The current study examined children’s understanding of No Diving warning signs. Normally-developing 7 to 10 year olds were asked questions to assess their understanding of text, images, and main messages on No Diving warning signs. These structured interviews were audio recorded and responses were later coded. Results revealed that children understood the behavior advised against (diving), why it is prohibited (can hit head on the bottom), and what can happen . They understood that breaking your neck results in limitations in mobility and can occur from diving, but they did not anticipate that such an injury is likely to occur. There were no gender and few age differences, but diving experience was associated with children significantly downplaying their risk of injury. The findings suggest that having No Diving warning signs explicitly mention a broken neck, may serve to remind children of this potential consequence at the time of decision making. Active adult supervision is particularly important for children who have prior positive diving experiences. Unintentional injuries are the leading cause of death for children in the United States, Canada, and most developed nations ,2. A chiDiving related injuries are often catastrophic and result in life altering effects for victims and their families . Most diWarning signs are typically posted in areas where individuals are likely to get injured, with the goal being to alert, inform, and/or remind individuals of potential hazards and unsafe behaviours that should be avoided. Not surprisingly, for warning signs to be effective the sign must both elicit attention and be understood by viewers ,13. FactCaution, Warning, Danger) that is immediately understood as communicating something about risk is an essential feature on warning signs [Research with adults reveals a number of factors that affect viewers’ understanding of the message communicated by a warning sign, include the language expressed  and pictorial images shown. Including a signal word , what behavior is defined by “diving”, what a sign saying “No Diving—shallow water” means, what the terms “permanent injury” and “you can break your neck” mean, and what the image  is intended to communicate. To examine their injury-risk appraisals related to diving, they gave ratings of dangerousness, likelihood of injury, severity of potential injury, and stated whether or not one can wind up in a wheelchair for life from diving. Children 7 to 10 years were tested because this represents an age range in which children increasingly receive less direct supervision and make more autonomous decisions about their activities [The aim of the study was to examine children’s understanding of the typical components of No Diving warning signs, including: signal word  or older  group, with equal numbers of boys and girls in each group. All participants were typically developing, as reported by their parents. Nearly all children (95%) had taken formal swim lessons. Generally, parents were unable to report on how long or consistently the child had been in lessons, but they were confident in reporting on whether or not the child had been taught how to dive into the pool and had experience doing so as part of their swim lessons; children confirmed this information during the interview. Of the 120 children, 90 had diving experience (39% or 63% of younger and 51% or 82% of older children), meaning that they had experience diving into open water ; no one reported any injuries from doing so. The sample comprised predominantly middle-upper income families , with 71% of parents having some/completed college/university, and nearly all of the participants Caucasian (98%).Children aged 7 to 10 years were recruited throughout the community in Guelph and the surrounding area  and allocated into either a younger , jumping in different ways , or standing  on a ladder in a pool or lake area. The photos were obtained through an online images search, with similar images included to show boys and girls equally often and in the same situations. In addition to the photos, three clipart images of a figure diving into water were included and randomized within the deck, with different types of dives represented (see To determine children’s understanding of what constitutes a “dive” they were given a deck of 23 image cards (randomized) and asked to sort these into Diving and Not Diving boxes, as they thought best. The deck comprised 20 colored photos of boys and girls who were in a similar age group to the participants (7–10 years old), with the photos showing individual children either diving in a variety of ways  and to say what could happen if they ignored the sign and dove into a pool having shallow water.To assess children’s understanding of common phrases that are used on warning signs to communicate about the consequence of diving into shallow water children were sequentially presented (randomized) two signs that said No Diving—Shallow Water and then under this said either You could break your neck or You can become permanently injured, and they were asked to explain what each phrase meant. Note that we purposefully embedded the consequence phrases within the context of a No Diving warning sign because our aim was to determine how children interpret these phrases when they see them under typical warning circumstances.Understanding Images. To explore children’s understanding of a common clipart image used on no diving warning signs, they were presented a sign that said Danger! No Diving—Shallow Water that had a clipart image showing a broken neck but no interpretive text, and asked to explain what the image was telling them  and were asked what the safety signal word meant; they were given up to one prompt if they indicated they did not know or said something unclear. Children were then shown the No Diving—Shallow Water sign, and asked what the sign would be trying to tell them if it was hanging near a pool and then to comment on what could happen if they ignored the sign and dove into a pool having shallow water; again, up to one prompt was allowed; children answered questions with reference to themselves, not all children in general. The researcher then asked the child to look at each one of the photos they had put in the Diving box and to rate each one for how dangerous it would be to do the dive shown in the picture into a pool having shallow water . These scores were then averaged to create one score for each child for danger of diving into shallow water. Children were asked to rate both how likely it would be to get hurt from diving into a pool having shallow water , and to rate the severity of the possible injury , 3 = very serious, such as hospitalized, 4 = death). The children were shown a No Diving—Shallow Water sign with a clipart image of a character diving into shallow water and breaking their neck  while the child went into another room with a research assistant. For the photo sort task, children were given a randomized ordering of photos and asked to sort these into two boxes—one for Diving photos and the second for Not Diving photos. The structured interview then was completed, with this audio recorded for later transcribing and coding. At the conclusion of the session, the child was thanked, reminded about safety practices near water, and given a gift card for participating.For diving status, children were assigned a score based on whether they did or did not have experience . Responses to open-ended questions were transcribed and then coded using a scheme developed for each question individually, with higher scores indicating greater understanding. Children’s understanding of the terms Danger, Warning, and Caution were coded as: 0 = no clear understanding; 1= understanding that it is indicating something you should not do; 2 = understanding that you should not do it because of physical injury. Answers to the question of what a “No Diving—Shallow Water” warning sign means were coded as: 0 = no clear understanding or answer has nothing to do with safety ; 1 = understands that one should not dive because of safety but does not clearly state why; 2 = clear understanding that one should not dive because the shallow water makes it unsafe and likely to get hurt. Answers to what could happen if one ignored the sign and dove into a pool with shallow water were coded as: 0 = answer has nothing to do with safety ; 1 = answer that reflects a “can get hurt” idea; 2 = mentions a specific way one could get hurt by hitting the bottom ; 3 = mentions specific possible consequence of hitting the bottom . Responses for their level of understanding of the consequence phrases  were coded as: 0 = no clear understanding, 1 = answer indicating being seriously hurt and hospitalized, 2 = clear understanding that effects involve limitations in movement and are lifelong . Children’s responses about what was happening in the clipart image that appeared on the warning sign  minimally. The data of the primary coder were analyzed.t-tests, a Bonferroni adjustment for family-wise error rate was applied; the results reported are based on this adjustment having been applied.Descriptive and parametric statistics were applied to characterize the data and evaluate the pattern of results as a function of age group, gender, and diving experience. Several preliminary data checking procedures were applied before analyses were conducted, including screening for outliers using Cook’s distance and checking that variables were normally distributed ; no issuPrior to initiating this research, the study protocol was reviewed by, and approval was obtained from, the Research Ethics Board committee at the University of Guelph (13MY009). Participants and their custodial parent granted written consent prior to participation in this study.r = 0.32, p < 0.01), these factors were not considered simultaneously in the same analyses. Rather, in executing the ANOVAs we assessed for each separately while controlling for the effects of the other variable. In addition, gender differences were examined, where appropriate.Both age and diving experience were of interest, however, because these variables were positively correlated , children correctly identified “diving” photos and images with nearly perfect accuracy, 98%. Thus, children are aware of the variety of forms that diving can take and judge that all of them would qualify if one is referring to “diving”, such as in a warning sign.Danger, Warning, and Caution and determine factors that affected this understanding, a mixed ANOVA was conducted with age group  and gender  as between-participant factors and signal word type  as a within-participant factor, with diving experience entered as a covariate. Results revealed a significant main effect of age group, F  = 10.99, p < 0.05, ηp2 = 0.08. Although all children understood that the terms were alerting you to something you should not do (score of 1), older children demonstrated a better overall understanding of the signal terms compared to younger children . There also was a significant main effect of signal word, F  = 24.41, p < 0.05, ηp2 = 0.18. Follow-up paired-comparison t-tests revealed that children’s understanding of Danger significantly exceeded their understanding of the terms Warning and Caution  = 8.11 and t (119) = 9.20, p < 0.001, respectively), which did not differ from one another, p > 0.05. There were no significant differences related to gender, p > 0.05.To test for differences in children’s understanding of the terms Danger, Caution, Warning) as a within-participant factor, with age group entered as a covariate. Results revealed an interaction of diving experience with signal word, F  = 3.49, p < 0.05, ηp2 = 0.08; there were no significant effects related to gender, p > 0.05. Three independent t-tests comparing experienced and inexperienced divers’ understanding of each signal word revealed, as shown in Danger (t (89) = 7.07, p < 0.001), but it did not enhance children’s understanding of Warning or Caution, p > 0.05.To explore if diving experience affected children’s understanding of these signal words, a mixed ANOVA was conducted with diving experience  and gender  as between-participant factors and signal word type  and gender  as between-participant factors, with diving experience entered as a covariate. Similarly, an ANOVA was conducted with diving experience  and gender  as between-participant factors, with age group entered as a covariate. Results of both ANOVAs revealed no effects of age, gender, or diving experience. Children understood the sign to mean that one should not dive because doing so was unsafe because of shallow water .To explore children’s understanding of what a “p > 0.05. Children rated diving into a pool having shallow water as being very dangerous , very likely to lead to injury , and likely to lead to a very serious injury that would require hospitalization .To explore children’s appraisals of injury risks related to diving in shallow water, their ratings of dangerousness, likelihood of being injured (injury vulnerability), and potential severity of injury were examined. In each case, an ANOVA was conducted with age group  and gender  as between-participant factors, with diving experience entered as a covariate. There were no significant effects due to child age and/or gender, F  = 3.72, p < 0.05, ηp2 = 0.03. Children with diving experience judged their risk of injury to be significantly lower than those without diving experience .To explore if diving experience affected these appraisals of injuries, a separate ANOVA was conducted for each appraisal with diving experience  and gender  as between-participant factors and age entered as a covariate. The only effect was for diving experience, Text Based Messages. First, children’s scores for what could happen if they ignored a “No Diving—Shallow Water” warning sign and dove into a pool were analyzed. An ANOVA was conducted with age group  and gender  as between-participant factors, and diving experience entered as a covariate. Results revealed a significant main effect of age group, F  = 4.44, p < 0.05, ηp2 = 0.04. Older children provided more detailed responses about consequences associated with diving into a shallow pool than younger children . There were no effects related to gender, p > 0.05. An ANOVA with diving experience  and gender  as between-participant factors and age entered as a covariate, revealed no significant effects related to diving experience, p > 0.05.Permanently Injured”. An ANOVA was conducted with age group  and gender  as between-participant factors, and diving experience entered as a covariate. Results revealed a significant main effect of age group  = 5.04, p < 0.05, ηp2 = 0.04), indicating that older children had a better understanding of the term than younger children . There were no effects related to gender, p > 0.05. An ANOVA with diving experience  and gender  as between-participant factors and age as a covariate revealed no significant effects.Second, children were asked the meaning of the term “Break Your Neck” also was assessed. An ANOVA was conducted with age group  and gender  as between-participant factors, and diving experience entered as a covariate. Similarly, an ANOVA was conducted with diving experience  and gender  as between-participant factors and age entered as a covariate. The results of these ANOVAs revealed no effects of child age, diving experience and/or gender on their understanding of the term, p > 0.05. Children understood the phrase to mean that there would be limitations in movement that lasted for life . Consistent with this, when asked whether or not it was possible to wind up in a wheelchair for life from diving into a pool, 78% agreed with the statement and Chi Square tests revealed no differences related to age or diving experience, p > 0.05. When these children were asked how they had learned about the dangers of diving into a pool having shallow water, 47% reported learning this on their own based on pool experiences and the remaining 53% reported being taught this through swim lessons. Chi Square tests indicated that these percent scores did not vary with age group or diving experience, p > 0.05.Children’s understanding of the term “Images. Children’s understanding of the clipart images was also examined. An ANOVA was conducted with age group  and gender  as between-participant factors, with diving experience entered as a covariate. Similarly, an ANOVA was conducted with diving experience  and gender  as between-participant factors and age entered as a covariate. Results of both ANOVAs revealed no significant effects, p > 0.05. Regardless of age, gender and/or diving experience, children interpreted the cartoon image as showing that diving will lead to hitting your head on the bottom of the pool .Warning signs are intended to alert viewers to hazards and risk behaviors to avoid. Although these are assumed to be equally effective across a broad age range, the majority of research on this medium has focused on adults. Much less is known about children’s understanding of warning signs. Moreover, despite the fact that diving is a risk factor for spinal cord injury even in children , there iWith regard to images, the fact that children categorized clipart images showing diving in the same way they did actual photos confirms that they have no difficulty understanding the representational diving behavior depicted in the clipart images used on warning signs. Moreover, despite variation in the type of dives depicted , children categorize them all as “dives”. This is an important finding because it indicates that children generalize across different exemplars to understand that “diving” refers to many different types of head first entries into a pool. Therefore, it is less important as to what specific diving image is shown, as long as the word “diving” appears on the warning sign with the image.on its own to alert children to the risk of permanent  injury. However, when the image is placed in the broader context of text-based information on a No Diving warning sign and the totality of our results are considered, the results indicate that children 7 to 10 years understand the dangers and potential seriousness of consequences from diving into shallow water.Children also were asked to explain what the diving image on the warning sign was communicating. The majority interpreted the image as indicating that diving will lead to hitting your head on the bottom of the pool. However, they generally did not interpret the image as depicting someone breaking their neck from doing so. Thus, this very popular image on No Diving signs is not effective Danger was used. Thus, Danger should be the signal word of choice for warning signs targeting children. When presented a sign saying “No Diving—Shallow water”, children also correctly interpreted the text to mean that one should not dive because doing so was unsafe. Although they did not always elaborate to explain how the shallow water made it unsafe, ratings of their injury risk appraisals revealed they understood that diving into a pool having shallow water was very dangerous, very likely to result in injury, and that this injury could be very serious and require hospitalization.With regard to text-based messaging, children understood that all three popular signal words are communicating something one should not do. Nonetheless, they showed the greatest understanding that there was a safety issue when the term spontaneously mention permanent and catastrophic effects when asked about what could happen from diving in shallow water. Rather, they discussed consequences in more general terms . Nonetheless, when questioned directly, children’s responses indicated that knew that “breaking your neck” would result in limitations in movement that lasted for life, and the majority agreed that one could wind up in a wheelchair for life from diving into shallow water. The pattern of these results suggest that children may not routinely anticipate or consider that permanent and catastrophic injury is likely to result from diving into shallow water, but they understand that this can occur. Explicitly saying on No Diving signs that one can “break your neck” may bring this knowledge to consciousness in the situation, thereby maximizing effectiveness of the warning to deter diving by children. In addition, providing active supervision by adults has been shown to reduce children’s risk behaviors [Despite this knowledge and understanding of diving-related injury risks, it is noteworthy that the majority of children did not ehaviors ,27 and aehaviors ,29, actiImportantly, this research also provides insights regarding whether there are differences in children’s understanding of No Diving warning signs that relate to their gender, age, and past diving experience. There were no significant differences in boys’ and girls’ understanding of No Diving warning signs. Although boys typically engage in more risk behaviors and experience more injuries than girls, including diving injuries ,5,9,30, and text-based information, the results suggest that younger children’s understanding of diving in shallow water is comparable to that shown by older children .There were a few differences in results related to children’s age. Children at older ages showed a better understanding of the signal words than younger children, although all understood these were alerting you to something you should not do. In addition, older children more frequently than younger children reported that the term “permanent injury” means a lifelong effect, although all children understood that it was referring to a severe injury. Finally, although younger children understood that it was dangerous to dive, this was prohibited, and doing so could result in a very serious injury requiring hospitalization, they were less likely than older children to interpret the text information about shallow water as indicating a concern about hitting the bottom of the pool. However, they did interpret the clipart image as warning about this consequence of diving (see above). Thus, although there were some age differences that emerged when examining selected aspects of the data, when one considers children’s comprehensive understanding of No Diving warning signs that comprise both image very dangerous and likely to lead to a very serious injury that would require hospitalization, children with diving experience expected their personal risk of injury to be lower than those not having diving experience. No Diving warning signs, therefore, are likely to be less effective for those children who have past experiences successfully engaging in the risk behavior; similar effects of past experience have been noted in research on warning sign effectiveness with teens and adults [Diving experience biased children toward assuming less likelihood of injury. This finding is consistent with other studies that have found that experience with an activity predicts greater risk taking because children develop an optimism bias and downplay warnings about injury risk, assuming that risk behaviors pose less risk of injury for them than less experienced peers ,33,34. Td adults ,23,35. AFinally, although this study focused on warning signs, it is not our intention to suggest that this is necessarily the best or only strategy for preventing diving-related injuries. Without doubt, maximizing reductions in these injuries will require a comprehensive and multi-faceted approach. For example, integrating active supervision with signage and enforcement strategies , and coupling this with environmental modifications  that reduce risk of serious injury or prevent risk behaviors , addresses many significant risk factors for diving injuries.Although the current study provides insights into what children understand about diving into shallow water from warning signs, there are some limitations that merit discussion and consideration in planning future research. First, the sample in the study was fairly homogeneous and comprised predominantly Caucasian, middle income, and well educated families. A more diverse sample would be desirable in future studies because exposure to factors that could influence children’s understanding of diving risks  would be expected to vary with income and parent education levels.Second, nearly all the children in this sample had participated in formalized swim lessons, however, reliable information on the extent of swim lesson experience could not be obtained. This precluded our examining the extent to which swim lesson experience influences children’s understanding of diving risks. In future research, therefore, it would be useful to gather more systematic information on the nature and extent of swimming lesson experiences and to determine how these experiences influence children’s understanding of the text- and image- based messages communicated in No Diving warning signs. Findings from such research could provide important information on aspects of swim and/or diving instruction that merit changing.Finally, results suggest that prior experience is a risk factor for diving even in the presence of a warning sign cautioning against doing so: children with experience rated their likelihood of injury from diving as lower than did children without such experience even though there were no group differences in ratings of the extent of dangerousness or severity of potential injury. We did not, however, measure the nature or extent of past diving experience to determine if differences emerge related to these factors. It could be, for example, that one needs experience in the same situation  before an optimism bias emerges about injury risk. Or, that the extent of optimism bias is positively related to the extent of past successful diving experiences. These are important relations to examine because the findings could have aide in identifying which children are at greatest risk of ignoring a No Diving warning sign and, therefore, in greatest need of active supervision.The results of this study on No Diving warning signs revealed that children understand the behavior advised against , why it is prohibited , and what can happen from doing the behavior . They knew that if you “break your neck” this would result in limitations in mobility for life and the majority agreed that diving can result in being in a wheelchair for life. Nonetheless, children do not routinely consider that permanent injury can result from diving into shallow water. Explicitly saying on No Diving signs that one can “break your neck” may improve the effectiveness of signs by reminding children in the risk situation what they know, namely—that there can be severe and life-long consequences of diving. The results also suggest that children with past successful diving experience comprise a high-risk group that may be less likely to comply with warning signs. Active supervision is essential for all children in drowning- and diving-risk situations, but is particularly important to ensure the safety of children with prior positive diving experiences as this seems to constitute a “high risk” group.


We therefore analytically and numerically study how the choice of dt affects the inference in our network model, finding that the relationship between the inferred couplings and the real synaptic efficacies, albeit being quadratic in both cases, depends critically on dt for the excitatory synapses only, whilst being basically independent of it for the inhibitory ones.Biological networks display a variety of activity patterns reflecting a web of interactions that is complex both in space and time. Yet inference methods have mainly focused on reconstructing, from the network’s activity, the spatial structure, by assuming equilibrium conditions or, more recently, a probabilistic dynamics with a single arbitrary time-step. Here we show that, under this latter assumption, the inference procedure fails to reconstruct the synaptic matrix of a network of integrate-and-fire neurons when the chosen time scale of interaction does not closely match the synaptic delay or when no single time scale for the interaction can be identified; such failure, moreover, exposes a distinctive bias of the inference method that can lead to infer as inhibitory the excitatory synapses with interaction time scales longer than the model’s time-step. We therefore introduce a new two-step method, that first infers through cross-correlation profiles the delay-structure of the network and then reconstructs the synaptic matrix, and successfully test it on networks with different topologies and in different activity regimes. Although step one is able to accurately recover the delay-structure of the network, thus getting rid of any  This result can be intuitively understood by examining the extreme case Jij → −∞; in this case, the only surviving contribution to the probability of firing during dt , is the baseline probability νiε before the large, negative jump Jij in Vi; such term, integrated over a uniform distribution becomes νidt/2, which inserted into JInf,ij ≃ −1/2. dt → 0, the limit case’s behavior of JInf is essentially attained already for Jij ≤ −Jext.If we assume, instead,


Menopause is a complex biological phenomenon which is affected by socio-cultural and physiological factors. These factors may cause different experiences and concerns for menopausal women from different countries and even among women of diverse ethnic groups living in the same country. The signs and symptoms of menopause are exacerbated by the negative attitude of menopausal women and their deep concerns.We aimed to explore self-experienced concerns of Iranian menopausal women residing in Tabriz.Phenomenological approach was used for analyzing the participants’ experiences and perceptions about menopause. Data were collected through 18 semi-structured in-depth interviews; carried out from February to July 2012. Participants were menopausal women aged between 46-57 years who experienced menopause no more than 4 years before the interview. All interviews were audio recorded and transcribed verbatim. Constant comparative analysis of the data was conducted using MAXQDA 10.Participants’ concerns were classified into 4 main themes, including: inability, aging, isolation, and healthiness.Understanding these concerns might contribute to the enrichment of the existing literature by providing evidences from a different culture, assisting to design effective supportive strategies, planning training programs and appropriate infrastructures for women to improve their quality of life during the menopausal period. Menopause is a physiological event which characterized by apparently falling levels of estrogen and can lead to the development of symptoms such as hot ﬂashes, night sweats, vaginal dryness, mood swings, libido decline, insomnia, lethargy, fatigue, irritability, anxiety, depression, heart palpitations, and joint pain . The symMenopausal symptoms have shown differences among women in different countries, among women of different origins living in the same country, and among women born in the same place living in different countries . For exaSome women experience a profound sense of loss at menopause  which may lead them to feel that life has lost its purpose . A qualiUnderstanding these concerns might contribute to the enrichment of the existing literature by providing evidences from a different culture, and helping to design effective supportive strategies and appropriate infrastructures for women to improve their lives during the menopausal period.Overall menopausal symptoms are found to be less common in societies where menopause is viewed as a positive rather than a negative event , 16. WomA quantitative research to address specific aspects of the menopausal transition showed that Iranian women consider menopause as a natural event. But exposure to a new situation and deal with the phenomenon depends on their attitudes. Iranian women’s concerns are about complications such as osteoporosis, sexual problems and aging . They alIn spite of extensive research on menopausal symptoms and its psychosocial aspects, little is known about the personal meaning or view of the menopausal transition as experienced by Iranian women. Furthermore, there is not any exclusive study about concerns of menopausal women regarding their culture. The current phenomenological study explored the lived experienced concerns of menopausal Azeri women.This study was a part of larger phenomenological study that explored physical and psychosocial experiences of the menopausal women. The main objective of this research was to explore the menopausal women’s concerns.A hermeneutic phenomenological approach, as described by Van Manen (1990), was used to explore the women’s concerns about menopause. Hermeneutic phenomenology aims to “uncover the structure of lived experience”. It is important to understand the lives of individuals in their own context by taking into account individuals’ life experiences and meanings derived from those experiences. Furthermore, to gain a full understanding of the meaning or essence of an experience, the experience needs to be described and interpreted , 22.The ethics committee of Shahid Beheshti University of Medical Sciences approved the study beforehand. Each participant was informed about the purpose of the research, its procedures, risk, benefits, and the voluntary nature of the participation. Furthermore, the subjects have the right to stop the research at any time. The informed consent was given to the participants and explained in detail for illiterate women.The context of this study was set in Tabriz (a city in the northwest of Iran with population around 1.5 million). A sample of 18 menopausal women was recruited by health care providers in the urban health centers over six months (from February to July 2012). They were a heterogeneous group from different educational levels, occupational and marital statuses. Samples were selected through the purposeful sampling method. In this type of sampling, researchers recruit sample respondents with a rich experience of the phenomenon (menopause) and the ability and tendency to express their experiences . No part We defined menopause according to the World Health Organization classification as a condition of absence of spontaneous menstrual bleeding for more than 12 months, for which no other pathologic or physiologic cause could be determined. We selected those who met our eligibility criteria, which included lacking a history of endocrine disorders, hysterectomy, oophorectomy, and psychological disorders. Those with menopausal age less than 40 years or reached menopause more than 4 years before recruitment were rejected from the study.Face-to-face, in-depth, and semi-structured interviews were performed for data collection, and all interviews were audiotaped. Participants were given the opportunity to talk about the study-related issue. All of interviews were conducted at the urban health centers. For achieving the maximum variance of participants, we selected 10 health centers that were located in different places with respect to socio-economic conditions. The interviews were conducted by a single researcher (first author), in Azeri language and took place in a quiet private room, and no one was present except the researcher and participant during the interviews. The interview guide had three questions, which were provided to collect data about experienced concerns of menopausal women. The interviews were continued until no new information or opinions were obtained about the interview topics. The average length of interviews was about 30-50 minutes. All audiotaped interviews were transcribed verbatim. A pilot study on three women had been conducted to refine the interview guide beforehand. The interviewer asked three main questions to help the interviewees get focused. The questions were as follows: “What did you feel when you became aware that you were going through menopause?”, “What was your main complain during your menopause?”, and “Were you concerned about these complains?” All the written transcripts were compared with the audiotapes for accuracy, and any errors in transcription were corrected. After becoming familiarized with the raw data, we classified and coded them.With regard to Van Manen’s research activities about the selective or highlighting approach, the statements or phrases that seem particularly insightful into the phenomenon was used in this study. Data were analyzed concurrently with the data collection, using thematic analysis as described by van Manen . To gainIn order to bring the meanings to the surface, the researchers frequently wrote, rewrote, went into depth, and reviewed the findings several times. On several occasions during the research/analysis process, the researchers ‘stepped back’ and looked at the whole context again, and analyzed how each part has contributed to the whole . FinallyThe trustworthiness of the findings was enhanced using Lincoln and Guba’s criteria: credibility, transferability, dependability and confirmability . To achiOne of the mentioned participants was illiterate, and the recorded interview was explained exactly and read for her word by word. Also, bracketing was used to increase credibility . DependaEighteen semi-structured and in-depth interviews were conducted. The mean age of participants was 52.11 ± 2.9 years (age range: 46-57 years). The characteristics of participants are shown in .Thematic analysis showed 4 main concerns, composed of “inability”, “elderly”, “isolation”, and “losing wellness”. Findings are shown in .All of the participants were worried about their “inability” in the future. Menopausal women were concerned about “inability” to live an independent life, performing the religious rituals, performing daily housework, and forgetfulness.All of the participants were worried about losing their autonomy and being a burden to their children and other family members. Muscle and joint pain was cited as the leading sign of the sense of “inability”.“I’m afraid of osteoporosis; I love to travel. I hate being dependent on others and I am afraid to be a burden to my family; I like to manage my family, if one day I lose my autonomy, I will break… ” .“I have severe pain in my knees and back; I am worried about becoming paralyzed. If I am unable to move and become immobile, who will do my housework? Nowadays, nobody helps the others…. I’m afraid of becoming a burden to under obligation of my children… “.About half of participants disclosed that they could not perform their daily prayers and other religious rituals due to urinary incontinence. The urine is considered impure (Najes) in the Islamic rules, and therefore, it invalidates the daily prayer. Muslims are commanded to pray with clean clothes. “I have this urine problem; I go to the toilet normally but when I laugh, cough and sneeze a few drops of urine come out. I change my underwear continuously. I can’t pray because I’m unclean and impure … I am very concerned about it…” .Less than half of the participants suffered from premature fatigue. They mentioned that they could not perform their daily housework as usual because they get tired very fast. “I can’t do my chores, because I get tired too fast. Whenever I can’t finish my daily chores I get nervous, but I can’t do them right and conduct them correctly, I like my house to be clean and organized. Sometimes I am preoccupied about the future. What will happen if I lose the capacity to clean my house, what would become of my life? .About half of the women were worried about their episodic memory loss and indicated that their memory was impaired after menopause. They mentioned that they had problems in recalling people’s name, messages, telephone numbers and addresses, and they cannot plan for their daily life. “My memory condition worries me. I can’t remember some of the words, I have no memory of anything to be able to talk with people, and I can't hold a conversation anymore” . "I am telling my children: don’t give me anything because I may misplace it; When someone asks me something, I forget it” .Some women were concerned about getting older after the onset of menopause. In their view, menopause has a close relation with aging and it is the start of senility. Two sub-themes that covered this theme were “future” and “appearance”.Some women expressed their concern about the future and aging. “I’m worried about my future and health. What I’m doing in the future? I feel my body shrinking down, and my health worsens day after day. What will happen to my health? ” .Half of the participants were concerned about their face and skin. “After menopause the wrinkles are appearing in my face. Every time I glance in the mirror, I see wrinkles, and I remember my youth and the years I lost” . But majority of participants mentioned that the aging is not associated with menopause. "Menopause is not getting old. Getting old depends on our feelings and spirit. If a woman exercises and travels; she can stay young even 20 years after menopause or even more. I hope to get old after the age of 80 or 90" . “The wrinkles are a part of my face; they are not related to menopause. This is a normal process which is the result of aging not menopause” .The sub-themes of this experience were isolation for mood swing and malodor urine.Some participants expressed concerns for mood swings, irritability, depression and their tendency to bring about loneliness that affected them after menopause.“I am always sad and depressed. My children and my husband are very kind, and I haven’t any problem in my life. But I feel really sad since I became menopause. Sometimes I feel my children get tired of me. They don’t understand me. They say, you are always impatient … I know that if I got irritated, nobody would like me… people must be kind and patient. I know this and I am afraid that nobody can tolerate my mood, and I will end up alone” .Some participants disclosed that they have urinary incontinence and are concerned of urine malodor and isolation. ”I suffer from incontinency. I think that I smell like urine. I’m worried. If I smell continuously, nobody likes me. Nobody wants to speak with me. Nobody wants to come to my house .One of the participants’ concerns was expressed around health problems, including osteoporosis, blood sugar and lipids, muscle skeletal problems, psychological problems, myocardial infarction and forgetfulness.A number of women were worried about osteoporosis. ‘’I heard about osteoporosis. My mother suffered from osteoporosis; my sisters were affected also. I’m afraid that one day I am affected by osteoporosis just like my mother and sisters . Some participants mentioned that menopause was a predisposing factor for diabetes and elevation of blood lipids. “I have diabetes. My physician told me that it’s due to the menopause. I am concerned that my blood pressure and lipids might be raised. I am afraid of high blood pressure .Half of the participants stated that they had suffered from joint pain and muscle stiffness, especially in the mornings. “When I wake up, I have lots of muscle and joint pains. My body felt extremely stiff and achy and one or two hours must be passed till I feel better by exercise, and I should do some exercises. I think why I am always sick? What is my disease? .Some of the participants were concerned about their psychological problems. “I cannot sleep well since I became menopause. My doctor warned me about harmful effects of sleeplessness on my heart and blood pressure. Do I have psychological problems? Do I have a serious disease? .Some of the participants expressed their concerns about Alzheimer and forgetfulness after menopause. “I forget everything; I forget the order (Rakat) of my prayer. I’m worried about getting Alzheimer. I think my brain is hanging ."Sometimes, my children’s friends call and leave a message. After getting off the phone, I forget who called. I forget the massages. Last week, I couldn’t find my house after getting off the taxi. I was very afraid. I told myself: What should I do? A Few moments later, I remembered my home address. I am afraid that one day I lose my mind and get Alzheimer".This study is the first qualitative research that conducted to explore Azeri menopausal women`s concerns and hidden fears associated with menopause. This study demonstrated that the main concerns of women were “inability,” “aging,” “isolation,” and “healthiness and well-being”.These women were worried about losing their independency, and having a productive life, outward appearance and the inner nature of aging, bereaving their communication with others because of their irritable and changing mood, as well as bad smell secondary to their urinary incontinence, and finally suffering from osteoporosis, cardiovascular diseases and cancers. Their fear of inability was also aggravated by experiencing pain in their joints and muscles. They were worried about pain worsening that may lead to their inability to perform daily activities and leave them to be a burden for others.The concern about functional ability may be related to feelings of losing autonomy and decreasing self-esteem in addition to the viewing menopause as an ageing process. It is demonstrated that cancerous people concern about being a burden for other family members, and experience a feeling of losing their identity by increasing dependency to others .There are very limited facilities and social services for elders in Iran . So, theThe participants mentioned the inability to perform religious rituals resulted from urinary incontinence as a concern during menopause. It is well documented that religion has beneficial effects on adjustment to physical, social, and existential aging . ReligioIt is essential to be clean and free of any fecal and urine material for praying in Islam. The religion has a strong relation with Iranian culture and daily praying is one of the most important and vital parts of Iranian women's life. So, women's concern about inability for praying was expected.The concern about inability for performing housework resulted from premature fatigue. Management of house chores is among the main responsibilities of Iranian women and failure to conduct them induces the sense of inability. It is demonstrated that Jordanian menopausal women concern about fatigue , perhapsOur findings showed some of the participants were worried about elderly. Their concern was related to deteriorating health and "feature and their face." While others considered aging as a natural process which should not be worried about it. In another research in Iran, women concerned about aging . Similar Our findings indicated that the minority of women who worried about their appearance came from middle social class according to their education and socio-economic class. Delanoe et al. in a qualitative study noted that “concern about seeming” expresses mainly from the middle social class women . It seemThe influence of endocrine function on mood swing of menopausal women needs to be researched. Probably, psychological factors, lifestyle, body image, interpersonal relationships, role, and socio-cultural factors affect mood swing in menopausal women . The parIn a qualitative study, some women thought they should seek help if they experience a swinging temper because it seemed so intolerable . In anotWomen expressed their concern about isolations due to odorous urine resulted from incontinency. They concerned about their relationships with their family members and friends, which were endangered by urinary incontinence and might lead to the loss of social relations, social support and identity. Fear of the smell of the urine is reported very often by women who experienced urinary incontinence . In addiOur participants also worried about their physical and mental health. Iranian women`s concern about osteoporosis, and blood pressure was reported in another study . Thai miThis study was a qualitative study, and the findings can provide a deep understanding of women’s perceptions and experiences about menopause; findings which could not be achieved through quantitative studies. Variety in sampling was an advantage of the current study. Participants of the study belonged to different socio-economic backgrounds. However, this study has some limitations. Menopause is a private and sensitive issue in life of the Azeri women, and speaking about such topics is not easy. Although the authors tried to develop an intimate atmosphere during the interviews, the participants may not completely be comfortable to reveal their feeling and experiences. Voluntary participation made a frame for exclusion of the experiences of those who did not wish to participate in the study for any reason. Also, all participants were selected from an urban community of Tabriz. Therefore our findings do not reflect menopausal experiences of rural communities or other Iranian ethnicities.Menopausal women experience four main concerns of inability, aging, isolation and losing wellness and healthiness. It seems that our participants felt insufficient support by their family members. Regarding the recent trend of Iranian population toward elderliness, integrating the comprehensive educational and care program for menopausal women and their family members in primary health care system and developing appropriate infrastructure for elderly people seems to be necessary.


Health of migrants is known to be above-average in the beginning of the migration trajectory. At the same time reports from non-government organisations (NGOs) suggest that undocumented migrants in Germany tend to present late and in poor health at healthcare facilities. In this paper, we explore the health status of undocumented migrants with a mixed method approach including complementary qualitative and quantitative datasets.t-test and with a generalized linear model analyzing the impact of living without legal status on HRQOL. The quantitative research was complemented by a qualitative ethnographic study on undocumented migration and health in Berlin, Germany. The study included semi-structured interviews, informal conversations and participant observation with Latin American migrants over the course of three years. The study focused on subjective experiences of illness and health and the impact of illegality on migrants’ health and access to health care.Undocumented migrants attending a NGO based in Hamburg, Germany, were asked to fill in the SF-12v2, a standardized questionnaire measuring health-related quality of life (HRQOL). The SF-12v2 was analyzed in comparison to the U.S. American norm sample and a representative German sample. Differences in mean scores for HRQOL were evaluated with a n = 96) as compared to the U.S. American sample (p < 0.005). Living without legal status displayed a significant negative effect on subjective mental and physical health (p ≤ 0.003) in the generalized linear model when adjusted for age and gender compared to the representative German population sample. The ethnographic study, which included 35 migrants, identified socio-economic conditions, the subjective experiences of criminalization, and late presentation at healthcare-facilities as the three main factors impacting on health from migrant perspective.HRQOL was significantly worse in the sample of undocumented migrants (The present research suggests a high morbidity and mortality in this comparatively young population. The ethnographic research confirms negative impacts on health of social determinants in general and stressassociated with living without legal status in particular, both are further aggravated by exclusion from health care services. In addition to the provision of health care it appears to be important to structurally tackle the underlying social conditions which affect undocumented migrants’ health.Living without legal status has a negative impact on health and well-being. Limited access to care may further exacerbate physical and mental illness. Possibilities to claim basic rights and protection as well as access to care without legal status appear to be important measures to improve health and well-being. The number of undocumented migrants in Germany is estimated to range from 100,000 up to 1,000,000 . While tMigrants without a valid residency permit in Germany are referred to as undocumented migrants. Every state institution in Germany is obliged to report migrants, who cannot provide a valid residence permit, to the police or migration authorities, according to §87 of the German Residence Act [Aufenthaltsgesetz] with few exceptions. As a result contact to official institutions for any purpose including claiming basic human rights, such as labor rights, protection from crime or access to health care can result in deportation and makes undocumented migrants vulnerable to exploitation.Access to medicine for undocumented migrants is regulated by §§4 and 6 of the German Asylum Law [Asylberwerberleistungsgesetz]. It offers access to health care for acute or painful diseases and obstetric conditions. In practice accessing health care according to the German Asylum Law requires sharing personal data of undocumented migrants with state institutions in accordance with §87 German Residence Act, which can result in deportation when seeking health care.Since access to health care under the German Asylum Law is effectively associated with a risk of deportation for undocumented migrants, other ways of dealing with health conditions are usually employed. Presence of disease is neglected as long as possible and health services are only accessed if self-medication and informal network support proved unsuccessful , 6–12. WUndocumented migrants have been reported to be younger and less healthy than common patients at health facilities , 16. FurSince undocumented migrants systematically elude themselves from empirical research, representative data on the health status of undocumented migrants is unavailable. While undocumented migrants do not appear in official registration data nor in hospital and health insurance records, self-reported health-related quality of life (HRQOL) can provide insights into the health and well-being of this hidden population.Health-related quality of life (HRQOL) represents a broad concept of health. It is a multidimensional construct incorporating physical and mental well-being as much as social relations and functional competences . HRQOL hA European review found migrants to rate their health poorer than the usual population , some evSince data on health of undocumented migrants is scarce, the objective of the present study is to assess the health status of undocumented migrants by using a standardized HRQOL-questionnaire combined with qualitative ethnographic analysis adding insight into perspectives on health of undocumented migrants.We applied a mixed methods approach to combine the advantages of a standardized instrument to measure subjective health with the benefits of qualitative research in generating knowledge about experiences, biographies and social interactions. Triangulation of different types of data and research methods increases the validity of data and allows gaining more comprehensive insight into health of undocumented migrants.Undocumented migrants are frequently confronted with situations that may appear threatening to them, given their inability to claim their rights and the possibility of being denounced to authorities by others. An utmost concern in designing the study was to balance gathering comprehensive information against the danger of keeping migrants from participating due to their sensitivity to data collection. Furthermore much effort was made to ensure participants in both studies understand the voluntary and anonymous nature of the research. The quantitative study was approved by the ethical committee of the Medical Association of Hamburg, Germany (Aerztekammer Hamburg). For ethnographic studies in Germany, ethical review is not formalized; the qualitative study followed the ethics declaration of the German Anthropological Association (DGV e.V.). In both studies the principles of the declaration of Helsinki regarding ethics in medical research were followed. Informed consent was obtained verbally in both studies. In the quantitative study, migrants who were not capable of communicating in English, German, Spanish or French themselves or through an interpreter of their choice were not included in the study. The interviews and conversations in the qualitative ethnographic study were all conducted in Spanish. The names of all participants were changed.The present sample consists of migrants who visited the organization for medical counselling of refugees and migrants in Hamburg (short: Medibuero) within a research period of six months in 2007. The Medibuero is a local NGO organizing health care anonymously and free of charge for undocumented migrants.The Medibuero was at the time of research the only NGO offering access to health care for undocumented migrants in Hamburg. All migrants visiting the Medibuero for a doctor’s appointment, who consented to participate, were asked to complete a standardized questionnaire about HRQOL after they had been attended to by the Medibuero staff. Questionnaires were filled in by the migrants on the spot in the Medibuero office or, where help was needed, researchers assisted participants in filling out questionnaires. Age and gender were recorded together with physical or mental health complaints for which medical care was sought.Short Form-12v2 Health Survey (SF-12v2) constructed by Ware et al. to measure HRQOL : ‘Please, please, I need to see a doctor.’ After that, I got better, but then I got really, really sick again. It was the fear of the police, that the police would come find me. (…) A friend told me I could come live with her for a while, so I moved all my stuff, imagine, doing all that while being so sick. (…) With my ears, I was so ill, I said to myself, I want to rest, I am sick. If the police come – they come, I don’t care. I’ll go back [to Bolivia]. I couldn’t sleep. It was difficult, you know. I don’t know why I am suffering…so much stress…and with my son [starts crying], I am sick, my ears hurt… Sometimes I don’t know what to do.” Dominga came from La Paz, Bolivia to Berlin in 2009. The woman in her early twenties was invited over on a tourist visa by a Bolivian family who employed her  as a care-taker for their children. They had paid for her travel costs, and expected her to pay off her debt by what came down to working for less than one Euro per hour. Half a year after she arrived, when her visa had already expired, Dominga realized that she was pregnant. After she had digested the shock of the unplanned pregnancy, Dominga decided to keep the child, and to make a life for herself and her son in Berlin. The following years were shaped by hardship: as an undocumented migrant and single mother, Dominga relied heavily on friends and non-governmental organizations to get by. She received perinatal and postnatal care through the Berlin-based Medibuero, one of the non-governmental organizations introduced above. The rent for the apartment she lived in was paid for by a network of women supporting undocumented Latin American migrants. A few months after her son Christian was born, Dominga started working as a cleaner in private households. She could only work for a few hours at a time, as she had no one to take care of her son while she was working. When her child was not yet a year old, she had to leave the apartment she was living in because her former employer, who felt that she had betrayed her by leaving her ‘job’ and not paying off her debt, had found out where she lived. Dominga was worried that she would denunciate her to the police. She explained in an interview:“There is no security here. What happens to my son if I get sick again? Who takes care of him? It is too much stress, too much fear.” .Dominga was ill for almost one year. In addition to the ear infection, both she and her son suffered from a persistent cough and were eventually diagnosed with pneumonia by a Medibuero doctor and hospitalized for 10 days. In the end, she decided to return to Bolivia:trauma” and a “shock”: “Nobody tells you what it is like to be illegal.” Like most other research participants, Jaime came to Germany to improve his life, to “get ahead” by studying and earning money. He suffered a great deal from what he perceived to be a failure to achieve his aims. He said:I was very depressed, it was a bad life. It was tearing me apart. To see your dream shattered means to see yourself shattered.”“Jaime, a young man from Chile, had come to Europe – first to Italy and then to Germany – with the aim to study. His student visa application failed, however, and he ended up as an undocumented migrant in Berlin. The four-hour interview was not recorded, as he was concerned about confidentiality, so the following narrative is based on extensive notes. At the time of the interview, Jaime’s status had been legalized through marriage. Looking back, he described being an ‘illegal immigrant’ as a “losing reality”, as he puts it. Linking his physical and emotional health to his living circumstances, he commented:This [living illegally] really pushes you to the limit. It’s an emotional crisis; it’s a state of un-well-being. Bad alimentation, too much work, too much stress, sleeping badly. All of this directly affects the heart.” .“He started drinking heavily, started “Tabea: “The situation [being illegalized] affects me, it even affects my health! Sometimes I stumble into a depression. I can’t even travel; I always have to watch out. (…) I am always scared, I have so much fear. So far, I never ran into a control. Thank God! (…) If I didn’t believe in God, I couldn’t go on here; I wouldn’t be able to bear the situation, right? Because it’s a situation… it’s a shitty situation really.”Interviewer: “And how does that affect your health?”T: “I am very depressed, every time I leave the apartment I say, my God, please protect me. That nothing bad happens to me, because I don’t know what’s going to happen. Because of that, I can’t live in tranquility. So, that [sighs]… that affects my health, because I am always nervous, I always live with this fear that something could happen to me. And I get depressed because I feel trapped, I can’t do anything, everything has to stay secret, I have to lie, when somebody asks me if I have a student visa, or when I met a guy, I can’t tell him the truth because I am scared that he might think something else [that she only wants to be in a relationship to get married and be legalized]… So, I have my limits, I have met people who have lived here illegally for 10 years, and I tell them: How do you live?? Tell me, how do you live?? (…) I have been here for 7 months. I can’t do it, I can’t!! I always have this fear, I always cry, I am not doing well.” Tabea came to Germany in 2007, together with her German boyfriend whom she met in Bolivia. She wanted to study German in order to improve her education and subsequently, her job opportunities. Like Jaime, she was denied a student visa, and once her tourist visa ended, she was illegalized. In an interview, she described how her illegal status affected her life:We utilized a mixed method approach to investigate subjective health of undocumented migrants and influencing factors. We demonstrated that HRQOL of undocumented migrants is significantly lower than in comparison groups, in particular mental health is rated lower and pain intensity is rated higher. The results of the qualitative research illustrate how negative social determinants, stress and fear, and exclusion from the health care system contribute to a deterioration of the health of undocumented migrants.Undocumented migrants rated their health significantly worse than the general population in all eight dimensions of HRQOL measured by the SF-12v2. Scores were particularly low in the dimensions assessing pain, mental health, role limitations due to mental problems and social functioning. Subjective physical and mental health was worse for undocumented migrants than for German and U.S. American comparison groups. Given the mean age in the U.S. American norm population of more than 50 years, it is likely that undocumented migrants were not only less healthy but as well much younger than their U.S. American comparison group in accordance with what has been described in the literature , 16. TheThe ethnographic study supports these findings, sheds light on the prevalent stressors and explains how and why the health status of undocumented migrants is often significantly worse than the health status of legal residents, as discussed below.SF-12v2 physical and mental health summary scores as well as the eight subscales correlate with social determinants of health such as socioeconomic background, education attainment, income and employment . They arThe results of the qualitative study support this interpretation. In regard to undocumented Latin American migrants, however, this study also shows that negative social determinants are not limited to factors such as poor housing and precarious labor conditions, but are largely due to the inherent fragility of their life , due to In addition to precarious socioeconomic conditions, for example job insecurity, which also affect others groups of society, undocumented migrants experience additional stress of criminalization and fear, as described in the case examples. Fear of deportation and discrimination have been shown to independently affect subjective health of migrants , 29, 30.Negative impacts of socioeconomic hardships, insecurity and fear may be exacerbated by limited access to healthcare. The ethnographic study and the available literature suggest that problems in accessing healthcare are common among undocumented migrants and particularly affect the people who recently migrated , 28.Long latency before physician consultation can lead to more severe symptoms, chronification, or to a general deterioration in overall health. Undocumented migrants experience more pain than the comparison groups. High scores of pain and poor general health can be indicators for long latency before accessing health care – a characteristic pattern of health care seeking behavior of undocumented migrants described in the literature , 15, 28.Quantitative study: Given the lack of available data about population size and characteristics and the seclusion of the population, no random sampling could be conducted. Age and gender distribution within the obtained sample were similar to the demographic characteristics of undocumented migrants described by other health care providers , 15, howt-test indicates. Non-parametric tests could not be applied to the U.S. data for lack of detailed data. As part of sensitivity testing, the generalized linear model was recalculated on the basis of data transformed by complex logarithmic transformation [f(x) = ln(1/(1-(MCS/100))] to comply better with model requirements. Transformed data indicated the same grouping , similar differences and significances and nearly straight relations between age and mean scores. Similarity of results of the models based on original and transformed data indicates that the generalized linear model on the basis of the original data represents the interrelations sufficiently.Statistical tests applied were based on normal distribution. The scores of the obtained sample in the eight dimensions of subjective health were slightly skewed, for all but the dimension of general health and social functioning, to the left, indicating that differences might be overestimated. However, summary scores of the obtained sample of undocumented migrants were normally distributed, but the comparison groups displayed slightly left skewed scores . Given tQualitative study: Undocumented migrants constitute a diverse population, and differences in regard to region of origin, educational background, gender, and migration experience will shape the living conditions and consequently the health experiences in Germany. Compared to other undocumented migrant groups, Latin Americans in the present sample were relatively well-educated, and most of them did not migrate because of war, violence or hunger – their main reason to migrate to Europe was a lack of economic opportunities in their country of origin –45. ThusWhile being descriptive in nature, the present research sheds light on the health status and need for health care of a hidden vulnerable population often overlooked in health care planning. Subjective health and quality of life have for the first time been described in undocumented migrants in Germany using a valid and reliable instrument that allows inference from HRQOL to morbidity, health-care-needs and social determinants , 26, 38.


N = 1362), with a focus on four parenting style dimensions: responsiveness, demandingness, neglecting, and intrusive. Responsiveness seems to capture major divisions in parenting. Adolescents in families with fewer economic resources experienced their parents as somewhat less responsive, but responsiveness was not related to parents’ education. Low parental education was on the other hand associated with perceptions of parents as neglecting and intrusive. Viewing parents as demanding did neither vary with parental education nor with family economy. Substantial variations in parenting styles persist in present-day Norway, and these variations correspond moderately with the families’ placement in the social structure. Indicators of parenting and parenting styles may be useful indicators of some aspects of child and adolescent well-being.Previous research has documented the associations between parenting and parenting styles and child and adolescent outcomes. Little is known, however, about the social structuring of parenting in contemporary Nordic welfare states. A possible hypothesis is that socioeconomic variations in parenting styles in present-day Norway will be small because of material affluence, limited income inequality, and an active welfare state. This study examines social variations in parenting as perceived by Norwegian adolescents ( How parents raise and rear their children is related to their offspring’s lives in many ways. Following Baumrind’s seminal work on parenting and authority Baumrind , 1978, aThus, parenting which combines high levels of warmth with moderate levels of control seems associated with higher levels of well-being among children and adolescent. It has been argued that the positive effects of this type of parenting have “transcontextual validity” and are found across different “ecological niches” in terms of parents’ social position, ethnicity and family type . Often, specific parenting practices do not have definite, predictable effects; rather, the results will vary with the parenting style displayed by parents. The effects of particular practices will depend on the emotional environment in the family, and “(p)arenting style alters the parents’ capacity to socialize their children by changing the effectiveness of their parenting practice. From this perspective, parenting style can be thought of as a context that moderates the relationship between specific parenting practices and specific developmental outcomes” (1993: 493).Parenting styles are thus associated with the In empirical studies, parenting styles have been operationalised in different ways. A very influential typology has been proposed by Baumrind , with exconfigurational, i.e. as particular combinations of the responsiveness and demandingness dimensions , and practically free health services, relieves parents of some of the financial burdens of parenting. The welfare state which directly and indirectly conveys norms and ideals of modern parenting to all families could have had repercussions in terms of more homogeneous parenting practices.Demographic changes may also impact on the socially structured patterns of parenting. Socioeconomic disparities are intersected by new divisions because of changing family structures  and the increasing proportion of immigrants in the population. A recent British study, for instance, suggests that parenting “in contemporary UK is structured primarily by family structure and not by social class”  conducted when the child/adolescent respondents were 12–18 years old, supplemented with the 2006 interviews (1065 respondents participated both years). Because of partial non-response, the number of respondents in separate analyses will be somewhat lower. The 2003 interviews are not used since only a few of the parenting questions were asked at that time. As usual in panel studies of long duration, sample attrition was considerable . Among those who were interviewed in the first wave in 2003, however, 70 % (1362 out of 1937) participated also in 2009. A main purpose of the project was to study consequences of low income for children’s well-being, and families assumed to be “poor”  were initially oversampled. Later, as the Norwegian economy developed favourably and parents’ careers evolved, many of the families improved their economic conditions, and less than one fifth of the “poor” children in 2000 were still living in a “poor” family in 2008. Because the economic divide between the two sample parts had narrowed, they are pooled in this paper, but a dummy variable indicating subsample origin has been included in the multivariate regression analyses in order to adjust for possible effects of different sample origins.The present study analyses the 2009 interviews , suggests the degree to which adolescents experience their parents as disinterested, unhelpful and unconcerned, while the interpretation of the fourth dimension, intrusive (two items), is that it reflects how parents act in overly controlling and invasive ways.The factor analysis indicates that four dimensions capture much of the variations in the adolescents’ answers. The first dimension (high loadings on six items) reflects the degree to which parents are experienced as understanding, easy to communicate with, accepting, supportive and trustworthy. This dimension is clearly similar to the main component of the Baumrind typology and is therefore termed Chronbach’s alpha coefficients (Appendix Table r = 0.44); thus, parents perceived as responsive were also often perceived as observant of the adolescent’s activities. Responsiveness and the neglecting dimension were, on the other hand, negatively correlated (r = −0.44), indicating that feelings of neglect often went together with parents perceived as less responsive. Demandingness was also negatively correlated with the neglecting dimensions, although weaker (r = −0.26), while the intrusive dimension had comparatively low correlations with all the three other parenting dimensions.The parenting dimensions were interrelated in characteristic ways (see Appendix Table Family income is the yearly average for 2007 and 2008 of the sum of disposable (i.e. post-tax) incomes for all household members, divided by household weights  of the monetary value of the household members’ bank accounts, stocks, shares, and similar assets which easily can be converted into cash. The importance of such financial assets for families’ level of living has been demonstrated in recent studies . Elmelech . The thiThe associations between the family economy indicators and the parenting dimensions deviated from linearity, in particular ways for each of the four parenting scales. In order to reflect these patterns, the economy variables were recoded into categories as described in the tables.parental education, i.e. the parents’ average number of years in formal education (including the compulsory 9 years), obtained from Statistics Norway’s educational register, and recoded into three categories. Those who lacked educational information (<5 %) were considered as having elementary schooling. Non-Western immigrant  indicates that both parents were born in a non-OECD country. Family structure, based on questions asked the interviewed parent, indicates with whom the adolescent was living; both biological parents, or one biological parent  and a step-parent, or in a single-parent family. Parental employment, also based on parents’ answers, indicates whether any adult family member was employed at the time of interviewing. Parent’s self-rated health is a three-level ordinal variable based on the interviewed parent’s answers about his/her overall self-assessed health situation. About four per cent had missing values on these questions and were assigned the sample’s modal value.Other explanatory variables include First, the sample distributions and the bivariate associations between the parenting dimensions and the independent variables are displayed. These bivariate analyses may be confounded, however, since several of the independent variables are correlated . Therefore, multivariate OLS regression models are used in order to show the cross-sectional relationships between parenting, as reported in 2009, and the total family economy and the other indicators of parental and family characteristics, adjusted for other covariates.causal effects, however. Unmeasured circumstances such as the work history of the parents, or their personal traits and social skills, could have affected both the families’ economic resources and their parenting styles. The panel structure of the data offers a way of approximating a causal estimate , could not produce changes from 2006 to 2009 in the adolescents’ perceptions of their parents’ behaviours. Given these assumptions, the changes in perceived parenting from 2006 to 2009 must be due to changes in the adolescents’ environments from around 2006 to around 2009. Using this logic, a more unbiased estimate of the role of family economic resources can be obtained, by analysing how changes in these resources influenced changes in the perceptions of parenting.These cross-sectional analyses do not necessarily indicate  Allison . We assuchange scores for the parenting dimensions . Similarly, we calculated a categorical variable indicating how the total family economy changed from 2004/2005 to 2007/2008. Also other change scores were included as predictors: A variable indicating family disruption (a dummy variable showing whether married/cohabitating parents in 2006 had split up in 2009); indicators for change in parental employment ; and a variable indicating deterioration (versus being stable or improved) from 2006 to 2009 in the interviewed parent’s self-rated health. Together, these indicators reflect developments in the environments of the adolescents which could influence their views of their parents. The models, with changes in perceived parenting as outcomes, were estimated by OLS regression. Gender, immigrant status, and parental education were not included as predictors as they are, in principle, invariant circumstances which could not lead to changes in perceived parenting. – The analyses were performed with SPSS Version 21.Accordingly, the 2006 and the 2009 interviews were used for estimating bivariate associations displayed in Table The The lower half of Table multivariate OLS regression analyses indicating the effects of the structural indicators while controlling for the effects of the other independent variables. Responsiveness increased consistently with a better total family economy, and responsiveness was significantly higher (using the standard p < 0.05 criterion) in the “richest” families, compared to families lowest in the economic hierarchy. Less responsiveness was also reported by adolescents aged 16–18 (compared to younger adolescents) and by adolescents whose parent had reported poor health, but neither parental education, gender, nor non-Western immigrant background was associated with responsiveness.Table As to demandingness, marked age and gender variations can be observed, but neither parental education, total family economy, nor non-Western background had any noteworthy associations with this parenting dimension. As to the neglecting and intrusive dimension, Table changes in adolescent circumstances are followed by changes in the perceptions of parenting, it is not unlikely that these circumstances have a direct causal effect on the outcomes. OLS regression analyses based on this logic are reported in Table If B = −0.18, p = 0.06), while the astonishingly large effect of increased parental employment on intrusive parenting was probably due to chance.Nevertheless, after adjustment for other environmental changes and for the constant family-related factors (both measured and unmeasured), an improved total family economy from 2004/2005 to 2008/2009 was consistently associated with higher reporting of responsiveness in 2009 than in 2006. In families with the largest economic gains , the positive change in perceived responsiveness was significantly larger than the change reported in families with practically stable (or declining) economic resources. Separate analyses indicated that this pattern occurred both in families with high and low parental education (tables not shown). Thus, Table r = 0.44) indicates that the two dimensions represent somewhat diverging aspects.This study indicates that Norwegian adolescents’ perceptions of their parents can, to a considerable extent, be captured by four underlying dimensions: Responsiveness, demandingness, neglecting and intrusive. Variations in responsiveness seem a particularly important aspect of the differences in parenting in contemporary Norway. The structure of parenting dimensions, as reported by adolescents, are in many ways congruent with the models developed several decades ago by Baumrind , 2013. RHowever, the results question whether the actual variations in parenting in Norway can be adequately reflected by only these two major dimensions. Two other dimensions, named neglecting and intrusive in this study, emerged from the adolescents’ answers. Also the neglecting and intrusive dimensions distinguish to some degree between adolescents’ experiences, and future studies should explore whether such additions to the parenting dimensions are fruitful also in other social settings. While the responsiveness dimension, and also demandingness to a certain extent, represent varying degrees of positive experiences, neglecting and intrusive parenting signify unsatisfying parent-offspring relations which research also should pay attention to.Furthermore, the analyses revealed how the experience of parenting varied according to the adolescents’ structural positions. Girls more than boys experienced their parents as demanding, while boys experienced their parents as more intrusive. This could reflect that gendered expectations continue in spite of decades with gender equality policies  change in adolescents’ reporting of parental responsiveness. This pattern suggests that also in present-day Norway, a family’s placement in the economic hierarchy influences how the parent-offspring relationship evolves.A main issue for this study has been to investigate the hypothesis that the Norwegian context, characterised by material affluence, high educational levels, comparatively small income inequalities, and a supportive welfare state, would tend to weaken the associations between parenting and the families’ socioeconomic position. The findings both concur, and do not concur, with this hypothesis. The family economy seemed to have no associations with demandingness and the intrusive dimensions, and was only weakly associated with neglecting, in line with the hypothesis. Perceived responsiveness was, on the other hand, related to the income had usually negligible associations with variations in parenting. Only when the family’s financial assets were taken into account and used to form a composite indicator of the family’s total economic situation, a distinct association between families’ economic resources and responsive parenting emerged. Wealth and financial assets may actually be a better indicator of a family’s overall economic situation than yearly income in present-day Norway. The mechanisms linking economic resources to responsiveness cannot be further explored in these data, however. Relative deprivation might lead to parental stress which the adolescents experience as unresponsive parenting; but one could also speculate that when adolescents in an affluent society come to realise that their families are relatively unsuccessful in economic terms, they react with diminished respect and more critical attitudes towards their parents.A noteworthy finding is furthermore that variations in yearly Parental education was, on the other hand, associated neither with responsiveness nor with demandingness, but perceptions of neglecting and intrusive parenting varied clearly with parents’ education. The assumption that higher education would imply closer knowledge of modern theories of parenting and therefore be associated with more responsiveness was not supported, but the association between education and the neglecting and intrusive dimensions could nevertheless signify that parental education influences parenting. Studies from several countries . Thus, the social and socioeconomic patterns found in this study would not necessarily be replicated if other aspects of the parenting complex had been examined. Another limitation should also be mentioned: Parenting dimensions were extracted from a set of 17 questions, but the extent to which these items represent the “universe” of parenting in Norway cannot be ascertained without broader studies. Moreover, because of the sampling design and sample attrition, the adolescents analysed here cannot be considered a random sample of Norwegian adolescents born 1991–1997. However, the main purpose of this study has been to analyse the associations between perceived parenting and indicators of parental and family characteristics, and associations estimated from a somewhat unrepresentative sample will seldom diverge dramatically from those found in an entirely representative sample. It can also be noted that variations both in parents’ educational level and in families’ economic conditions are well represented in the analysed sample. The sample has a low-income bias—14 % of the sample were below the “poverty line” in 2008, compared to a nation-wide poverty rate of 8 % in 2006 among families with children (see Nadim and Nielsen N = 1937) with the distributions in the analysed sample interviewed in 2009 (N = 1362). In the latter, 24.8 % of the fathers had college or university education, as against 21.4 % in the 2003 sample, and the proportion of non-Western families was reduced from 18.0 % in 2003 to 14.7 % in 2009. Attrition from 2003 to 2009 was therefore more marked among certain family categories, but the 2003 and 2009 samples had nearly the same proportions of intact families and of parents with “very good” self-rated health. In conclusion, it is not probable that sample bias has led to drastically distorted results, in particular because attrition has resulted in an “upwardly biased” sample where it is likely that associations with socioeconomic indicators could have been attenuated.Parenting is a composite phenomenon, and parenting The results could be relevant for how indicators of a family’s economic situation should be constructed in childhood research. Family income could be a one-sided measurement; it is striking that family income had rather small associations with perceived parenting in this study, compared to the associations which emerged when the total family economy indicator was utilised. Rising affluence in rich countries could have implied that many families’ material standard of living, as well as their feelings of economic security, have become more linked to wealth and less reliant on current income. This suggests that financial assets or other indicators for family wealth should be taken into account when the economic resources in the families of children and adolescents are measured.Moreover, this study implies that indicators of parenting could be useful child indicators. As argued in the Introduction, it seems documented that the quality of parenting is associated with an array of outcomes representing both the well-being and the well-becoming aspects of children’s and adolescents’ lives. Adolescents’ assessment of the parent-offspring relation is relevant not only because of the associations between parenting and other outcomes of interest, but in its own right: Viewing parents as responsive, interested, but not uncomfortably intrusive, will constitute an important aspect of a satisfying parent-offspring relationship as seen by the adolescent.That parenting-related aspects could be included in systems monitoring child well-being, has indeed been recognised in recent child indicators research. “From the earliest years, the child’s sense of subjective well-being is intimately bound up with relationships, and particularly with parents and peers”, was pointed out in a recent UNICEF report UNICEF :40. A stA difficult issue is how to decide cut-off points which distinguish meaningfully between clearly satisfying and unsatisfactory parenting. In the UNICEF study, response alternatives ranged from “very easy” to “very difficult”, and the percentages answering “very easy” and “easy” in each country were reported. Whether this cut-off level reflects adequately a positive experience of parenting is open to further research. In the present study, the same difficulty is present, as we do not know how particular values on the parenting dimension scales are associated with other well-being measures.Differences in responsiveness and demandingness, but also variations in neglecting and intrusive parental behaviours, capture large parts of the variations in Norwegian adolescents’ experiences of parenting. Responsiveness is a particularly important dimension. Adolescents in families with fewer economic resources experience their parents as somewhat less responsive and supportive, but responsiveness appears to have no associations with parental education. Low parental education seems on the other hand to be related to more frequent perceptions of parents as neglecting and intrusive. The demandingness dimension, signifying the monitoring and controlling attitudes of the parents, did neither vary with parental education nor with families’ economic resources. Social variations in parenting dimensions in contemporary Norway seem relatively restricted, however, but the link between perceived parental responsiveness and the families’ economic resources is noteworthy.