii) psychological capability, (iii) physical opportunity, (iv) social opportunity, (v) reflexive motivation, and (vi) automatic motivation.I also became interested in this diet that vegans follow and what they do because there is no lactose in it, and so for me that was a sure thing, I was sure that I wouldn’t be consuming lactose”.Content analysis showed that some health issues or dietary restrictions potentially drove respondents to reduce their meat consumption. However, it is important to emphasize that the health problem or dietary restriction was not always directly related to meat consumption. Nevertheless, they motivated the participants to review their eating behavior, helping to reduce meat consumption. Participant Mateus, 30, for example, told how his lactose intolerance led him to become interested in vegan meals: “allergic to some kinds of meat, like pork and shrimp”.Other participants reported problems that directly impacted their meat consumption. This is the case of Leonardo, 21 years old, for example, who is “The acquisition of new knowledge and skills, as well as information, mainly nutritional and culinary, seems to be critical for consumers to be able to make a transition to diets with lower meat consumption. Consumers usually acquire these skills through information published on the internet, through information provided by nutritionists, or in courses. In particular, the ability to learn new meatless recipes appears to spur changes in consumer eating behavior. Amanda, 34, for example, explained this as follows:“I think what worked for me and helped me, and might help other people, is getting familiar with recipes. Who knows, on social media, social media profiles, YouTube channels that promote vegan and vegetarian recipes. Because there you can find recipes and you can make cool food that doesn’t have any meat in it, and I think that is what helped me most”.Obtaining nutritional knowledge, in turn, also plays an important role in reducing meat consumption, as it helps the consumer to feel safe when making food exchanges. Ricardo, 27, for example, said:“I went to a nutritionist, questioned him and asked things […] he then helped me a lot to understand how to put a menu together, replacing a certain spice and why it’s important to do that, and other kinds of food that have proteins similar to meat”.Content analysis has shown that the high cost of meat can also drive a change in eating behavior. Participant Jessica, 23 years old, for example, reported that“meat these days is really, really expensive! So, whether you like it or not, a diet based on plants, on grains, ends up being a little bit… cheaper”.now that I’m in charge of the stove, the fridge and all that, I’m finding it easier [to reduce my meat intake], right?”.The act of cooking or buying one’s own food also proved to be an important facilitator for reductions in meat consumption. The participants seem to have greater freedom of choice to make changes in their eating behavior when they are responsible for preparing or purchasing their food. Patricia, 52, for example, commented that “Access to restaurants and fruit and vegetable markets was also frequently cited by the respondents as a facilitator to reduce meat consumption. In the case of restaurants, it seems important for consumers to have access to places that offer meat-free meals that are tasty, nutritious and affordable. Carolina, 19, for example, commented:“One really cool thing that I saw at my university is that, for instance, the canteen, the university restaurant there, has a vegetarian option that varies a lot every day of the week and is regulated by a nutritionist… So, having that option available at universities, in schools, makes it easier”.Fruit and vegetable markets, in turn, are a place to buy a wider range of vegetables, helping to replace meat with other food components. Matthew, 30, for example, stated:“You know, I think the fruit and veg market helped me a lot. Doing the shopping there. I mean, I said to myself ‘today, I want to get this at the market… I want to get something that I don’t usually eat’, and then I’d get it”.“gave her a vegan protein” to help her meet “the need for protein”.Access to nutritionists is another potential facilitator for those who wish to reduce or who are already reducing their meat consumption. These professionals can help consumers to choose appropriate food substitutes and feel safe about their health. Helen, 37, for example, said her nutritionist The respondents stated that the influence or support of people close to them represents an important facilitator for reducing meat consumption. Having contact with friends or family who are already vegans or vegetarians or being able to count on the support of others in their eating behavior change seems to create a favorable and welcoming social environment for meat-reducing consumers. Leonardo, 21, for example, said:“I think that influence has something to do with it… I have friends who also do this with their food or meals, I mean, with less meat, and I think that this ended up making me a bit more of a vegetarian and vegan, so that helps as well”.The endorsement of opinion leaders also represents a potential enabler for reduced meat consumption, with athletes, online influencers, and celebrities inspiring consumers to continue the food transition process. Eliza, 29, for example, stated that,“I go rock climbing and the person that I think was the best climber at the time is a vegetarian. So, I started to look for high performance people who are vegetarians”.Some interviewees commented on the perception of better health performance after adhering to diets with less meat consumption. They reported improved digestion, greater physical disposition, better sleep quality, and weight loss, among other perceived benefits. Eliza, 29, for example, commented:“I feel like doing more exercise, I feel better eating less meat, and I feel healthier in general. So, it’s good for… for everything, for your self-esteem, for… I feel less tired and I digest food more quickly”.the way that animals are treated as well, right? It’s really cruel at the slaughterhouse, you know? It’s a life that goes at the slaughterhouse”. However, it is worth noting that although consumers show concern for animals, this motivation alone may not be strong enough to generate a lasting behavior change. Isabela, 26, for example, stated that although she went some time without eating meat after watching a documentary, today, she is “aware of how animals are treated”, but “even so”, she eats meat.Some participants also spoke about their animal welfare concerns regarding meat consumption. Roberta, 29, for example, talked about “In addition to the concern for animal welfare, the participants also claimed that the change in eating behavior is related to concern for their own health. A comment made by Gustavo, 43, exemplified this issue:“I began to rethink my diet a lot, not only regarding meat but also things that I eat that don’t have any meat in them. Mainly cutting out, reducing, eliminating ready-made processed food, things that have a lot of processed spices and a lot of preservatives in them, a lot of artificial flavoring. So, I cut down on these things a lot and as a result I also cut down on my meat consumption”.of cattle involving… widespread deforestation to make way for pasture and also of the gases produced by cattle that affect the environment”. Notably, reflexive motivation stemming from an environmental concern does not often seem to be the main reason why consumers reduce meat. Concern about meat-related environmental issues may even only arise after the reduction begins. Elaine, 22, for example, said she initially cut down on meat because she did not like the texture and only later began to “develop a greater interest in sustainability issues”. Thus, despite environmental awareness being a potential facilitator for reducing meat consumption, in some cases, concern about environmental issues may only arise after the change in behavior has begun and depends on the information made available to the consumer.In line with the previous literature, concern for the environment as a motivator for reducing meat consumption was identified among the interviewees. Roberta, 29, for example, spoke: “Informed consumers may have a greater incentive to change their eating behavior. The sources of this information can be diverse, such as formal courses, documentaries, social media, and health professionals. Participant Suelen, 21, for example, exemplified the role of studies and documentaries in providing information by stating that“I learned quite a few things through courses, documentaries, and classes at university that made me see that I wanted to reduce [meat] consumption in my diet”.I’ve reached the point where I can still satisfy my taste buds and hunger for food that tastes good, but also look after my health with the effects, you know, the results, that I have seen, right?”. Some participants also believed that a reduction was easier than the total elimination of meat from their diet. Amanda, 34, commented that “cutting down wasn’t so hard”, but she believes that “it would have been hard to cut out meat completely”.On the other hand, even for an informed consumer, completely abandoning a meat-based diet is an arduous task. The results showed that consumers who choose to reduce meat consumption experience a sense of flexibility. That is, by not identifying as vegetarians or vegans, they are free to consume meat if and when they wish. Gustavo, age 43, for example, stated: “I would say that eating less meat seemed a little more practical, especially in this remote format [owing to the COVID-19 pandemic] when I have to cook more and end up eating more because I’m staying at home. So, sometimes it’s more practical to replace meat with some broccoli, a boiled egg, perhaps some salad or grains in general”. There is a positive relationship between the feeling of doing the right thing and changing eating behavior , but I don’t buy them because they’re much more expensive”. In addition, meatless meals or products for preparing meatless meals are available in few commercial establishments and with little variety. Suelen, 21, for example, commented that, “replacing food is also very hard because you go to the market and they don’t have anything […]. You can’t even find TSP [textured soy protein] at the market, which is pretty basic stuff, right? It’s not easy”. In this context, the convenience related to the greater availability of meat-based meals represents an important barrier for consumers seeking to change their eating behavior. Marisa, 53, exemplifies how this occurs. “You end up eating it because it’s right in front of you, right? You’re hungry and you eat it”.Regarding physical opportunities, the respondents commented that the high prices of plant-based meats and other vegan and vegetarian options discourage the purchase of these products. Amanda, 34, for example, commented, “Meat-based food is part of the food routine of many Brazilians. From this perspective, social interaction is a barrier for consumers who live with people who consume meat regularly. Helen, 37, provided an example of the meat-free challenge of living with her son:“There are only the two of us at home. Am I going to make food and force him to do without meat when he wants to eat it? I end up eating it with him”. Another barrier identified in the interviews is related to the culture and tradition of meat consumption. After all, it is a central component of the meals of many Brazilians, and the social norm determines the consumption of meat as a standard. Leonardo, 21, for example, said that “It’s already kind of established in society that we need to eat meat and eat it in large quantities since childhood”. He thinks that “this could be a latent difficulty”. Other consumers also commented on the barbecue culture: “you see it in commercials, you see it in Brazilian culture, people having barbecues and all that”.Because of the culture and tradition of consuming meat-based meals, some participants also felt that changing their eating behavior could harm them socially. Matthew, 30, offered an example when recounting his experience with social events:“Sometimes there was an event at the company when I was still working and I had to go, I had to go because everyone went and there was only meat, there was nothing that a vegetarian could eat […]. And when you didn’t eat anything, you still felt bad, because people sometimes either made a joke or didn’t say anything, but they thought you were… you know? It’s a bit of a bad feeling like that, on both sides. People are not prepared to deal with it and so are you sometimes… you don’t want to go through this, so sometimes you prefer to avoid this situation […]. I don’t go to that kind of event anymore. Especially if it’s a barbecue, for example”.The social harm faced by people who seek to reduce their meat consumption is also due to the reluctance of those close to them. In this respect, consumers may have to deal with opposition, especially from family members, to their behavior change. Eliza, 29, for example, made the following statement about her mother:“She thinks it’s ridiculous to eat less meat or cut out meat altogether. So, this year, the meat I’ve consumed wasn’t bought by me. I haven’t bought any meat this year. It was all meat that my mother bought”.sometimes, meat is much more practical. You buy a packet of chicken wings and make it. So, it’s kind of difficult, this issue of researching what to eat and sometimes I don’t have time to make food as well”. Furthermore, Ricardo, age 27, also said that it could be difficult “to find food and learn how to buy it. This was an important point: learning to buy!”. It can be seen that a change to a non-standard diet requires additional effort on the part of consumers, who may be discouraged from changing their eating behavior.A barrier related to reflexive motivation cited by the interviewees was the perception of a lack of convenience in obtaining substitute foods or preparing meatless meals. Suelen, 21, commented that “only, my mother always says, ‘your health, you have to look after your health, with vitamins and all that, protein’, you know”.Additionally, there is a health concern with regard to consuming a low-meat diet. As meat is the main source of protein in a western diet , consumeMeat is really good, isn’t it? So, it’s hard to control the urge to eat it because I really like eating meat. It’s tasty”. Some consumers have also been shown to have developed an attachment to or dependence on meat consumption. Mateus, age 30, offers an example of this:Some of the interviewees stated that they enjoyed the taste of meat and that they felt the desire to eat it, demonstrating that they had hedonic feelings towards meat. Isabela, 26, for example, said: ““Baloney was something we ate a lot of when we were kids, because it was cheap. So, I eat this stuff from time to time, but I eat it with a guilty conscience, knowing that I’m eating something that’s not good for me, you know? But for the taste itself, just to satisfy that urge. Maybe I’ll be on my deathbed and I’ll be like, ‘Oh, I want to eat a sandwich’ just because I miss that sandwich, you know?”.since childhood we have been used to eating a lot of meat, so to stop eating it as adults is hard”. Laura, 26, also believes that a barrier to be overcome is “this habit of eating meat since we were children”.Likewise, the frequent habit of eating meat represents a barrier in the interviewees’ food transition journey. Leonardo, 21, said that “anyone who didn’t want to stop [eating meat] kind of closed themselves off from things other than meat”. The participants were convinced that meatless meals can be very tasty and assumed that other people would also notice this if they were willing to try it.In addition to consuming meat-based diets, the respondents claimed that a lack of interest in trying meals without meat represents a barrier to changing eating behavior. Typically, the respondents did not attribute this barrier to themselves but noted that other people in their environment are resistant to non-meat meals. Taís, 26, for example, stated that “The results revealed that multiple facilitators and barriers of capability, opportunity, and motivation influence the eating behavior of Brazilian consumers about reducing meat consumption. There are similarities and dissimilarities between what has been described in previous studies in the literature. Achieving future reductions in meat consumption will be challenging for all parties involved, both consumers and external agents. However, even though there are challenges, the integrated understanding of facilitators and barriers, as proposed in this study, offers insights that can assist in developing promising strategies for collective meat reductions in Brazil or other regions.The influence that the food context exerts on consumer choices can be seen. Therefore, providing infrastructure to support plant-based diets may be a promising option for encouraging a reduction in meat consumption . AnotherThe participants in the survey sample were satisfied with the improvements they noticed in their health when adopting reduced-meat diets. The reports of these consumers who are realizing in practice the benefits of the changes they have made to their diets could be used to promote diets with less meat. In this context, the reducers’ experience in the face of an internal conflict can act as an invitation for other consumers to try reducing meat consumption to obtain the same benefits.Previous studies have suggested that people may face internal conflicts regarding meat consumption since it is possible to feel love for meat and love for animals at the same time . On the Furthermore, science plays a particular role in information, as consumers may demand scientific evidence before considering a reduction in meat consumption to benefit the environment . TherefoIn Brazil, for example, there is “Segunda Sem Carne” (Meatless Monday), a social campaign that approaches the reduction of meat in a “light” way, inviting consumers to abstain from meat one day a week . More caA possible alternative to lower this barrier is the promotion of tasty meatless recipes. The objective of this strategy is to create a counterpoint related to hedonism. People fond of meaty meals will hardly stop liking meat, but that does not prevent them from developing hedonic feelings for meatless meals. This can lead, albeit moderately, to substituting meaty meals with meatless meals that are also appetizing. Another suitable strategy is to expand the offer of alternative protein options in commercial establishments. This could help to familiarize consumers with tasty alternatives prepared by chefs who know how to enhance the flavor of these foods .It has been noticed that an attachment to meat can represent a difficult barrier to overcome due to the connection created between the consumer and meat. A previous study suggested that people who have formed a connection with meat are less willing to reduce meat consumption and follow a more plant-based diet ,44,45. HThis study aimed to identify facilitators and barriers to reducing meat consumption in Brazil. Data collected through questionnaires and semi-structured interviews were subjected to content analysis to achieve this objective. As a result, 22 facilitators and 15 barriers of capability, opportunity, and motivation were identified that potentially influenced the reduction of meat consumption.In general, it can be said that all the factors discussed in this study work together to change eating behavior and maintain this practice. For example, when the interviewees were asked about the reason for the reduction in their meat consumption, they all responded with a set of factors, demonstrating that lower meat consumption occurs after the consumer accumulates several facilitators and overcomes several barriers in terms of capabilities, opportunities and motivations that make it possible to change eating behavior.As a theoretical contribution, this work reinforced previous research findings by confirming the presence of facilitators and barriers to reducing meat consumption previously suggested in the literature. This research also proposed and discussed eight new potential facilitators not been described in the previous literature, which is an essential contribution of this study: (i) health problems or dietary restrictions; (ii) acquisition of new knowledge, skills, and information; (iii) cooking or buying their own food; (iv) access to restaurants and fairs; (v) access to a nutritionist; (vi) feeling of flexibility in the diet; (vii) dislike of cooking meat, and (viii) habit of eating little meat. Additionally, four barriers identified in this study were also not previously described in the literature: (i) health problems or dietary restrictions; (ii) price of substitutes; (iii) meat availability, and (iv) social interaction. Hopefully, this set of proposed new facilitators and barriers of capability, opportunity, and motivation will guide future research that will become part of the growing body of literature on reducing meat consumption.From a practical point of view, this work offered information that various stakeholders can use in reducing meat consumption since it is expected to be necessary to rely on multiple capabilities, opportunities, and motivations for the feasibility of substantial reductions in Brazilian people’s meat consumption. This will require joint efforts from various civil, economic, political, and market actors, such as consumers, researchers, NGOs, public entities, industry, retailers, restaurants, and opinion leaders. After all, as possible generalized reductions in meat consumption would generate collective benefits, the responsibility to make efforts to this end lies with everyone.This study has some limitations, mainly due to its sample size, meaning that generalizations cannot be made. In addition, the data collected were based on self-reported behaviors, which do not always accurately reflect the actual behavior of consumers. It is also important to note that the study was carried out during the COVID-19 pandemic period, a period characterized by significant changes in consumer habits and behaviors.Brazil is among the world’s largest meat consumer market countries , and a more holistic view of the eating behavior of Brazilian consumers stands out. In this context, future research could investigate consumers who want to reduce meat consumption but have not yet managed to change their eating behavior, as well as Brazilian consumers who do not intend to make such a change. Both approaches could help identify new barriers to reducing meat consumption in Brazil and other countries. Additionally, given Brazil’s continental dimensions and cultural diversity, further studies could investigate the facilitators and barriers to reducing meat consumption in different geographical regions. A more segmented investigation would allow the planning and application of more targeted interventions. It also highlights the need for future studies that address the importance of reducing meat consumption for humans, animals, and the planet.Finally, this study did not allow for an in-depth analysis of each of the dimensions of the COM-B model. Therefore, further studies could focus on a single dimension for a more detailed assessment. This work was not intended to exhaust a topic of global importance but to pave the way for future theoretical, managerial, and political discussions.


Human milk banks (HMB) play an essential role by providing human milk to infants who would otherwise not be able to receive mother’s milk. There is currently no donor milk bank in Turkey. For any new health intervention to be successful, determining its acceptability is a vital first step. This study intends to determine the opinions, knowledge, and attitudes of native Turkish and refugee women living in Çeştepe, Aydın, a rural area in Turkey, about HMB.A population-based cross-sectional, mixed-methods study was conducted. Qualitative study data were collected through in-depth interviews with 33 women, and quantitative study data were collected using a questionnaire. A total of 271 women in the region were included in the study. Qualitative data were thematically analyzed and then a conceptual framework was created. Logistic regression was performed for quantitative data.Fifty-seven point nine per cent of the women were willing to donate breast milk, whereas only 27.7% were willing to use donor milk for their babies. Religious concerns, fear of infectious diseases, and distrust in people they did not know were among the reasons for the negative attitudes of the women. Fear of infectious diseases was mentioned specifically by native Turkish women, and religious concerns were reported both by native Turkish and refugee women. The importance of breast milk and religion were among the reasons for positive attitudes. Additionally, odds of having a positive attitude were 4.19 times higher in homemaker women ; 4.77 times higher in women with three or more children ; 6.12 times higher in women who had a positive attitude towards wet nursing ; and 2.68 times higher in those who had previously heard about human milk banking .Attitudes towards HMB are affected by religion, cultural beliefs, and concerns about the safety of breast milk in HMBs. Refugees and native Turkish women are found to have similar religious concerns. These findings should be taken into consideration in human milk banking initiatives and in activities to increase acceptance by the public. Breast milk meets all nutritional needs of a term baby in its first six months of life. Not every baby can have breast milk in desired amounts for several reasons. Due to reasons concerning the mother or the baby such as severe infections, use of medications, hepatitis B, hepatitis C, tuberculosis, substance use, premature birth, and low birth weight, breastfeeding is sometimes not possible , 2. WhenThe idea of HMB emerged in the 1900s as an alternative to wet nursing . The goaAccording to the 2018 national data in Turkey, 40.7% of children under the age of six months are exclusively breastfed since birth. Additionally, contrary to the recommendation that children under six months should be exclusively breastfed, 23% of children receive breast milk with other milk and 12% of children receive complementary foods in addition to breast milk . HoweverAcceptance by the public is a vital first step for any new health intervention to be successful. In this regard, opinions, recommendations, and attitudes of women will guide in creating models of HMB. Several hospital-based studies conducted in Turkey reported on the knowledge and attitudes of women about HMB –16. HoweThe qualitative part of this study intends to determine the opinions on HMB of native Turkish women and refugees living in a rural area called Çeştepe in Aydın, Turkey, and whether HMB was acceptable for them. The quantitative part of this study intends to determine these women’s knowledge and attitudes toward HMB and to establish the factors associated with HMB attitudes.A population-based cross-sectional, mixed-methods study was conducted. A mixed-methods approach was used with qualitative and quantitative data collection and analysis. The qualitative study preceded the quantitative study and provided insight and a deeper understanding of the native Turkish and refugee women’s perceptions and attitudes about human milk and HMB. The quantitative study subsequently enabled the quantification of the issues identified through the qualitative study. The study was conducted in a rural area called Çeştepe in Aydın. Çeştepe is a fertile agricultural area in western Turkey. The distance between Çeştepe and the city center is two km. The population of Çeştepe is 5767 . The main source of income is agriculture because agricultural lands are common in the area. The area receives migrants both from within the country and abroad; contains different socio-cultural structures of the country; and has refugees from a variety of ethnic groups. Most of the migrants in Çeştepe came many years ago from the Balkans  and have the same socio-cultural structure as that of local people. The region has been hosting refugees for the last ten years, especially after the Syrian War. The refugees are mostly from Syria, but some come from Iraq and Afghanistan. According to the information obtained from the headman of that region, approximately 60 refugee families live in the region.Purposive sampling was used to select the participants for qualitative interviews. This sampling technique was preferred because it allowed a purposive selection of participants who were knowledgable about breastfeeding and infant feeding practices, through personal experiences. The women were reached through the auspices of the headman of the region and the researcher who was working as a midwife in a primary health care institution in the region. When most of the data started to be similar, a saturation point was assumed to have been reached and data collection was ended. In this part of the study, IDIs were conducted with 33 women. Fifteen of these women with whom IDIs were conducted were refugees, eight were Syrians, four were Iraqis, and three were Afghans.All women who were aged over 18 years and had a birth in the last five years in Çeştepe, Aydın, were included in the quantitative study. According to the data registered with the primary healthcare institutions, there were 324 women aged over 18 years who had given birth within the last five years. Even if they were not registered in primary health institutions, the contact information of women who presented even once to hospitals was recorded. No sampling was performed and 291 women who were not included in the qualitative part of the study were invited to join the cross-sectional study. Two hundred seventy-one (93.1%) women agreed to participate in the study.In the qualitative part of this study, with an interpretive approach, a case study design was used to determine the perceptions of women about HMB milk donation and use of donor breast milk; obstacles and facilitators for its acceptability; and the ways to support breast milk donation and banking in the future. Qualitative study data were collected with in-depth interviews (IDIs) performed using a semi-structured interview form with seven open-ended questions, between the dates of December 2021 and January 2022. The questions that we used in IDIs were as follows: Do you know the meaning of breast milk banking and breast milk donation? Would you donate your own milk? Would you feed your baby with donated breast milk? Reasons for your positive / negative thoughts? Do you have any information on practices related to breast milk donation and use? What can be done to make sure donated breast milk is safe? Would you like to establish a breast milk bank in our country? Each IDI began with an explanation of the purpose of the study and obtaining informed voluntary consent from the participants. Interviews were conducted by an experienced researcher (NK) and another researcher (FK) who made audio recordings and took notes. IDIs were conducted in different sessions for each woman. Each IDI lasted 45 min to 1 h. All interviews were conducted in the local language and interviews with people whose mother tongue was Arabic were performed with the help of Arabic interpreters. Opinions of women who had IDIs were shown with their respondent codes, ages, and refugee status, native (N) or refugee (R).Cross-sectional study data were collected using a questionnaire in in-person interviews with women between February and March 2022. Data were collected in the participants’ homes. The questionnaire was developed by the researchers based on a literature search and in line with the thematic and conceptual framework determined with the qualitative method. Questions were designed to determine the knowledge and attitudes of women regarding wet nursing and HMB and their sociodemographic characteristics. The survey consisted of 27 multiple choice questions and lasted approximately 20 min. The questionnaire was prepared in the local language and interviews with people whose mother tongue was Arabic were performed with the help of Arabic interpreters.The dependent variable of the quantitative part of the study was the attitudes of women towards HMB. Attitudes of women toward HMB were determined using two variables: acceptance of breast milk donation or acceptance of the use of donor milk to feed an infant. A woman was considered as having a positive attitude toward milk banking if she was accepting of breast milk donation for banking and / or she was accepting of the use of donor milk to feed an infant. Independent variables of the study were age, education, family type, number of children, knowledge and attitudes toward wet nursing, and knowledge about HMB. A mother was considered to be aware of HMB if she had heard about HMB. A mother was considered to be aware of wet nursing if she had heard about wet nursing. Respondents’ attitudes toward wet nursing were evaluated using four variables: previously being a wet nurse for a baby, willingness to be a wet nurse for a baby, having a wet nurse for her own baby, and willingness to have a wet nurse for her own baby.The study was conducted according to the Helsinki Declaration for Ethical Principles of Research. Approval was obtained from the Clinical Research Ethics Committee of Ege University Medical School (17.12.2021-463216-924). Additionally, participants were asked to sign informed voluntary consent forms and necessary information about the study was given. The qualitative part of the study was reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist .Analysis of the qualitative data was performed manually using thematic content analysis. The data obtained from the IDIs were first transcribed. Another researcher checked 20% of the transcripts. After all interview transcripts were read separately by two researchers , common and different concepts were identified, a code was determined for each concept, and codes were grouped under thematic titles. Discrepancies were addressed by discussing differences in coding during research meetings and amending coding practice until coding was consistent. Then a conceptual framework was created for the themes Fig. . For theP-values less than 0.05 in the bivariate analysis were included in the multivariate binary logistic regression model to identify explanatory variables that were associated with the attitudes of women towards HMB. Multivariate binary logistic regression was performed using the enter approach. Ninety-five per cent CIs were used and significance was set at p < 0.05 in the analyses.Quantitative data were evaluated using the SPSS 24.0 statistics program. For descriptive analysis, numeric variables are shown as mean and standard deviation, and categorical variables are shown as numbers and percentages. Bivariate analysis was conducted to examine the association between dependent and independent variables, and crude odds ratios (COR) and their 95% confidence intervals (CI) were calculated. Then, all variables that had Based on the qualitative study, a conceptual framework with six main themes including awareness of the importance of breast milk, knowledge and attitudes toward wet nursing, knowledge about HMB, attitudes toward HMB, positive opinions about HMB, and negative opinions about HMB was created.The sociodemographic characteristics of the women n = 271) who participated in the survey are shown in Table  who partFifteen women (n = 33) included in the qualitative study were refugees. These women were aged 21 to 40 years and had one to three children.The women’s knowledge and attitudes toward breastfeeding, wet nursing, and HMB are shown in Table Sixty-seven point two per cent of the women reported that they exclusively breastfed their babies in the first six months. Only 2.7% of the mothers reported that they did not breastfeed their babies in the first six months.“There is nothing like breast milk; better than everything, it’s so good. Breast milk is very important for the baby’s development. Instead of giving formula, breast milk is much more precious. I think breast milk can be in no way harmful. Breast milk, how do they say, like antibiotics for the health, I think it can no way be harmful.  A refugee mother said: “Every baby who needs it should get breast milk. It is a good thing. Breast milk is healthier, I exclusively breastfed my baby, no formula, only breast milk.” .Almost all of the native and refugee women reported that they were aware of the importance and benefits of breastfeeding, and the superiority of breast milk to infant formulas. Eighty-eight point six per cent of the women had heard about wet nursing, and 12.5% had an experience of breastfeeding someone else’s baby. Seventy-seven point nine per cent reported that they could be wet nurses for other babies, 7.7% reported that their babies had had wet nurses, and 34.3% reported that other people could breastfeed their babies if they did not have enough milk.“Back in the old days, mothers used to breastfeed each other’s babies when they did not have enough breast milk. Like milk siblings, I used to hear stories about these from my mother.“ .In IDIs, most of the mothers said that they had known of wet nursing as a concept for a long time although they had no first-hand experience with wet nursing. “For example, my neighbor breastfed my child in the beginning. My mother-in-law breastfed this neighbor’s children and my child was breastfed by them, so it’s all a twist of faith.“  Similarly, refugee women reported that they knew about wet nursing and had experienced wet nursing in their lives. “My mother-in-law used to talk about this when we were living in the village in Syria; then I breastfed my big sister’s daughter. Old people, our elderly, used to talk about; there used to be a lot of wet nurses.“ .Some of them also said that they have had personal experience with wet nursing. Seventy-four point nine per cent of the women reported that they had never heard of HMB. Among those who reported that they had heard about HMB, 65.7% heard about it on social media, 20.9% heard about it from healthcare professionals and 13.4% heard about it from their friends.“I have never heard about human milk banks; I have heard about eye banks, blood banks, but never heard about this.” .Although some of the women reported that they had heard about HMB during IDIs, no native or refugee women had any specific knowledge about how HMBs work. Fifty-seven point nine per cent of the women were willing to donate breast milk, whereas only 27.7% were willing to use donor milk for their babies. Fifty-nine per cent of the women reported a positive attitude towards HMB (donor or recipient), and 53.1% of the respondents reported that they would prefer to have an HMB in Turkey; 32.5% were indecisive about this.“I would donate breast milk but I would not give donor milk to my child. I would think about how they collect and store such milk. I think formula would be healthier. I am a little obsessed about hygiene, so I would not be comfortable.“  “I think this is a good idea; babies who could not be breastfed could have breast milk instead of formula. I think this would be more logical, but I don’t know if I would take milk from the bank.“ .In IDIs, women generally stated that they would donate their milk to an HMB but would not take milk from the HMB for their children. Fifty-nine per cent of the women (160 women) who participated in the survey reported any type of negative opinion. Of the women who reported negative opinions, 76.3% gave religious concerns; 52.5% feared infectious diseases; 42.5% reported that they did not trust people; 22.5% reported that there were infant formulas today as alternatives to breast milk; 17.5% reported fear of allergies; 6.9% reported that they wanted their babies to be breastfed only by them; and 5.6% reported fear of spoiled milk as their reasons for their negative opinions about HMB.Because there is a possibility of becoming milk siblings, I neither donate nor receive milk. I would not donate; I mean if there had been no such thing as milk siblings, I would have both donated and received milk. Let’s say they will get married in the future, how will I know, so it’s a sin. So, instead of giving milk of somebody who I have never met, I’d rather feed my child with milk of somebody I know. Of course, I would not want to deprive that child of milk.” .In IDIs, women’s negative opinions about HMB were mostly about “receiving donor milk”. During IDIs, no one reported a negative attitude about “donating milk” except for religious concerns. ““No, I would not feed my baby with donor milk. I would not feel comfortable, I don’t know how I can explain. I would not want to give somebody else’s milk; I would worry that my baby would get infected, sick. For me it is better to give formula; I mean, it does not make sense to me.“ .In particular, native women spoke of the fear of infectious diseases as the reason for their negative attitude towards receiving donor milk from an HMB. There were no refugee women who gave this as the reason. “I don’t know whether I would trust and receive milk? I guess I would not want to give donor milk to my children. I mean, let’s face it, we don’t know what kind of people donate milk. I don’t know what’s in it, of course, we know that breast milk is natural but can we trust anyone with our child? No. Giving somebody else’s milk is the same thing. I think we can’t do that. Of course, I would want to give the milk of people whom I know and trust. I would feed my child with their milk and I would give my milk to their children. Another negative opinion was the feeling of “distrust”. During IDIs, women expressed distrust in two different ways: “distrust in people they do not know” and “distrust because of infectious diseases”. Native women often underlined the above-mentioned statements, whereas most of the refugee women gave “distrust in people they do not know” as the reason for their negative attitudes. Forty-one per cent of the women (111 women) who participated in the survey reported any type of positive opinion. Seventy-two per cent of the women with positive attitudes toward HMB gave the reason that babies who could not be breastfed could still have breast milk; 65.8% gave the reason that they trusted breast milk; 58.6% gave religious reasons; and 40.5% reported that they trusted healthcare professionals / the ministry of health.“I wish we could have places like this (HMB); thank God my children never needed wet nurses. I always breastfed myself; I didn’t even give formula milk but there are many children who cannot be breastfed. Let those who do not have breast milk have breast milk”.  “Breast milk is very important, those who have give to those who don’t. This is especially good for abandoned children. I feel very sad for them, I wish they could have breast milk at least until they are 6 months old”. IDIs showed that there were women with a positive attitude towards HMB. Positive attitudes were mostly based on knowing the “importance of breast milk”. One of the main reasons for positive attitudes among native and refugee women toward HMB was that “babies who cannot be breastfed can still benefit from breast milk.“ “I don’t see anything bad in this. If you ask why, for example, if a 1-month-old baby cannot be fed with breast milk, it is a very bad sin. That child needs breast milk. It is better to give the child breast milk. Let’s say, God bless, think about a baby who cannot be breastfed and suffer in a hospital. My baby can be breastfed, comfortable, but that baby there is hungry, this is a sin.“  “It is a very good deed to feed a hungry child, if that child stays hungry, then it is a sin. God forbid; if I give milk, that child can maybe live. If there was a bank here, I would donate.“ .Additionally, although religious factors were generally the reasons for negative attitudes, they also played a role in positive attitudes. The IDIs found that both native and refugee women thought that it was a “good deed” in a religious sense to feed a baby in need. “If it is approved by the ministry of health, by you, then it is good for me. But if it is something done by a normal citizen, I will not feel comfortable. I mean, I think they always check and quality control everything, packaging and then allow. In addition to these factors, trust in healthcare professionals and public health institutions was given as the reason for positive attitudes in native women. Factors for attitudes of women toward HMB are shown in Table This study intended to determine the attitudes of native Turkish and refugee women living in a rural area toward HMB. Almost all of the women included in this study agreed on the importance of breast milk and the majority reported that they breastfed their babies. Studies conducted in Turkey also underlined that awareness about the importance of breast milk among women was high , 15, 19.In this study, the majority of the women had heard about wet nursing and reported that they would be willing to be wet nurses; only one in eight, however, had experienced this. Although the use of wet nurses has decreased significantly today , mothersMore than two-thirds of the women included in this study reported that they had never heard of HMB before. Similar studies report that women have higher awareness in countries where HMBs are used –23 and lAlthough women are more willing to donate breast milk, they are quite hesitant about feeding their babies with milk from the bank. Only one out of four women reported that they would give donor milk from the bank to their babies. Previous studies conducted in hospitals or online in Turkey found similar results , 15. In Different from other studies , 26, in The present study showed that there were factors that could be used to increase positive attitudes toward HMB. Positive attitudes toward HMB were higher in women who reported positive attitudes toward wet nursing and in those who reported that they had previously heard about HMB. Several studies support these findings , 31, 32.As in the rest of the world, HMB would play a vital role also in our country making it possible for babies who cannot be breastfed for any reason to have access to invaluable breast milk. Even in countries such as Brazil where there are successfully established HMB systems, a widespread effort is still needed to encourage women to donate breast milk . MethodsAs an inherent characteristic of cross-sectional studies, the quantitative part is limited to explaining causality. Because there were insufficient refugees to achieve a good comparison with native women in the area, comparisons could only be made between refugees and native women in the qualitative part of the study. Additionally, because the study was conducted in a rural area, the study results cannot be generalized to the entire region. In our study, there was only information on people who were registered in primary healthcare institutions. However, even if they are not officially registered, the records and contact information of people who present to the institution only once are kept, so it can be thought that the results of the study represent the women in the region. The study has some major strengths, however. The mixed-methods used in the study allowed us to investigate different aspects of the study subject. Including refugee women in the qualitative part will be guiding because this is the first study on this subject that includes refugees. Being population-based is another strength of the study. The majority of the related studies in the literature evaluated women who had just given birth in hospitals, thus our study is important also in this sense.According to the findings of this study, the respondents’ attitudes toward HMB are affected by religious beliefs, cultural beliefs, and concerns about the safety of breast milk collected and stored via HMB. Refugees and native Turkish women were found to have similar religious concerns. On the other hand, the importance and benefits of breast milk were acknowledged by both groups. These findings should be taken into consideration in HMB initiatives and in activities to increase acceptance by the public in Turkey and countries with similar socio-cultural characteristics.