Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President’s Emergency Plan for AIDS Relief’s (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya.The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including “mobilizers”, HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care.Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC. Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female to male HIV transmission.–3 Since The United States (US), via PEPFAR, took an early lead in funding VMMC for HIV prevention programs in ESA. In Fiscal Year (FY) 2016, PEPFAR spent over 15 million US dollars (USD) for VMMC services in Kenya alone. These fuAs a part of this process, epidemiological model-informed quotas or “targets” are set by funders for the number of MCs to be performed within a given timeframe . In FY 2016, 264,490 PEPFAR-funded MCs were performed in Kenya, thus excPrevious research has highlighted ethical and practical concerns associated with VMMC implementation for HIV prevention. Among scDuring research for a parent study on the responsible conduct of HIV research in adolescent populations in Kenya we received anecdotal reports from local health leaders and community stakeholders that raised concerns about the ethical implementation of VMMC among adolescents. Given the known ethical and practical concerns linked to VMMC implementation across ESA, we set out to conduct a qualitative study to learn more about VMMC practices “on the ground” in Kenya. Presented below, an analysis of the qualitative data we collected revealed that the pressure to meet funder-set service-delivery targets appears to generate some unintended consequences concerning the services provided and/or standards maintained by VMMC IPs.HIV prevalence in Kenya in 2017 was 4.8% overall among individuals aged 15–49, with a range at the county level of between 0.1% and 21.0%. This stuTo recruit stakeholders for interviews, our Community Liaison Officer asked for assistance from authorities at the regional Ministry of Health, Ministry of Education, and Health Department. Additionally, we sought approval from six VMMC IP NGOs to conduct interviews with their staff members and observation sessions at their clinics see . Two of Based on preliminary fieldwork in the region in 2016, we developed interview guides for each stakeholder category via an iterative process that relied heavily on the input and experience of our Kenyan team members . These guides included questions related to careers, roles, and experiences with VMMC, use of targets/quotas, clinical/mobilization protocols and practices, record keeping/documentation, informed consent, HIV testing, benefits and risks, training, the structure/hierarchy of VMMC IP organizations, and remuneration see .Study participation was voluntary and all participants gave consent before interviews began. Stakeholder interviews were conducted by AG in English (Swahili and English in one interview). These interviews took place in quiet, secluded locations, lasted up to 90 minutes, and were audio-recorded with permission. Kenyan team members who are fluent in English, Swahili, and the local language listened to the audio-recorded interviews and translated and transcribed them in English. The transcription process involved three steps. First, audio-recorded interviews were transcribed verbatim. Second, the transcriber conducted quality assurance by reading the transcript while re-listening to the audio. Third, the transcriber submitted the English transcript and the audio file to the Study Coordinator (FSO) for final review and designation as the final version of the transcript. Any portions of interviews that contained Swahili were first transcribed in Swahili before being checked, translated to English, and rechecked for accuracy by the Study Coordinator. Each interviewee received 500 Kenyan shillings (approximately 5 USD) for their time and transportation.A Kenyan nurse and public health worker who is knowledgeable about VMMC clinical procedures and fluent in English, Swahili, and the local language (BO) was our primary field observer. He conducted two- to five-hour observation sessions at 14 VMMC clinics run by the two NGOs (six administered by IP A and eight by IP B) and alongside the mobilization team activities at 13 community venues (six from IP A and seven from IP B). These venues/activities included two schools , four public marketplaces , two fishing villages , and five inland villages (door-to-door adolescent mobilization). The nurse/public health worker documented what he observed in detailed field notes. A medical anthropologist (AG) supervised observation activities.We identified four health facility levels  for VMMC observation. Level 2 facilities include dispensaries and small clinics usually run by nurses that provide basic outpatient care to up 10,000 people. Level 3 facilities are health centers that serve populations up to 30,000 and are staffed by midwives, nurses, clinical officers, and occasionally doctors. They provide basic curative and preventive, minor surgical, and reproductive health services. Level 4 facilities are primary, high-volume referral hospitals that serve populations of 100,000 people. Services offered include curative and preventive care and surgeries and emergency services that are not available at smaller facilities. Level 5 facilities serve larger populations. They focus on specialized services and provide clinical supervision and support to lower level, primary referral facilities., 29Our Kenya-based research team selected VMMC clinics to ensure that we conducted observations at a variety of facility levels in various sub-counties, as well as during relatively active  and slow periods (less than 15) circumcisions per day. Out of the 14 VMMC facilities we observed, two were Level 2, six were Level 3, five were Level 4, and one was Level 5. Upon arrival at each facility, BO, our Community Liaison Officer, or our Study Coordinator (FSO) informed facility staff members about our research and provided them with details concerning their IP’s approval for our observations to take place before they gave verbal consent. Observation sessions tended to coincide with the arrival of adolescent VMMC clients and their subsequent intake, counselling, testing, and circumcision. The mobilization teams associated with these clinics were identified and approached outside of the clinical setting for permission to observe their activities . Before these observation sessions began, members of the mobilization teams gave their verbal consent to be observed. Prior to beginning in-school observation sessions, school authorities and teachers were informed about the research and gave us permission to conduct the research activities.The institutional review boards of the Pacific Institute for Research and Evaluation (PIRE) and the Kenya Medical Research Institute (KEMRI) approved all study activities, including all the informed consent procedures described above. Locally, the county-level Ministries of Health and Education and the directors of each IP gave us approval to conduct this research.Kenyan team members translated and transcribed the audio-recorded interviews and checked the final transcripts for accuracy. U.S.-based team members conducted an early analysis of interviewee transcripts and observation-obtained field notes. The potential for the pursuit of VMMC targets to contribute to unintended consequences emerged during early data analysis. We created the codebook to define and identify themes related to the use of targets in VMMC policy and service delivery. Two teamTo meet VMMC quotas, local IPs communicate target numbers to their VMMC clinics and to the mobilizers who are responsible for supplying these clinics with clients to circumcise. The numbers of adolescent clients who undergo VMMC vary across the year, depending on the relative availability of clients and/or the ability of mobilizers to access them.Data collected from the stakeholder interviews and field notes suggest that funder-designated targets for VMMC service delivery effectively motivate mobilizers and clinic staff. As one 33-year-old, male mobilization supervisor put it, “…target or quotas act as the engine to make us do a lot of work and ensure that there is continuous [flow of clients]” [Mobilizer 1]. For mobilizers especially, monthly remuneration (and their future employment) depends on referring enough clients to the clinic each week; failing means earning less, regardless of the amount of time and effort invested in mobilization. From our interviews we learned that while most mobilization supervisors receive a base salary from their IPs regardless of the targets, other lower-level, subcontracted “associate” mobilizers or “peer educators” only receive payment by providing clients and meeting targets. Describing the competition this system fosters among mobilizers, a 28-year-old, male community-level mobilizer explained, “…we are paid upon reaching the target […] so we are really competing, until somebody may grab your clients before you know it” [Mobilizer 2]. For VMMC clinics, achieving targets is essential to the continued funding of their respective IPs. A 49-year-old, male mobilization supervisor offered, “…targets… are about funding, and [if] you don’t reach your target, you don’t get funding” [Mobilizer 3]. However, data analysis revealed that beyond motivating staff members, the pursuit of targets may introduce problems for VMMC implementation. Presented below, these areas of concern relate to the ebb and flow periods of VMMC client availability ,, 33 and Adolescent client availability for circumcision rises and falls throughout the year, primarily due to academic schedules: schools do not allow VMMC mobilization to take place on school grounds near the time of exams or other especially busy periods in the year. This results in “high” and “low” seasons for VMMC among these age groups. As Mobilizer 1 explained:There are times when they are having exams, or when exams are approaching, or when there is athletics or ball [soccer]; when those are taking place, we don’t get people coming… we end up having zero clients cut [circumcised]. And you know, when there are zero clients cut, all the pressure comes to the mobilization supervisor because the surgeons will be saying, ‘We are ready to cut, where are the clients?’ So the buck stops on me as the mobilizer; so it is not a very easy task.Likewise, a 30-year-old, female mobilization supervisor offered, “We bank on schools so much. And now, when they are taking their exams, you can’t pick a child from school [….] …when schools are so engaged, then definitely I will not meet that target” [Mobilizer 4]. Recognizing the need to strategize VMMC service provision around local school schedules (and client availability), some IPs may institute “Rapid Results Initiatives” or similar short-term drives aimed at increasing dramatically the number of MCs conducted during school holidays., 35, 36 VMMC clinical teams are generally comprised of at least one surgeon, surgical assistant, counsellor, and infection prevention officer. During tReferred to as “moonlighting” by our interviewees, VMMC staff may sometimes work extra hours, late into the evening, and/or over weekends or holidays when they would not normally be expected to work (for which they receive extra compensation) in order to handle large client loads, meet current targets, or make up for previous months when a lack of clients meant targets were missed. One 33-year-old, female counselor explained, “Yeah, you are put into pressure and you have to get the targets. We always know we have to get our targets, come what may. So we do moonlight to get those targets” [Counselor 1]. Similarly, a 39-year-old male Clinical Officer told us: “…if the number is high sometimes we can extend to weekends; and based on the clients flow like now… schools are going to be closed, and hence the number of clients is going to be high. So tomorrow [Good Friday] we may work” [Provider 2].While severe adverse events (AEs) beyond minor swelling, bleeding, or infection are rare, when theThen the other factor is the high numbers given as targets annually. So if you look at the number of clients you should do, you get fatigued along the line because remember you stand all day. So if you do 20 clients or 25 clients in a day, every day, say from Monday to Friday, it is a hell of a tiresome job…. So most of those AEs [are] attributed to fatigue, because if you look at the timings of most of the AEs, it is usually late in the evening, after lunch, afternoon; so it has always been attributed to high volume in terms of target, and then fatigue, then people not following the protocol. You find somebody, because he wants to finish faster, they want to split [meaning the surgeon and the assistant each operate on their own] instead of [following] MC protocol [and working together]…. It reaches a point where you have to split where everyone is doing [operating alone] because the number is high…. [Provider 3]Another unintended consequence of targets for school-aged clients is the long waits they may experience at VMMC clinics before and after MC, especially during the high season. Despite mobilizer claims about the short duration of the procedure, inadequate numbers of vehicles to transport boys, rough road conditions , and sometimes understaffed and under-resourced VMMC clinics mean that adolescents may spend hours waiting to be circumcised and then to be ferried back home. While making observations at one Level 3 facility, boys arrived for circumcision at approximately 8am; due to the staff’s late arrival (and possibly understaffing), circumcisions began at 12.30pm. At 4.15pm, when we left, these children were still waiting at the facility for transportation home. Some of the children were crying and saying that they want the pain “to find them at home”. One child stated, “We were told it will only take 20 minutes. This is not 20 minutes!” According to one 32-year-old, male primary school teacher, “…one day I attended a facility and [found] that a number of people are to be cut, but the officers who are doing this are just two. So they will do it up to very late [in the evening] and these boys are just there hungry, just with one bottle of soda which will not sustain them” [Teacher 1].Data collected during interviews and observations suggest that the drive to meet targets may lead some VMMC mobilizers to use misleading or otherwise questionable mobilization practices to increase the number of adolescents they can refer for circumcision. As Mobilizer 1 explained:Another thing is the peer mobilizers, yeah, someone wants to meet his or her targets and that is the time that they engage in what I called the uncouth methods, whereby the end justifies the means; whichever means that can make those clients come out. So you end up having the clients coming, but they are not coming for the VMMC the way we want it. They have been pushed; they have been coerced…yeah. This one is happening because of these targets. So that is the downside of the targets.These practices are sometimes blatant: during one door-to-door village mobilization, the mobilizer kept referring to himself as “doctor” although he had no medical training. Another mobilizer, a 38-year-old male who referred to himself as a “VMMC champion” explained how he pays boys to help him mobilize their friends:For us we are calling it ‘broking [brokering] system’. So after the exercise, you tell him to go… and convince a friend and bring a friend… [….] For me I am using my own system being that we are not even allowed to give children money. But for me, because I have a target, and if I get my target, I am expecting 10800 KES [108 USD]. So I do divide this 10800 KES; maybe if he brings me two boys, I can give him up to 50 KES. I can even give out 100 KES [1 USD]. The moment I give that money, 50 bob, to that boy, he is going to bring me more four boys. So the more he bring boys for instance if they are four, I give 100–150 KES. At the end of the day, I will hit my target [Mobilizer 5].firimbi [whistle] … go and remove that sleeve of a sweater. That whistle is not going inside me…don’t blow the whistle inside me. I have refused…. I am not giving you [sex].” Later, when the husband’s brother arrived, he explained that his wife is refusing to have sex. In response, his brother said, “I was passing here to tell you to go for circumcision. Look at me, I have gone, and I am fine. I am now a clean person.” Explaining the benefits, his brother offered that MC reduces HIV risk by 60% and enhances cleanliness (“you avoid smelling”) and prevents cervical cancer.Other times, these practices are subtle and easy to overlook. During a promotional skit in which mobilizers played the roles of a husband, wife, and brother all discussing VMMC, the message to the audience was one of strong female preference for circumcised men. The wife told her husband, “Go and cut your While VMMC reduces the risk of HIV acquisition by 60%–41 or moThis practice of emphasizing the benefits (including reducing the time needed to bathe and risk of acquiring penile cancer) and incentives related to MC while downplaying the risks was common among our participants. The most often discussed risks included temporary pain, minor swelling, and bleeding, while the Government of Kenya VMMC consent form see  in use aAccording to interviewees, food, money, water, sanitation, clothing, and other basic needs are issues of concern for many adolescents’ households. During health talks, some mobilizers emphasized the incentives that boys will receive  following circumcision—items that may be significant inducements among impoverished children. During a village mobilization effort, one mother explained her reluctance to let her son be circumcised: “…this one is small. Even his heart was there because those who have come from circumcision are ‘seducing’ their friends to go also. They are telling them, ‘go and it is not painful.’ They are also giving people sodas. So that soda is what brings them nearer. I told this boy not to sneak, but to wait and I will take him there….” Offering a similar analysis, Provider 3 told us:Sometimes they also entice them for us; in the facility we give them a bottle of soda, Fanta to be specific because one, some of the boys come probably from poor families, they haven’t had a meal in the morning or breakfast and sometimes stay in the clinic for more than two hours, three hours and thus to maintain their sugars. [But] that one [soda] becomes a bait, especially for the young ones ‘We will give you a soda; we pick you with a vehicle’ …which is actually wrong because, it is like enticing a client which you are not supposed to, but that is how they [mobilizers] ply their trade.However, according to our interviewees and as we observed first hand, clinics sometimes lack sodas and/or underwear to give to clients.matumbo” [boiled goat intestines]; at the end of the talk, he implored those who still had their “whistles” to have them removed. He also told them: “Those who are still having the foreskin, you are the ones who are going to spread the diseases. In the future, you are the ones who are going to spread the HIV virus.” Later that same day, the mobilizer asked a large group of older students,“How many of you wish to get the HIV virus? If you don’t want to get the HIV virus, the only option is to remove the foreskin.” Revealing his awareness of this type of language and messaging within VMMC mobilization, Provider 3 explained:All six of the teachers we interviewed recognized social pressure as a primary motivator for MC among adolescents. During observations of mobilization activities, we saw firsthand how mobilizers sometimes make use of or encourage peer pressure to promote circumcision, including through the use of abusive and/or stigmatizing language. During a health talk in front of a large group of boys at a primary school, one male mobilizer referred to foreskins as the “sleeve of a sweater” and “cold This is demeaning and they try to create some peer pressure. Like when you go to those mass cuts in high schools, probably they registered like 100 clients, you would likely get another probably 30 or so who, because of the peer pressure, just jump into it. But if it was like walking from home to hospital and demanding for the service, they are not likely to have gone. But now that it is here, and so and so has gone and is my friend, I have to be in it.Current VMMC for HIV prevention guidelines and national protocols approved for use in Kenya require that adolescent clients must be at least ten years of age. Despite Yes, they bend the rules… because you know sometimes our current age according to WHO is 10 years and above. But when they [mobilizers] go to the field and get a nine-year-old for example, they coach this client and the parent, because we insist on seeing the consent. We always insist they put the ID and telephone number of the parent [on the consent form]. When they come to the facility, we [call to] confirm the age and whether the parent has consented for the child to be circumcised. And you know, they will tell you ‘yes I am 10 years old’, but when you look at the guy, he is probably 8 or. . . .We observed evidence for the mobilization of underage boys at ten of the 14 VMMC facilities we visited for observation, including boys (and their mobilizers) who readily admitted that they were underage. However, as Mobilizer 1 noted, age verification is not easy or straightforward in Kenya: “Yes, we have had some cases where children try to adjust their age. For instance, he is eight years old, but insists he is ten years old; and they are even able to calculate that they were born on this date and in this year. Being that we don’t have a way to verify that… then later you realize that this boy is underage.” Yet, during observations made during school health talks, as well as during community-based door-to-door mobilization activities, we frequently observed mobilizers not asking boys their ages, opting instead to ask for their class in school as a proxy for their age.Under pressure to meet targets, some Clinical Officers and other VMMC medical staff find ways to speed up the clinical process. For example, as we were told during interviews and observed firsthand at multiple VMMC facilities, providers may opt not to take patient medical histories or conduct preoperative examinations  and/or 30-minute post-operative check-ins, and yet fill in the requisite forms as if these activities had been completed. Other avenues for time-saving include rushing circumcisions, inadequate stitching, splitting surgical utensil and bandage packs between patients, not following recommended protocols or procedures , and stacking patients one after another with little pause in between, which raises additional sanitary and privacy concerns. According to an experienced VMMC surgeon:We cut a lot of corners and I will give you an example: […] so because of speed, you find that while one client is dressing [after circumcision], the other one is [already] undressing. Ideally, it is supposed [to be] that you finish with this client, you give [them] instructions on how to take medication and all that, but because of the high volume, you find that some of us we are not the ones giving out the medication. We assign somebody randomly, you know, who will be giving out the medication and the refreshment and so [the] information [they provide to the client] may not be correct. [….] Sometimes even the vitals of post-operation 30 minutes after [circumcision] are not done. It is skipped, or somebody else does [it]—probably a receptionist who is nonmedical, just to fulfill the requirements of the form. [This] is wrong because you are supposed to do the circumcision and the client rests for 30 minutes in a bed or a couch, then after that, you do the vitals then you discharge. Oh, even the wound care instructions, [that] information may not sink in for the client because it is presented so fast and there may not be [time] for questions. Yeah, there are so many corners we cut. [….] …at a clinic last year, I saw them hold that yellow form [medical files] and going through [and just] check, check, check… adding blood pressure, adding all these things, just filling them in . [Provider 3].One assistant surgeon, a 25-year-old female nurse, claimed her record time for completing a circumcision was six minutes. She too associated VMMC targets with client overload, and with rushing surgeries and an increase in adverse events. She explained:Sometimes you compete cutting clients and the clients are too much. The average time for a client’s [circumcision] is between 12 to 20 minutes. So when the clients are too much, and you want to meet your targets, you will perform the surgery a bit fast. So upon that you will have [an] adverse event and maybe a child will come back with a bleeder [an oozing artery or other blood vessel] you did not close [suture] well [Provider 4].Despite these concerns, it was beyond the scope of our study to determine whether an increase in major or minor adverse events was associated with high volume periods. This issue should be addressed by future research.When asked about possible improvements to VMMC implementation and potential alternatives to the use of targets, interviewees made two suggestions. The first was to move away from active VMMC mobilization toward more passive strategies like those used by sites that provide walk-in HIV testing services in Kenya. The second was to keep donor targets, but to lower them to make them more possible to achieve. As Mobilizer 1 put it, “[VMMC] should be a walk-in thing where people are circumcised at their time of convenience…. Basically, I [don’t] have problems with targets, but what I have issues with is the extremely large targets. A situation where the surgeon strains to meet the target. And I know when the surgeon is strained, the probability of having adverse events is high.” Citing a similar alternative, as well as the implementation of more reasonable targets, Provider 1 offered:The targets will dilute VMMC as a practice because the number is overwhelming. Imagine if you start working at 8.00am and you want to do circumcision [until] around 10 pm… it is a long day. So targets should be at least reasonable. So from my side, I can talk about the targets, and the targets [should be] revised …okay. Another thing is for instance… it should be incorporated to be like a clinic, in that if I come to the hospital I can even walk into the VMMC clinic. Not that I am being coerced to go for circumcision, but it should be part of us [an integrated part of the healthcare system]. You know the issue of targets is forcing people to go around looking for (clients) per day. It should be like a TB clinic. Yeah, like a walk-in clinic. So anybody can just come at his own time.Yet another provider, when asked about the effects of targets on mobilizers, made comments that suggest the importance of improved communication as a means to decrease target burden on mobilizers for the benefit of all: “They [mobilizers] are a bit intimidated [by high targets]. So when they  set targets without consulting them, sometimes they even go slow and yeah, it affects our performance [numbers of clients to be circumcised]” [Provider 4].Much effort has been made in epidemiological modelling of VMMC to determine who, when, and where to circumcise, and how many circumcisions will be necessary in order to curb the ESA HIV epidemic.–54 Yet iIn 2008, soon after the randomized controlled trials on HIV and male circumcision, and in advance of global efforts to implement VMMC, UNAIDS issued guidance for program decision-makers on human rights, ethics, and legal considerations. This gui…required to reward a team of mobilizers… so that any reward is based upon collective  success. [This] approach limits the likelihood of coercion by separating any immediacy of reward resulting from an individual mobilizer referring a particular client. Mechanisms that further minimize perceived or actual rewards on a per-client/per-mobilizer basis are encouraged.Despite these guidelines, our data suggest that this stated preference for team rather than individual targets may be misplaced, or at least may not make as much of a difference as intended, since teams may still be incentivized to use misleading or otherwise questionable practices. While individual mobilizers may not receive an immediate payment on a per-client basis, they may be remunerated individually once they collectively (as a team) meet or surpass a given target. By coupling target achievement to remuneration, targets provide pressure to ensure that adequate numbers of adolescent circumcisions take place. Yet perversely, target pressure sometimes leads mobilization teams and providers to choose ethically dubious, but rational strategies to increase uptake, reduce effort, and/or shorten circumcision times to accomplish more MCs per day. Unfortunately, such strategies carry potentially deleterious outcomes for the boys this intervention is intended to protect. Moreover, they may not be in keeping with the ethics and human rights values to which VMMC funders and IPs purport to adhere.Such strategies may include the mobilization of preadolescent clients, imbalanced discussions of benefits versus risks, abusive language and exploitation of social pressure to drive demand, and even dangerous shortcuts . One solution might involve increasing efforts to ensure that target achievement is entirely uncoupled from staff remuneration: mobilizers could draw salaries like the community health workers already working in the same communities—salaries that do not depend on targets. However, future research is needed to determine whether target alternative programs, such as the integrated healthcare/walk-in clinic/passive models suggested by our interviewees, can achieve the necessary number of MCs and do so without overly increasing costs. Indeed, efforts in Zimbabwe to integrate VMMC services into routine healthcare are encouraging, and endeConcerning mobilizer messaging, others have previously criticized the PEPFAR-endorsed tactic of claiming as a “key message” the beneThe practice of using in-school health talks for VMMC mobilization warrants special ethical scrutiny. Not only do teachers and other school authorities often attend these talks—individuals who may have undue influence over boys’ circumcision decisions—but the group-based nature of the talks, and the openness with which adolescent circumcision status is discussed and mobilization takes place, make these environments ripe for coercion. Recruitment of students for research in schools by teachers and other school authorities is discouraged by ethicists for similar reasons. One possIn January 2019, our research team presented study findings to policy professionals and program officials at a VMMC stakeholder meeting in Kenya. In the discussion that followed, we considered various solutions to the ethical and practical concerns highlighted here. One strategy we discussed to address the problem of high and low seasons of client availability and improve the quality of care provided at VMMC clinics was for funders and IPs to collaborate to develop “smart targets.” These targets could be set to rise and fall with low and high seasons to match more efficiently resources and mobilization efforts to client demand and availability. As a part of this process, IP technical advisors could also work closely with school administrators in their catchment areas to find ways to conduct more MCs throughout the school year while minimizing the impact on educational activities and progress. Stakeholders also recognized that the training and awareness of mobilizers, counsellors, and clinic staff needs to be strengthened, and that quality assurance measures should be enhanced and better monitored. Future studies should test the cost and feasibility of improving these aspects of care under real-world conditions.This is a qualitative study with very limited generalizability. Although we used purposive or convenience sampling methods in this study, efforts were made to select facilities of various sizes (levels 2–5), and to work equally with VMMC clinical staff and mobilization teams from both IP organizations. In addition, we conducted mobilization and clinic observation sessions during both the “high” and “low” VMMC seasons, including separate visits to a Level 3 and a Level 4 VMMC clinic on high and low volume days.This study relied on in-depth interviews and clinic observations. As in most qualitative studies of this kind, interviewee responses could be subject to social desirability bias. While we cannot exclude entirely the possibility of this bias, we made clear that we were only interested in interviewees’ honest recollections of, and reflections on, their VMMC experiences. Moreover, the fact that interviewees were often critical of VMMC practices and, for instance, in the case of some clinical providers, admitted to cutting corners in care, suggests that this type of bias may be less of an issue in this study.Finally, our presence as observers at VMMC facilities and during mobilization activities may have changed the behavior of staff members and clients. We anticipated this possibility early on and in response, chose a two-pronged approach method  to ensure the quality of data. This potential bias was also considered during data analysis and presentation for publication. For instance, all findings based on observations were cross-verified by data from in-depth interviews, and vice versa.When VMMC for HIV prevention first began to be implemented in ESA, much attention was paid to the ethical, human rights, and legal considerations by the organizations that were (and are) involved in it. Since then, much of the discourse has been replaced by programmatic and technical guidance concerning how best to meet ambitious VMMC targets, with less attention to the broader effects of pursuing targets in the field. As our research shows, those considerations have not gone away. VMMC funders, governmental organizations, and IPs remain strongly committed to human rights and ethical values in the pursuit of public health goals. As such, they have a robust interest in information about how VMMC programs are implemented on the ground in Kenya and across ESA. These ethical considerations should be given more weight in future research and in the routine quality assurance checks conducted by IPs and funders, and where feasible, by independent authorities.Further research is required to consider more fully the benefits versus risks associated with targets in mobilization activities and to develop improved or alternative systems through which to drive VMMC uptake. While PEPFAR already monitors VMMC clinical standards and practices (including recordkeeping) through the Site Improvement through Monitoring (SIMs) scheme, future pS1 File(DOCX)Click here for additional data file.S2 File(PDF)Click here for additional data file.


Some newly described steroid-related compounds, also found in the rest of the body, are formed and active in the central nervous system, particularly in the brain. Some are of pharmacological and physiopathological interest. We specifically report on two compounds, “MAP4343,” a new neurosteroid very efficient antidepressant, and “FKBP52,” a protein component of hetero-oligomeric steroid receptors that we found involved in cerebral function, including in Alzheimer’s disease. Some cholesterol found in brain and spinal cord is biologically largely independent of that found in the rest of the body Figure . It giveFirst, among “neurosteroids” , PREG 66 is rathSecond, “FKBP52” is a protein complexed with hetero-oligomeric steroid receptors that we found to have an unforeseen interaction  with theA  have led us to avoid the metabolism in the brain of 3β-hydroxy-Δ5 neurosteroids to oxydated 3oxo compounds; for this reason, we synthetized and used 3β-methoxy-Δ5 steroids which are not metabolizable to Δ4-3oxo steroids of unnecessary or even pathogenically activity: for instance, an appropriate synthetic derivative of PREG is the methoxylated compound MAP4343  andIn human beings, the most frequent and severe human senile dementia, the Alzheimer’s disease, currently is not biochemically explained nor treated in order to recover. However, there are several recent progresses for the diagnostic, biomarkers and imagery of the sick brain . Since tDistinct from Alzheimer’s disease, there are dementias which are exclusively tauopathy , supportConsequently, Tau, mostly in aggregated forms, is clearly involved principally in terms of neurodegeneration, and pathological Tau may be most appropriate as potential target for treating Alzheimer . The purcis/trans-prolyl-isomerase), thus classifying FKBP52 among the immunophilins which may bind many small molecular ligands function may be still far to be operationally favorable to treat dementias Figure . WorkingIn this “Perspective,” we have treated two distinct examples concerning steroid associated molecules involved in activities of the CNS. They exemplify typical compounds of (1) neurosteroid derivatives and (2) components of hetero-oligomeric steroid receptors. We are happy that, in a number of other laboratories, many publications (not reported in this “Perspective”), have followed our two original studies. This paper is not a review, but we hope to draw attention to the versatile involvement of the steroidal structure and thus in important physiopathological derivatives.The author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Diverse wellness-promoting mobile health technologies, including mobile apps and wearable trackers, became increasingly popular due to their ability to support patients’ self-management of health conditions. However, the patient’s acceptance and use depend on the perceived experience and the app appropriateness to the patient’s context and needs. We have some understating of the experience and factors influencing the use of these technologies in the general public, but we have a limited understanding of these issues in patients.By presenting results from an explorative study, this paper aims to identify implications for the design of mobile apps and wearables to effectively support patients’ efforts in self-management of health with a special emphasis on support for self-efficacy of activities contributing to health.An explorative mixed-method study involving 200 chronically ill patients of Stanford Medical Center  was conducted between mid-2016 and end of 2018. Amongst these, 20 patients were involved in a 4-weeks study, in which we collected the underlying wearable device use logs  and subjective use experience [via an Ecological Momentary Assessment (EMA)], as well as patients’ momentary perception of general self-efficacy in their natural environments and different daily contexts.The results indicate that mobile apps for health and wearables have the potential to enable better self-management and improve patients’ wellbeing but must be further refined to address different human aspects of their use. Specifically, the apps/wearables should be easier to use, more personalized and context-aware for the patient’s overall routine and lifestyle choices, as well as with respect to the momentary patient state  and health(care) needs. Additionally, apps and devices should be more battery efficient and accurate; providing timely, non-judgmental feedback and personalized advice to the patients anywhere-anytime-anyhow. These results are mapped on major sources of the individuals’ self-efficacy.Our results show how the apps/wearables that are aimed at supporting the patients’ self-management should be designed to leverage and further improve the patients’ general self-efficacy and self-efficacy of activities contributing to chronic disease management. Smartphone and wearable usage is growing rapidly. Currently, more than 2.5 billion people use smartphones with this number projected to reach 5 billion in 2025 . Along tSelf-management of health implies management of activities contributing to health including physical activity, nutrition, stress, sleep, medication intake, and management of symptoms . Self-maSelf-efficacy is the self-belief that an individual can manage his/her daily life and put in effort to get the desired behavioral and health outcomes . GeneralSelf-efficacy has been shown to improve self-management, in direct and indirect ways. A cohort study focused on a chronic disease self-management program found that after 7 weeks of a self-management program with an emphasis on self-efficacy , participants made statistically significant improvements in their health status, self-efficacy and health behaviors and had fewer emergency department visits . This stThe wide use of smartphones and wearables may provide a method for increasing self-efficacy and self-management in patients with chronic conditions, although there is limited research on its efficacy . Howeverin situ experiences with technology captured and self-reported self-management efforts, as well as and momentary self-efficacy assessments.This study presents results from an explorative mixed-method study of 200 chronically ill patients at the Stanford Medical Center . Amongst these, 20 patients were involved in a 4-weeks study, in which we collected the underlying wearable device use logs and subjective experience of use, as well as patients’ momentary perception of general self-efficacy in their natural environments and different daily contexts. This study is different from previous research in that it correlates In Today, I can manage to solve difficult problems if I try hard enough” and was asked on smartphone screen at a random time in predefined waking hours of the morning. We designed the EMA questions such that each SE question was asked to each participant in a uniform distribution, i.e., three times along the whole study duration. Additionally, we deployed EMA to evaluate the momentary user’s experience (QoE) with a wearable/mobile app, with questions along the Mean Opinion Score (MOS) . They were asked during the waking hours of a day randomly after closing the fitness app  on the phone, i.e., the user was not able to predict when, along the app usage, the QoE question will be triggered to him/her. Each rating is purely a subjective, episodic assessment of the event provided on the basis of the given perception of the user in a given context. The EMA method contributes to capturing the momentary “ground truth” SE and user’s QoE data in the studies. (iii) The Day Reconstruction Method (DRM)  entry survey/open-ended interview (ii) The Ecological Momentary Assessment (EMA), (iii) The Day Reconstruction Method (DRM), and (iv) The mQoL-Log. (i) The entry survey/open-ended interview on the Stanford-based Website (RedCap), was used to collect the patients’ health state and socio-demographics, current self-management behaviors, general self-efficacy and health status, and overall attitudes toward and experiences with mobile apps/wearable (if any) for self-management . (ii) Thre (MOS)  for ICT-od (DRM)  is a semod (DRM)  enablingThe interviews, surveys and DRMs data were analyzed by grouping words into clusters via an affinity clustering method. The coding and grouping of words into clusters was done by two independent coders. Inter-rater agreement was derived via a joint probability of agreement, i.e., the percentage of the time the raters agree in coding. We then derived statistics of the user’s interaction with the mobile app/wearable based on the mQoL-log datasets.n = 180) only completed the open-ended interview at the beginning of the study, where they went into length about why/why not they use mobile apps/wearables for self-management. Amongst the 200 participants, the first n = 20 participants who had a wearable  or a mobile application that the used for their own health self-management, committed to the 4 weeks or more (M = 35 ± 5 days) data collection part of the study where they answered the EMAs and completed the DRMs and had the mQoL-Log installed on their phones. The convenient sample of n = 20 participants was recruited by the team as a follow up and along the 4 weeks of data collection and interviews. Participants’ characteristics are shown in We recruited 200 participants from Stanford Medical Center , within the Bariatric and Metabolic Interdisciplinary Clinic or the Multi-Organ Transplantation Clinic. The Institutional Review Board of Stanford University has approved the study (IRB #29414 and #28265). All participants were informed about the goals of the study, the procedure, the data collected, stored and processed for the purpose of research, the risks and benefits of participation, and that they can withdraw from the studies and request his/her data deletion at any point in time, without any negative consequences. Each participant signed the consent form providing the above information in detail. At recruitment, all participants were assigned an anonymous identification code, which was used throughout the study. The collection of personal information  was kept to a minimum. Participants were included in the study if they were cognitively intact (assessed through their understanding of the study and consent form) English-speaking adults who used Android OS smartphones daily. Many study participants (n = 200), ranging from non-user or limited use and factors influencing that , to factors influencing the user’s experience (section “Use and Experience of Mobile Apps and Wearables by Patients”), to a specific focus on self-efficacy construct and our analysis how does it influence the use of technologies by patients (section “Self-Efficacy”).In the following sections we present the results acquired along our study for all participants (n = 10) do not use technologies for self-management of health and admit it, ranging from asking for advice on how it can be used  to denial of its use for their own health. An older male participant, visibly angry to be asked that question, pointed out “I don’t mix my smartphone with my health,” another female patient said “I do not want a phone reminds me about my disease” and yet another one “I have got a [Fitbit as a] gift and I dropped it.” Further, another one visibly amused by question said that “It’s all in here” [indicating his/her own head].Some participants (n = 18) may have tried or have some experience with technologies contributing to own self-management, but did not use it regularly at the time our study was conducted and did not have any plans to use it in the near future. The input for these participants we got is that “Privacy is an issue,” “It’s complicated,” “I do not know how to use it,” and “I am not a techie.” These types of statements apply equally to older male and female patients.Some patients (n = 172) were actively using smartphone apps or wearables for their own use. Most frequently used mobile applications were dieting applications like MyFitnessPal or calorieCounter, or exercise ones  or the built-in Apple “Health.” As the study took place at Stanford, many of the participants (n = 48) mentioned Stanford Health Care “My Health” App, enabling them access to their own Stanford Health records. Additionally, they mentioned the importance of Google Search, WebMD, Facebook (for keeping in touch with loved ones), games, notes (to register symptoms), medication reminder apps, calendar, or a bible app . The rest of the participants (n = 27) mentioned that they use the built-in activity tracker apps  and treat their smartphone as a “wearable,” even if they are aware of potential inaccuracies as they sometimes forget to take along their phones. The external wearable devices were used include Fitbit, Apple Watch, iFit, JawboneUP, Garmin, Samsung Gear, Nike+. Many participants  or because these wearables have their own screen, where they can see the numbers  without going into the phone app. In fact, based on datasets collected via mQoL-log we derived that the participants were interacting with a wearable  or a mobile app  on average less than 5 min a day. When asked for the context of the wearable/apps usage along the DRM, they declared that they usually use these apps when alone or as a distraction when surrounded by others , who are not paying attention to the participant checking his/her phone. None of the participants declared their wearable/app usage and content  to be a topic of the social interaction.Overall, the experience of using smartphone, apps and wearables was reported as a positive one, as even one of the patients admitted – smartphone apps “Keep me sane” (S5). Along this line, there are multitude of factors influencing the nuances of the user’s experience with mobile apps and wearables. We have used 100+ expressions from our 20 patient’s weekly DRM interviews, additional 180 patients’ interviews in the clinic. We have distinguished the following factors influencing the user’s experience and discuss them in light of previous research on factors influencing the experience of commonly used mobile applications as identified in a 2012 study . We firsIn The issue of preferring an input of long text or manual data on laptop (larger screen) is still present. Overall, the application interface in terms of application/wearable interaction was mentioned very often, yet not in negative terms of bad interface design, but in positive terms of application/wearables notifications keeping the user informed and content. Notifications provided by applications where discussed much more often than the application interface itself. Wearables’ notifications are there to fit in the routine and unobtrusively support the user’s goal matching along a day. For non-routine days, e.g., with less physical activity – the lack of notifications from wearable will be the first indicator of “bad” day in terms of matching the user’s goal: “If I do not get notifications along my afternoon, I know I am in trouble” (S12). Additionally, notifications had to be found to be informative. Notifications that did not serve any purpose resulted in participants abandoning the device  or turning off the notifications completely from these specific applications. An example of a helpful notification was, e.g., “Each 1000 steps I get reminded to drink water” (S10).In In our study, some individuals complained about applications not providing expected services or about the poor performance of their underlying network that influenced the provision of these services. A participant said, the “Internet can be touchy” (S7), to express their concern with the underlying network connectivity. Additionally, the participants complained about the lack or erroneous apps sync, low accuracy of Chinese input recognition, or inaccurate GPS. The lack of constant reliability can be a source of irritation: “When and app doesn’t work as it should, my blood pressure skyrockets with the frustration” (S5). Ultimately, participants expressed that if an application is constantly malfunctioning or not refreshing content, they will stop using the application all together.In Battery efficiency is consistently influencing the experience of the mobile users on a growing scale. Users are using more and more applications and services while continuing to expect that their phone will support them throughout the whole day. One participant was travelling and used an additional battery to support their needs. Overall, users recognized that the battery capacity issue related to usage, e.g., navigation, with screen on, GPS and continuous data and Bluetooth devices’ connectivity. Similarly, users also expected wearable charge to last at least the whole day, “if it didn’t last the full day (8 hours), then I walked for free” (S3). Additionally, a participant even mentioned that the battery time influenced her activity, “I don’t walk when [my wearable] is charging” (S2). Overall, participants mentioned having a significantly worse experience if their device did not support their full day of use.In Mobile users noted missing features of their specific phone, which then hindered their experience, e.g., lack of or a faulty synchronization between Bluetooth devices, and lack of GPS for some older phones, lack of features for privacy settings. Additionally, participants expressed their desire for additionally features including devices that allow for greater personalization of behaviors, automatic nutrition calculations, data fusion between multiple sources , a wearable that is waterproof, a wearable that has an ability to assess the swelling of a leg and help to self-manage the CVD patient’s fluid retention. Moreover, participants mentioned that a symptoms manager application that derived automatic checklists from notes would be a more effective way of tracking symptoms than through traditional note-taking applications. Nobody mentioned explicitly EMF issues yet two were worrying of too much synchronization, which cannot be disabled (Fitbit).In n = 15) indicated cost as a factor influencing their experience, as they mentioned their inability to purchase a smartphone or mentioned their inability to buy a wearable (n = 5). Only one of the participants who owned a wearable mentioned price as a factor influencing their expectations and experience: “it’s expensive, it shall work” (S7). Contrastingly, the fact that build-in apps and services are cheap and accessible was emphasized. Very few of the participants followed up with a reflection that given the affordability of the apps and services, the leak of personal data is the price to pay for having the affordable service and that the personal data privacy is definitely an issue (as mentioned earlier).Very few participants . Mobile devices reminded users to take their medications, drink water and conduct many other important daily activities . Mobile devices also allowed users to plan their day by looking at traffic, prices of petrol, designated routes, weather and downloading podcasts ahead of time to listen on the commute. Additionally, some participants indicated that technology helps them set up their routine, while other indicated that they wish that technology could support them in creating a better routine . Contrastingly, some users did not use their devices daily. For example, a participant only used their wearable for sport activities, leaving it behind the rest of the day. Another participant only used their smartphone while traveling, leaving it behind when at home or at the office.In Mobile devices and wearables form an important part of users’ lives. Applications are there to support healthy  or unhealthy (ex. being “lazy” and watching videos on the phone). They can also be modified to fit a user’s routine: a clip being put in a pocket, clip (on bra) for users working (ex. in a production line) where they are not allowed to have anything on a wrist; watch for people who are active and wish to get updates on their steps throughout the day . Besides design modifications for routine, there is also esthetic modifications. Participants mentioned the need for “showing off” to others  or hiding from others that a wearable is used . Lifestyle choices are also related to listening to educational/informative podcasts of audiobooks via a smartphone while commuting and having an adequate support for that. Without smartphones, many participants reported feeling “naked” or when a wearable is lost a patient expressed that she “lost her life” (S12).This factor was not mentioned in the 2012 paper  and consThis factor has not been mentioned in 2012 paper  and consIf the user mentions that he/she shares data with others, they are usually family members, same age and potentially aiming for the same goals . The persons with whom the data is shared are there to support the participants’ self-management efforts; while the participant supports their efforts. An example is a participant  who shares Fitbit data via setting up competitions with his younger niece living in other state across the country and suffering from bipolar disorder. He pointed out that he knows that physical activity is recommended in her state and he is supporting her from far away.When commenting on wherever they would share the data with their medical team, they, on the one hand, again point to accuracy, “doctor wont’ trust the data.” On the other hand, some participants commented that they had not received negative feedback from their medical teams (nurses and clinicians), in contrary, the inputs were positive like “whatever it takes to get you more healthy” or “whatever contributing to your health is good.” The participants would be generally accepting to share the data with their doctors.This factor has not been mentioned in 2012 paper  and consWearables and mobile device applications are designed to allow users to easily visualize trends. It allows users to see their previous successes as well as previous failures. Although wearables and apps enable users to see the trends, the target levels are predefined. For example, the target step levels are usually at 10,000 steps and some participants admitted that even though that set target was too high for them and they had never been able to achieve this predefined goal, they were not “tech savvy” enough to know how to change the goal. The self-defined targets do not encourage subsequent increases in effort. It was suggested by Kate Lorig verbally that wearable or apps should first monitor the user (based on passive monitoring) and then suggest a feasible goal. This more flexible goal setting, based on user goals, past experiences, trends should allow any user, regardless of their technical skills to benefit, adjust and feel good about achieving their goals.Social networks should theoretically allow and facilitate users to find people living a similar lifestyle and undergoing similar challenges. Although that can be true in some cases, social networks self-representation are not always accurate . TherefoThere are many applications and wearables that send motivational notifications to users after achieving a certain goal or to remind the user to continue tracking . These notifications provide users with a reminder to and sometime encouragement to continue their hard work in achieving their goal. Although a lot of these notifications can be helpful, one participant pointed out that the MyFitnessPal coaching feature is “giving up on her” (S9) when she has not logged for few days. That was discouraging and she pointed out that it could be redesigned better – the device should not give up on an individual ever, as it really feels judgmental and discourages the person from progress . Now it’Current evidence in behavioral medicine and health psychology shows that habits are hard to change . It can Additionally, participants reported that their emotional state influenced their daily interactions with the apps/wearables. For example, a participant (S20) discussed that they received the device as a gift. Since it was a gift and something, they did not intend to purchase they do not use it as often. The importance of emotional state was also discussed in terms of daily interactions, participants expressed that they had momentary expression that a wearable is a “friend” or “enemy” depending on if they had met the goal (and felt good) or not (and felt bad).Limitations of this study include the fact our sample was a convenience sample, included only self-selected participants, limited time and we did not log the content on the health app or wearable used. In terms of the convenience sample, the researchers were only available to talk to participants at certain times of the day, this may have influenced the recruited participants. Participants were self-selected to participate in this study, and this could have influenced the study pool for people with a particular positive or negative view on wearables and applications. We are not able to quantify this bias. Additionally, due to the structure of the clinic, sometimes time was more limited with specific participants. Moreover, participants perceived the EMAs for self-efficacy differently. Some perceived them as encouraging, while some thought these were annoying, as they were tired in the morning and were not in a mood for challenging questions.Our study illustrates that applications and wearables that are aimed at supporting the users’ self-management should leverage and further improve the patients’ self-efficacy of activities contributing to self-management of chronic disease. The results indicate that mobile apps for health/wearables have potential to enable better self-management and lead improved wellbeing but must be further refined to address different human aspects of their use. Specifically, the apps/wearables should be easier to use, more personalized and context-aware for the patient’s overall routine and lifestyle choices, as well as with respect to the momentary patient state  and health(care) needs. Additionally, apps and devices should be more battery efficient and accurate; providing timely, non-judgmental feedback and personalized advice  to the patients anywhere-anytime-anyhow.Improved belief increased health outcomes, and we must re-engineer technologies to better engage the ones who need the solution the most and even further improve this belief  and co-design with patients   and Michael D. Amylon, M.D., Stanford University (Protocol 29414). The patients/participants provided their written informed consent to participate in this study.KW collected the data and coded it (with MF). KW and SW wrote the first draft of the manuscript. SW, KW, HR, WC, and MF contributed to all versions of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


For adults, associations have been shown between unemployment and mental health, including that national unemployment can affect mental health and life satisfaction of both the employed and the unemployed, but to different degrees. The aim of this paper is to analyse how national unemployment levels are related to adolescent life satisfaction, across countries as well as over time within a country, and to what extent and in what ways such an association depends on whether the individual’s own parents are unemployed or not.Previous research shows that parental unemployment is associated with low life satisfaction in adolescents. It is unclear whether this translates to an association between n = 386,402) life satisfaction and parental unemployment were collected in the Health Behaviour in School-aged Children (HBSC) survey, in 27 countries and 74 country-years, across 2001/02, 2005/06 and 2009/10 survey cycles. We linked this data to national harmonised unemployment rates provided by OECD and tested their associations using multilevel linear regression, including interaction terms between national and parental unemployment.Repeated cross-sectional data on adolescents’ (aged 11, 13 and 15 years, Higher national unemployment rates were related to lower adolescent life satisfaction, cross-sectionally between countries but not over time within countries. The verified association was significant for adolescents with and without unemployed parents, but stronger so in adolescents with unemployed fathers or both parents unemployed. Having an unemployed father, mother och both parents was in itself related to lower life satisfaction.Living in a country with higher national unemployment seems to be related to lower adolescent life satisfaction, whether parents are unemployed or not, although stronger among adolescents where the father or both parents are unemployed. However, variation in unemployment over the years did not show an association with adolescent life satisfaction. This has however not been analysed before.Adolescents living with one or two unemployed parents report lower life satisfaction –4. By exThere is also a possibility that adolescents in general may be affected by high national unemployment rates, even when their parents are not unemployed , 5. Amonstronger among those with unemployed parents. There is support for such cross-level interactions between national and personal unemployment in adulthood [Although national unemployment may affect adolescent life satisfaction in general, the impact could be assumed to be dulthood , 12, butLife satisfaction among adolescents is a relevant outcome to study in relation to national unemployment, in particular since life satisfaction has already been examined in relation to parental unemployment –4, and hTo fully understand the importance of national unemployment for individual life satisfaction, it is important to distinguish cross-sectional associations between countries as different from and not directly generalizable to temporal associations within countries . We aim This study analyses how national unemployment levels are related to adolescent life satisfaction, across countries as well as over time within a country, and to what extent and in what ways such an association depends on whether the individual’s own parents are unemployed or not. This is done through combining national harmonized data on unemployment with individual data from repeated cross-sectional school surveys among adolescents aged 11, 13 and 15 years old in the years 2001/02, 2005/16 and 2009/10.What this study contributes to previous knowledge is mainly to analyse the importance of national unemployment for the wellbeing of the age group of young adolescents, something that has previously been analysed mainly among persons who are of an age to be on the labour market. The role of parental unemployment in the above-mentioned relationship is an added contribution.The Health Behaviour in School-aged Children (HBSC) study is a WHO collaborative cross-national study performed every fourth year in Europe and North America . Each suFor the current study, open access data were used from the HBSC waves 2001/02, 2005/06 and 2009/10, for each country with at least 2 waves . ScotlanThe Ethical Review Board in Umeå, Umeå University, Sweden (reference nr: 2017/282–31).This study uses secondary, publicly available data. The use of secondary data for this project was ethically reviewed by The original data collection underwent ethical review and gained approval in each separate country according to national regulations, and sometimes in schools , 24, 25.The survey was anonymous and the data files that are provided by HBSC on their data bank contain no personal identifiers and no school identifiers; access to data files are given only after registration on the website, and we have kept data files secure on one computer.Here is a picture of a ladder—the top of the ladder 10 is the best possible life for you and the bottom is the worst possible life—in general where on the ladder do you feel you stand at the moment? This is an adapted version of the Cantril ladder, which has shown acceptable reliability and convergent validity among 11–15 year olds in Scotland [Life satisfaction, the outcome measure, was captured by the question: Scotland .The variable was left-skewed and somewhat truncated at the highest value, but more so among the 11-year olds (skewness − 1.21) than among the 13-year olds  and 15-years old (skewness − 0.89). See Additional file International datasets for unemployment are based on combinations of data from national employment office records, censuses and labour force surveys. The variable used here was “Harmonised Unemployment Rate” (HUR), computed by the OECD with the specific intent to be comparable internationally and across time, and available from the OECD open data repository . The HURr = − 0.755 for the natural log of GDP per capita in purchasing power parities). This is expected given Okun’s law, which predicts a close relationship between unemployment and national production [Gross Domestic Product (GDP) per capita was considered for inclusion but was not used due to its high correlation with national unemployment , and if the answer was “no”, there was a follow-up question on why he or she did not work, with the options “sick, retired or studying”, “looking for a job”, “is a stay-at home mom/dad” or “I don’t know”.both parents were absent or unknown, this was coded as missing . Additional file We recoded this into one combined variable with the categories unemployment (=“looking for a job”) of only mother, only father or both parents. The parents who were in the opposite category, i.e. “not unemployed” could thus be parents who were working  was available in the dataset. For Germany in 2002 and Slovakia in 2006, the school variable was missing, and “school” was treated as only one group within those country-years. Though sample weights were available to compensate for the clustered sampling, these were not used since we did multilevel analysis (with schools as one level) to compensate for the clustered sample, and the weights were intended for single-level analyses (not divided by level), and thus not suited for this analysis.The role of parental unemployment for the association between national unemployment and adolescent life satisfaction was analysed in three steps: First through bivariate correlations between national unemployment, aggregated percentage maternal/paternal unemployment, individual maternal/paternal unemployment, and average adolescent life satisfaction. Individual-level variables were aggregated to be measured at the same level – means and percentages for country level, deviations from mean at country-year level Table , − whileSecond, by including parental unemployment as a control variable in the regression analysis of national unemployment in relation to life satisfaction Table , Model 2Analyses were performed with MLwiN through STATA version 12.1, using the command runmlwin .fixed effects), but also estimates of how much of the variation is attributable to each level of analysis (termed random effects). As suggested by Merlo et al. [Mixed effects models produce not only coefficients for associations , using STATA:s command lrtest. The empty model was compared to a single-level model (linear regression).The respondents were evenly distributed between survey years, age groups and boys/girls. A majority did not have any unemployed parents (94.7%), while 1.9% had only an unemployed father, 3.2% only an unemployed mother, and 0.3% had parents that were both unemployed. 25% had separated parents.National unemployment rates varied widely across countries and years, as shown in Table aggregated parental unemployment though. Point-biserial correlations between national unemployment and individual parental unemployment were significant but small, country level national unemployment was correlated 0.0525 (p < .001) with mothers’ and 0.0457 (p < .001) with fathers’ unemployment, mean-centered yearly national unemployment correlated 0.0387 (p < .001) with mother’s and 0.0606 (p < .001) with father’s unemployment (data not in table). National unemployment as well as percentage of parental unemployment were significantly and negatively correlated with life satisfaction across countries for all years, but not in change across years; see also Figs. Correlation between national unemployment and country-level percentage of parental unemployment was high, on country level 0.66 for aggregated maternal unemployment and 0.63 for aggregated paternal unemployment, on country-year level 0.76 for maternal unemployment and 0.91 for paternal unemployment Table . These sCountry-level unemployment (mean across years) was associated with lower adolescent life satisfaction, an association that remained significant after controlling for parental unemployment Table . CountryInteraction analysis between national unemployment  and individual parental unemployment showed that the association between national unemployment and life satisfaction was stronger among adolescents with an unemployed father or both parents unemployed, compared to adolescents with no unemployed parents. For adolescents with an unemployed mother the association between national unemployment and life satisfaction was virtually the same as among respondents with no unemployed parents.Having unemployed parents  was in itself associated with lower life satisfaction. When adding the interaction term, the association of mothers’ unemployment to life satisfaction remained strong, while the association of fathers’ or both parents’ unemployment decreased (becoming non-significant for the latter).Being a girl, older age and having separated parents was associated with lower life satisfaction.Sensitivity analyses showed that results remained significant, though with smaller coefficients, after controlling for log-transformed GNI (not in table).Table additional effect of national unemployment for those only having an unemployed mother, though mothers’ unemployment was independently related to lower life satisfaction.Higher national unemployment was associated with lower adolescent life satisfaction, cross-sectionally across countries but not over time within countries. Notably, this applied whether the parents were unemployed or not, although stronger among adolescents with unemployed fathers or with both parents unemployed. There was no Adolescent life satisfaction is an important indicator not only of general wellbeing, but also of mental health and the absence of mental ill health . Some ofSome have argued that the effects of macroeconomics on children and adolescents are wholly mediated by the situation within the immediate family , 10, 39,mental and somatic health complaints to various measures of national unemployment [youth unemployment [National unemployment has to our knowledge not previously been analysed in relation to adolescent life satisfaction. There is, however, research relating adolescent ployment , 40, 41.ployment , 40, or The relationship between unemployment in relation to health or wellbeing could differ between countries , 19, 42.Studies indicate that for adults, regional and local unemployment rates within countries could also matter for health and well-being , and forThat parental unemployment is related to lower adolescent life satisfaction has been shown in earlier research , 40, butNational adult unemployment, which is the main variable of interest here, is even less likely to be affected by adolescent life satisfaction.Regarding individual or family-level unemployment, it cannot be exluded that health selection is partly or mainly responsible for the association between being unemployed and self-reported health and well-being of the unemployed person, i.e. that persons with lower health status are more likely to become unemployed , 17, 47.Health selection might be less prominent when unemployment rates rise steeply, due to changes in the drivers of job-loss. One European study shows that in countries that combined high national unemployment and a recent sharp increase in the unemployment rate, the unemployed population on average had fewer limiting longstanding illnesses compared to in countries with low and/or or stable unemployment, which was interpreted to be a compositional effect – when the labour market is insecure, everyone is at higher risk of losing their employment, even those in good health .The unemployed parents are here contrasted not only with working parents but also with parents who were sick, retired, students or stay-at-home parents. The reason for this coding was that we assumed that unemployment carries its own stigma. However, having parents who are home due to illness could have an even heavier effect on adolescent life satisfaction; something to explore in future research. The effect of having a stay-at-home parent could differ depending on gender norms of the country; also, in a country where stay-at-home moms are a norm, women who lose their job might go back to considering themselves a stay-at-home parent even when they would prefer to work.Notably, we found no added effect of national unemployment on life satisfaction when the adolescent exclusively had an unemployed mother. This should thus be considered in relation to gendered norms for work and stay-at-home parents . In settlevels of youth unemployment but not changes therein [The lack of associations across time is in accordance with a previous study on adolescents using HBSC data. This study found associations between health complaints and  therein . It is a therein . The sta therein . In our However, it is possible that the association we have detected is a proxy for other, systemic between-country differences. One direction for future research is to explore this over longer time. It is also possible that associations might be non-linear, for instance due to threshold effects, i.e. adolescents may not be aware of changes in national unemployment rates until those rates reach a crisis level.One strength of our study is that the HBSC has a large sample, representing adolescents in numerous countries and over several years with different levels of unemployment. The statistical method used here allows for the inclusion of more than one survey wave, resulting both in a larger sample with greater variation to be analysed, and the possibility to analyse time and geography separately . The metThe validity of our results is supported by the use of a standardised measure of national unemployment. Unemployment statistics can differ depending on national definitions; but the variable used here has been adjusted by the OECD to be internationally comparable. Though this variable was available for fewer countries, we preferred that over using a less comparable variable.It should be mentioned that several macroeconomic conditions have such a close relationship with unemployment that they are difficult to disentangle from each other. Although our results did hold when controlling for GNI per capita, we cannot exclude that national unemployment may function as a proxy for other national macroeconomic characteristics.Self-reported data can be both a strength and a weakness. For example, adolescents may be unaware whether their non-working parents are actively looking for work. We assume that this would underestimate rather than overestimate parental unemployment: when adolescents report that the parent is looking for a job, it is probable that this has been a topic of conversation at home; but if the parent is not discussing their job search at home, the adolescent might instead erroneously report them as sick or a stay-at-home parent, in which case we would not code them as unemployed. The strong correlation between aggregated parental unemployment and national unemployment supports the validity of the self-reported parental unemployment.Exposure and outcome variables are from independent sources, minimizing the risk of shared method variance .The questionnaires have been carefully translated to national languages in such ways as to ensure comparability. Even so, certain variables, especially life satisfaction, could be perceived differently in different countries and languages. However, self-reported life satisfaction is a well-established measure, used a lot in previous research on adolescents , 14, 35.The survey is cross-sectional and thus causality on individual level cannot be inferred.Living in a country with higher national unemployment across the years seems to be associated with lower adolescent life satisfaction, and this seems to apply whether their own parents are unemployed or not, although stronger among adolescents where the father or both parents are unemployed. However, variation in unemployment over the years did not show an association with adolescent life satisfaction.Adolescent life satisfaction is vital for for adolescents’ mental health, quality of life and academic performance; all of which are burning issues for national policy makers. Findings of potential independent effects of national macroeconomic factors on adolescent life satisfaction open up new avenues for national policy, but this needs to be explored further in future research.The conclusions here highlight the question of the societal costs of unemployment, above and beyond immediate economic costs such as lowered tax revenue and expenses for unemployment benefits and other social welfare. If, as our results indicate, national circumstances might be related to adolescent current life satisfaction, this can be considered not only a social cost in the present but also a potential social and economic cost for the future, if adolescents’ current life satisfaction has an impact on their education performance, life choices, or future mental health.Other impacts of economic cycles are important to consider. One study shows that an increase in adolescents’ psychosomatic symptoms in a region of Sweden was largely explained by an increase in their worries about family finances during the Swedish economic crisis of the early 1990’s (but not at later time points) .Another aspect to consider for policy makers is the importance of the unemployment of both men and women. Often, the employment status of fathers is given prominence, especially in countries with a sole-breadwinner model. Based on our results, it is important to note that not only paternal but also maternal unemployment shows a negative association with adolescent life satisfaction. In our study, though the negative effect of fathers’ unemployment was somewhat stronger, the unemployment of mothers was higher than that of fathers, meaning it affected more adolescents.Additional file 1: Figure S1. Histogram of self-reported life satisfaction, by sex and age group, n = 386,402.Additional file 2: Table S1. Content (coding) of the variable for “Unemployed parents”, n = 386,402.Additional file 3: Figure S2. Gender specific scatter-plot of general versus parental unemployment by country.


This article presents a review of the literature that pertains to the experiences of therapists who work directly with child sex offenders and/or people with pedophilia. We draw together results from studies that attempted to identify how therapists experience such work and how they were personally impacted by it. Usually, such studies are embedded within one of the following theoretical frameworks: Secondary traumatic stress, compassion fatigue, vicarious traumatization and burnout. Most literature on the topic has therefore sought to determine to what extent and why, work-related stress responses may occur among these therapists. The aim of this paper is therefore to provide insight into this, arguably, important line of research, while evaluating the current knowledge as well as providing recommendations for future research efforts. Since the 1980s, awareness and recognition of the problems related to the sexual abuse of children has grown drastically. While previously overlooked, it now commands the attention of professionals and lay communities alike as being a major societal issue . AlthougIn response to the public’s growing concern stemming from the aforementioned issues, criminal justice policies have expanded in an attempt to decrease the number of sexual offences against children. The psychological treatment of sex offenders and people with pedophilia is thought to be an essential part of such prevention strategies . In manyAt this point, it is clear that the therapeutic work with people who are sexually attracted to children is thought to be an important line of work that employs an increasing amount of professional personnel. However, not much is known about what it is like to work with this client group, as most of the emerging research on the topic has focused on “the victim” or “the perpetrator”, while less attention has been brought to the role of “the healer”. Furthermore, research that did focus on sex offender treatment tended to center on technique factors and its effectiveness, rather than the process of conducting such therapy .Pedophil* or Sexual Abuse, and different forms of the term therapist* (such as psychologist*). We only included publications available in English. Additional, specific publications were also identified using different strategies like “snow-balling”  work: c stress , compass fatigue , vicariotization  and burn(burnout . All fou(burnout . Whereas(burnout . Over ti(burnout .n = 24). In fact, most literature that has dealt with sex offender therapists has portrayed this line of work as mentally, physically, and emotionally draining , making it possible to questions the reliability of its results. Based on their interpretive phenomenological analysis, Several authors have, however, reported either low levels of stress and/or a variety of positive experiences among sex offender therapists . In examFinally, some studies of relevance to this issue have been inconclusive, reporting either mixed results or a lack of cut-off scores, making it difficult to evaluate the results .client-focused, therapist-focused and organizational-focused explanations .In other words, these clients are perceived to be especially difficult to work with, due to such behavior. Categories like “sex offenders” may, however, be too heterogeneous to discuss as a single entity . These eFurthermore, it seems to be a common belief that sex offenders are especially difficult to successfully rehabilitate, thereby, potentially, explaining negative responses among treatment providers. Defining “difficult”, “rehabilitation” and “success” in this context is, however, not an easy task . Althougexternal to the therapist .Many “moderating factors” within therapists have, however, been theorized. Yet, few studies incorporated these factors into their research. The role of treatment providers’ individual differences, in relation to the experience of work-related stress, has therefore not been studied widely or systematically . In the Studies that included therapist-factors tended to focus on demographic variables, such as age or gender, which were correlated with test-scores on questionnaires . No cleaSome authors argue that the use of either positive or negative coping-mechanisms may mediate or moderate the effects of the work-content. According to Moreover, Actually hearing what they’re saying and how they’ve actually offended against a child or how they’ve managed to manipulate and rape a victim… is quite distressing and quite upsetting. But, you know you’re there to do a job and, and to help rehabilitate them so there are no more victims, that’s important” (pp. 300-301).Some research, which included therapist-factors, focused on therapists’ personal abuse histories. It has been hypothesized, that a large proportion of therapists who chose to work with sex offenders, were, in fact, abused as children, which in turn could account for the presumed high levels of work related stress among sex offender therapists .Furthermore, 75% of the 252 sex offender therapists, who returned a questionnaire by Interestingly, this topic also surfaced in a grounded theory study conducted by While such hypotheses are interesting, as it is not inferred that dealing with sex offenders is necessarily traumatic in itself, there is currently not enough evidence to draw firm conclusions. More research, focused on therapists’ personal abuse history, is therefore warranted.Therapists’ conceptions about this client group may well influence how work with them is experienced. While numerous studies have focused on therapists’ attitudes towards this population , only onPreviously, it was noted that an increasing amount of therapists work with sex offenders and people with pedophilia. Based on the following results, however, it would seem that, overall, few therapists chose this line of work, perhaps due to negative attitudes towards these types of clients. No more than 4,7% of the 86 German therapists that participated in a survey conducted by Some therapists may decline such clients in order to prevent judgment from others in their community. Results from the previously introduced study by iIn order to conduct successful sex offender therapy many, potentially conflicting, demands require careful consideration. Since therapy with these populations is often court ordered, a frequently asked question is, for example, how to define clear boundaries between therapy and punishment . It can Another widely debated question concerns which approaches to sex offender treatment are the most effective and ethical. This relates, for instance, to what kind of stance therapists should take towards such clients. One school of treatment specialists contended that the first step in treatment should be to break denial and obtain disclosure by adopting a “confrontational approach” towards clients . In the The abovementioned examples are included in this review because they highlight unique ethical dilemmas inherent in this line of work. While it is outside the scope of this review to discuss these questions in detail, we argue that such ambiguity may prove to be relevant in explaining potential negative effects from working with sex offenders, as such dilemmas may be strenuous to cope with. However, no researchers have, to our knowledge, focused on this potential relationship. Additional research that includes ethical aspects of these therapists’ work is therefore necessary.Some researchers investigated more general aspects of sex offender therapists’ work, such as their caseload, which was found to be the only significant predictor of burnout in a questionnaire study by As such, we should expect sex offender therapists to be exposed to general work-related stressors common across occupations. In other words, identified stress symptoms among sex offender may not (only) result from working with sex offenders. In some cases, then, negative impact may be better explained by drawing on theory from general work psychology.In this review, we aimed at outlining the existing literature concerning sex offender therapists’ experiences and the effects of this line of work on these. These studies were, however, not without theoretical and methodological limitations, some of which will be assessed in more detail in this section.Many research contributions within this field treated “sex offender therapists” as a homogenous group. However, therapists working with sex offenders come from a variety of educational backgrounds and provide counseling in various contexts. Searching for general experiences and impacts among these practitioners may therefore prove difficult.Additionally, to our knowledge, research to date has been conducted exclusively on English-speaking therapists, with the exception on one study . This isAnother sampling bias may be that most researchers drew their participants from organizations such as USA-based ATSA , which could further limit our possibilities to make any generalizations based on results from these studies.Despite evidence to the contrary, working therapeutically with these clients was mostly portrayed as strenuous work in the discussed literature. One possible explanation for this apparent paradox may be that most researchers are aware of the results that were published by Moreover, most researchers, including Nevertheless, such research may be challenging to conduct for a number of reasons. As mentioned, categories like “sex offenders” and “pedophiles” include heterogeneous individuals, making it difficult to determine whether or not it would be meaningful to search for a unified ”nature”, which, in turn, could account for therapists’ “symptomology”. Similarly, “therapists” may not react uniformly to the demands of their work. Taken together, the time may therefore be ripe to explore other theoretical perspectives, in relation to sex offender therapists’ work experiences, than those associated with work-related stress.Because the majority of research in the field is based on questionnaire studies, these studies seem to fail to address important aspects of the experiences of treatment providers within this field. While the validity of several of these questionnaires have already been criticized, in relation to the lack of profession-specific questionnaires , the folIn addition, no research to date included reference groups outside the field of sexual abuse, to our knowledge. Also, no norms (base-rates etc.) currently exist for clinicians . At thisAdditionally, the results of these questionnaires, which are typically based on one of the aforementioned theoretical constructs, where usually correlated with, for example, demographic variables thereafter. While correlations may provide some useful insight into a phenomenon, claims of causality should be made with great caution .We can conclude from the literature discussed in this review that some therapists who work with sex offenders are negatively affected by their work. There is, however, also sufficient evidence to determine that a considerable amount of these therapists find satisfaction in their work.Overall, therapists working with sex offenders and people with pedophilia provide a vital contribution to our society. Enhancing our understanding of the challenges these therapists may face is therefore of great importance. Yet, in order to support treatment providers in their work, it should also be recognized that it is of equal importance to understand its rewards. As discussed in this review, most studies to date have, however, solely focused on determining the negative impacts of this line of work. Furthermore, a pursuit to identify, measure, and separate the negative impacts from the positive may be a questionable endeavor because such features, in fact, could be interrelated and coexist. It was, for instance, precisely the challenging nature of sex offender treatment that made it exciting to work with as well .Furthermore, we argue that “experience” must not be reduced to a concern with symptomology, as valuable aspects of human experience are left out. Instead, individual differences as well as dynamic and contextual features must be taken seriously, in order to achieve a holistic understanding of the issues in question. While not dismissing the value of questionnaire-based research, qualitative strategies may be better suited for this endeavor. Interpretive phenomenological analysis offers a promising avenue to this end, as a result of its consistent focus on the experiential content of consciousness . Another