Background and Objectives: The goal of this survey was to identify the relationship between the level of satisfaction with body image, perceived health, and the usage of social media among freshmen medical university students. The influence of social media and peers was also related to body image. Materials and Methods: An online survey was distributed among freshmen healthcare students. The questionnaire collected sociodemographic, anthropometric data, and information about students’ perception about healthy lifestyle using open-ended questions, as well as their opinion about the importance of perfect body image and the level of satisfaction with their physical appearance. Questions focusing on the use of social media and the relationship with body image collected data on the use of social networks and how they affect students’ opinion about their own body image. Psychometric data were also gathered using the Body Consciousness Scale. For the statistical analysis, QSR NUD*IST  Vivo 12 was used for qualitative data and IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, version 23  was used for descriptive and comparative results. Results: In total, 77 students aged 20.09 ± 2.47 years, of which the majority were women (75.30%), were included in the survey. The use of social network was about 4.81 ± 3.60 h/day. Facebook was the most used social networking site (94.80%), followed by Instagram (92.20%), Snapchat (16.90%), WhatsApp (15.60%), and TikTok (10.40%). The most common reason for using these sites was socialization. We found that 64.90% of healthcare students were normal weight. The main barriers for having a healthy lifestyle, as they were perceived by students, were the busy schedule and the lack of time needed to prepare healthy meals, lack of motivation, and lack of money. Women scored higher for the Private Body Consciousness and Public Body Consciousness scales. The main aspects related to a healthy lifestyle referred to physical activity, consumption of fruit and vegetables, water consumption, and a good quality of sleep. Gender differences were discussed as well. Conclusions: The results illustrated the complexity of the relationship between social media and body image and the need to prevent body image concerns, especially in young women. Lifestyle is defined as a pattern of behavior, the attempt to ensure optimal health, or the sum of health-related habits that have a positive effect on overweight and obesity ,2. In thAccording to current data, lifestyle is based on personal choices and identities and has a significant influence on the physical and mental health of the people . At the According to the WHO, late adolescence (from 19 to 24 years) is an important stage in a person’s development and is defined as a period in which the individual prepares for work and assumes adult responsibilities . The basDuring the period of their academic studies (late youth), students should be physically and mentally healthy, practicing an active life and having healthy eating behaviors to maintain their health status. They need a good physical and mental condition to cope with the effort required during their academic years and to have a satisfactory body image ,8. A pooBody image has several components, which can be divided into two dimensions: (a) Perceptual  and (b) attitudinal (how we feel about these traits and how these feelings affect our behaviors) . Body imResearchers have identified that healthcare students have an increased focus on their own health, practice a better lifestyle compared to other student populations, and have a favorable perception of their own health and body ,13. The Body dissatisfaction and exposure to the thin-ideal image are major predictors of the development of an eating disorder, the latter having significant health implications. Students experience psychological and social changes, which are more pronounced in subjects experiencing considerable social pressures . Thus, tIn the Western European countries, body image has become increasingly important, with images of movie stars and fashion models having a strong impact on girls’ body shape and image perception. Such means of mass communication and various sociocultural pressures are considered to cause an increased awareness of being thin as an ideal and contribute to the misperception of body weight . Media hThe influence of advertising on social networks and its effect on young people’s self-image has been studied ,19. SociIn the last decade, social networks have become the most common form of sociocultural interaction for young people due to various factors such as communicating with peers, maintaining contact with friends and family, and sharing information. On social networks, people often present an idealized version of themselves by uploading only the most attractive images of them (which can be edited and enhanced) in their profile and removing any images they find unattractive. Although social networks contain images of several different types of people , these are generally used to interact with colleagues. Finally, in addition to images, people often post other content related to appearance and comments on social networks, which could also impact users’ feelings about their appearance .However, among students, it has been shown that comparison to other colleagues’ pictures and posting on social media influences self-satisfaction with the body image considerably. Body dissatisfaction and exposure to thin-ideal images are major predictors for eating disorders. Social networks have a strong influence on young people, even changing their habits and lifestyles ,24. SomeThe goal of the present study was to explore health-related beliefs, body image perception, and influence of social networks on the ideal body image among freshmen healthcare students enrolled in kinesiotherapy studies with a focus on gender differences. The study is part of a larger one focusing on health status, body image, and the impact of social media on the ideal body among healthcare students in Romania.The questionnaire was sent to 90 freshmen students enrolled in Balneo-Physio-Kinesiotherapy specialization. The respondents were informed about the purpose of the study and the confidentiality of data. No incentive was given to the participants. Students were informed that they could withdraw from the study whenever they wanted without consequences. The inclusion criteria were students enrolled in their first year of study and surveys returned before deadline. Criteria for excluding surveys from the research were incomplete questionnaires or questionnaires submitted after the deadline. Finally, 77 questionnaires were included in the research.The questionnaire was created using Google Docs and was distributed online during March–April 2021. The qualitative research design was developed to obtain detailed information about students’ perceptions of the following aspects, namely healthy eating, body image, and the influence of social media.−The first part of the questionnaire gathered sociodemographic and anthropometric data .−The second section contained items evaluating students’ perception about healthy lifestyle. The items were constructed as an open-ended question . One item referred to the free association method and asked students to write the first 5 words that came to their mind when they thought of a healthy lifestyle.−The third part of the questionnaire addressed the Body Consciousness Scale developed by Miller, Murphy, and Buss in 1981 . This in−The fourth section included items related to body image and aimed to identify the main characteristics that students associated with their body, the opinion about the importance of body image today, and the level of satisfaction with their body image. The answers were rated on a Likert-type scale from 1 to 10, where 1 = very dissatisfied and 10 = very satisfied.−The fifth section comprised questions focusing on the use of social media and the relationship with body image .−In the sixth section, students were asked to open a separate document, draw the first thing that came into their mind when they thought of a healthy lifestyle, and upload that document in the space provided within the questionnaire.This study used a triangular research method which included drawing, free association method, and open-ended question surveys. The study collected information regarding the following issues:2 was categorized as underweight, 18.5–24.9 kg/m2 as normal weight, 25.0–29.9 kg/m2 as pre-obese, 30–34.9 kg/m2 as obese class I, 35.0–39.9 kg/m2 as obese class II, and ≥40 kg/m2 as obese class III [The data were analyzed using a qualitative data analysis program, QSR NUD*IST  Vivo 12, also called NVivo. To present the sociodemographic characteristics of the samples, we performed analyses using IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, version 23 . Results for descriptive statistics were expressed as means and standard deviations (SD), frequencies, and percentages. The same library was used to report the results of the Body Consciousness Scale. A qualitative analysis (word cloud) of the students’ personal perception of a healthy lifestyle was created using the Orange software . Using tThe present study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethical Committee of Faculty of Medicine, University of Oradea, Romania, with the registration number No. 26214/18.11.2020.The respondents were students enrolled in the first year and studying kinesiotherapy specialty. Students came from rural and urban areas, aged M = 20.09 ± 2.47 (with a minimum of 18 and a maximum of 39 years old). Most of them were female students (75.30%). Body Mass Index (BMI) was also calculated, conforming to WHO guidelines. The detailed information about sociodemographic and anthropometric data are presented in The results of this survey present findings concerning different aspects of students’ life, perceptions about health and body image, and the use of social networks. The themes that emerged from the present research are presented below as headings and supported by quotes from the participants. Each quote is accompanied by the identification number assigned to the participant (participant ID), sex, and age of the participant in parentheses.The first question in the second section of the survey invited students to reflect. They were asked to mention, in a few words, what their perception of a healthy lifestyle was. The results obtained are shown in As shown in the word cloud visualization, where the size of the word indicates the frequency of its use, the most used words were “sports”, “vegetables”, “fruits”, “healthy eating”, “balance”, “healthy food”, “nutrition”, and “diet”. The importance of hydration, sleep, and rest are highlighted as the main components of a healthy lifestyle through words such as “water”, “hydration”, “sleep”, “rest”, “relaxation”, “proper sleep”, “balanced sleep”, and “high fluid intake”. The students also focused on mental and social health, mentioning various words that refer to these components of a healthy lifestyle, such as “happiness”, “friends”, “optimism”, “positive thinking”, “positive attitude”, “positivity”, “meditation”, “motivation”, “active social life”, “socialization”, “healthy thinking”, “walks”, “outdoors walks”, “nature”, “mental health”, and “soul”.A healthy lifestyle is necessary starting with the health of the physical body, to the mental, emotional, spiritual well-being ; Through a healthy lifestyle we stay in shape, we will have a longer and happier life ; The main reason why I consider it is necessary to have a healthy lifestyle is to avoid certain diseases, to maintain a general state of well-being .Regarding the reasons why a healthy lifestyle is necessary, most students scored an increased quality of life, physical, mental, and social well-being and lack of diseases: A healthy lifestyle is necessary because in this way we can maintain both physical and mental balance of the body. Moreover, a healthy lifestyle gives us the opportunity to have a pleasant physical appearance ; For physical appearance, implicit self-esteem and health ; You feel much better in your body, it helps to have a better physical and mental condition ; Because it helps us look better, but in addition our body will feel much better, and this can also help us in emotional states .Some of the students highlighted the relationship between a healthy lifestyle and physical appearance or body shape: To lose weight, to keep fit, for immunity ; To develop muscle mass ; For better physical condition, optimal body weight, better mood .At the same time, practicing sports, as another important component of lifestyle, helps to maintain a good physical condition, a harmonious body, to lose weight, and to increase muscle mass, as evidenced by the participants’ answers: I should eat fewer sweets, I should quit smoking, I should practice more sports ; I should reduce sedentary lifestyle, eat a lot more fruits and vegetables, be more organized with the time I eat, and drink less coffee .Most students acknowledged that they had an unhealthy eating behavior, characterized by high consumption of fast food, high carbohydrate intake, low consumption of fruits and vegetables, and other unhealthy behaviors: Lack of motivation and will, laziness, insufficient time ; The busy schedule and the responsibilities of some days, job and college ; Time, money .Some students mentioned that they would change these things in their lifestyle but face certain obstacles, most often highlighted by the lack of time, busy schedule, lack of motivation, and sometimes money: N = 14), “slender” (N = 13), “sensitive” (N = 9), “beautiful” (N = 9), “small” (N = 12), “acceptable” (N = 12), “healthy” (N = 11), or “cared” (N = 6).The students were asked to mention three characteristics that they considered most important when thinking about their body and the way it looked. Thus, the most used words were “fit” (p < 0.001).The level of satisfaction with body image measured on a Likert-like scale from 1 to 10 (1 = very dissatisfied and 10 = very satisfied) showed that most students were satisfied with the way they looked (M = 7.61 ± 1.57). The Spearman correlation analysis showed that the level of body satisfaction correlated negatively with BMI: The higher the BMI, the lower the satisfaction related to body shape ; This is what people see for the first time, plus the media promotes so-called perfection and people tend to frame people in those patterns ; Body image is important only for that person and not for those around them, however it influences relationships between people .Students were also asked to express their opinion about the importance of body image in today’s society and culture. Most believe that beauty standards have been created by culture and imposed by social media: The body image steals glances, as it were. If you do not have an attractive body image, people will look at you differently, at least that is what I realized and saw in my case, but that is another story. I have been satisfied with myself for many years and people’s opinions no longer matter ; I do not necessarily think that body image is important, for me everyone must feel good in their body no matter what the world says .Some other male students considered that the body image is not important: N = 73), followed by Instagram , Snapchat , WhatsApp , TikTok , YouTube , Pinterest , and Discord , with students spending an average of M = 4.81 ± 3.60 h/day on these networks. The most common reasons why students used social networks were for socialization , entertainment , an information source , or a way to relax .Although the participants mentioned the use of several social networks, the results show that Facebook was the most used among students ; Sometimes it makes me feel uncomfortable in my body, but most of the time it does not affect me ; Sometimes it motivates me to reach the stage where I am satisfied with my body ; I don’t compare myself to anyone, I’m my only competition ; After I started maturing, they didn’t influence me at all. When I was younger, they had an extremely great influence .For the most part, students stated that social media and peer posts did not influence how they felt about their own body and did not influence the tendency to compare themselves with others. Some of the female students stated that they were affected by these posts in a negative way, leading them to feel insecure and uncomfortable in their own body or becoming envious, while others felt motivated to make a change about the way they looked: It increases the desire to socialize and the need to express yourself freely ; Some people think that it is not a very positive impact, because many people are disrespectful when they see such people, but many of these stars should motivate us to become our best version ; It helped me develop my level of knowledge, I found information that I would not have found ; At least, sedentary lifestyle occurs because we keep looking on social networks and physical activity remains forgotten ; The impact may be different for each person. It may not affect me at all while other people are trying to change because they want to be appreciated and integrate into the standards that are being promoted ; As for me, these social networks kidnap a lot of my life .The impact of social networks on body image was found to be seen differently by the respondents. Students considered that social networks had a negative consequence on their psychological status, while some others mentioned that the body-image standard imposed by the social media helped them motivate themselves to become more careful with their weight. Many students agreed that significant time was invested in social networks to the detriment of the individual study program, of the physical activity, or of the effective face-to-face socialization: Private body —M = 13.19 ± 2.89,Public body —M = 17.68 ± 3.22,Body competence (which refers to effective body functioning)—M = 9.83 ± 2.13.A three-factor structure of BCQ indicates three dimensions of this scale:p = 0.001): The older the students, the lower their desire to be concerned on with the external appearance of the body.The correlation analysis showed that there was a negative correlation between students’ age and public body subscale , as well as rest and hydration. Although, in theory, they knew the guidelines for following a healthy lifestyle, many of them acknowledged that they would have to improve many aspects to reach a positive lifestyle . Our results are different from others conducted on students, in general, showing that they failed to achieve a healthy lifestyle due to the practice of diets, lack of physical activity, consumption of cigarettes, and high level of stress . In addiThe results of the present survey show that the most important barriers for a heathy lifestyle perceived by students were the busy schedule and lack of time needed to prepare healthy meals, lack of motivation, and lack of money. Some studies have reported similar findings, showing that the most common factors perceived as barriers to a healthy diet were time constraints, high food prices, and availability, followed by a lack of motivation in food preparation, which is intricately linked to intention, the main factor in predicting behavior regarding the consumption of healthy foods, such as fruits and vegetables ,39,40,41N = 50), while the rest of the participants were underweight , overweight , or fell into the first class of obesity . However, on a Likert scale from 1 to 10, most participants in our study were quite satisfied with the way they looked. Similar to our results, some other studies conducted on students showed that, in general, most students had a normal weight [BMI values are useful predictors for the risk of bodily dissatisfaction, as some authors have identified ,43, withl weight ,46, althl weight ,48. Howel weight  identifiThe scores for the three BCQ subscales proved that women had high scores on the Private Body Consciousness and Public Body Consciousness scales, similar to another study showing that women scored higher on Public Body Consciousness  and wereN = 73), followed by Instagram , Snapchat , WhatsApp , and TikTok , with the most common reason for using these sites being socialization. There is evidence that social media and internet use are associated with concerns about body image and eating disorders, especially in women, but the causal direction between specific social media and body dissatisfaction cannot be clearly highlighted [The students in our survey mentioned Facebook as the most used social networking site  can lead to a negative image of one’s own body . Thus, pHowever, the participants of this study stated that social networks had both a positive impact on their lives. Social networks increased the desire for free expression and helped students develop knowledge or even motivation by overcoming their own condition regarding physical appearance. However, social networks also had a negative impact by creating addiction, wasting time, or negatively affecting self-image.Alperstein  showed tSocial media has the potential to allow more fluidity in gender expression but it also has the potential to perpetuate stereotypes, including beauty standards and body ideals . Social The relationship between the promoted image about thinness on social networks and eating disorders and dissatisfaction with body-image has been identified by several studies. For example, Jiotsa et al.  revealedThis study brings important results regarding body image, body satisfaction, and the impact on social media on contentment with body image among healthcare students from their first year of study. Another strength is represented by the fact that quantitative and qualitative results are presented, covering a gap of information about students enrolled in kinesiotherapy studies. Third, the results reveal gender differences in perception about body image.The limitations of the study are represented by the small number of subjects involved in the research and the fact that results cannot be generalized for all categories of students enrolled in different medical specialties. Also, the alpha Cronbach score for the BCQ scale must be evaluated with precociousness, as multiple studies have obtained, in general, a low alpha Cronbach score between 0.59–0.78 ,68,69.The results of the present study highlight the relationship between body image, the influence of social networks, and the importance of a healthy lifestyle on students’ quality of life. Due to the utility of the findings, such information should be disseminated among students, especially to those from medical sciences who are the promoters of a healthy lifestyle and those who will work on providing healthcare to people in need. The impact of these relationships on the satisfaction with body image and the impact on both physical and mental health are important, especially on subjects at this age. In addition, because healthcare students will work with teenagers and young adults, it is useful consider factors such as satisfaction with physical appearance, ideal body image, and the impact of media and social media on health status. The relevant relationship between the perception of one’s physical appearance and depression , stress The results of the present study illustrate the complexity of the relationship between social media and body image among healthcare students. Furthermore, they emphasize the need to prevent the concerns on the individual’s concept of one’s body, especially in young women. Because of the important impact on physical and psychological health, as well as on practices related to healthy lifestyle, these findings are useful for students, healthcare workers, and university staff to provide better assistance to students and to encourage a high quality of life and satisfaction during academic years.


The “Healthy China 2030” plan states that it is necessary to formulate and implement physical health intervention plans for special groups, including women. Based on questionnaire data from women in seven Chinese cities, our research analyzed the status quo of women’s fitness, its influencing factors, and the differences in and characteristics of different types of women’s fitness demands from four aspects: demography, fitness motivation, fitness behavior, and fitness demands, so as to provide a reference for the promotion of women’s fitness. A total of 3473 valid samples were completed. The questionnaire included five age groups: there were 146 in the “20–29 years old” group, 829 in the “30–39 years old” group, 1088 in the “40–49 years old” group, 1105 in the “50–59 years old” group and 305 in the “60 years old and above” group. The questionnaire used in this study was a self-made questionnaire. The contents of the questionnaire included age, occupation, educational level, family circumstances, and health status, women’s fitness behavior, fitness motivation and fitness demands. The results show that the current situation of urban women’s fitness in China is characterized by low frequency and short duration of exercise. The internal factors affecting women’s fitness demands include fitness motivation and fitness behavior. The external factors affecting their fitness demands are social environment and family environment. The differences in women’s fitness demands mainly come from women’s occupation, monthly income, and family stage. Women are the main force of national health: women’s physical health determines the physique of future generations and even of the whole nation ,3,4,5,6.A study on the age, occupation and family circumstances of middle-income women by questionnaire showed that Chinese middle-income married women account for 12.8% of the total population. Chinese women’s family work and childcare factors reduce the leisure time of married middle-income women and limit their sports participation behavior . InfluenHence, our paper focuses on women’s individual characteristics , family characteristics , fitness motivations, fitness behaviors, and fitness demands. Based on the data, our paper describes the current situation of women’s fitness in urban China is characterized by low frequency and short duration. The internal factors affecting women’s fitness demands include fitness motivation and fitness behavior. The external factors affecting their fitness demands are their social environment and family environment. The differences in women’s fitness demands mainly come from their occupations, monthly income, and family stage.We developed a survey design scheme for the current situation of women’s fitness in urban China. Based on the existing theories of fitness demands, three basic dimensions of women’s fitness demands structure are determined. The three basic dimensions are fitness behavior, fitness motivation and fitness demands. Then, we analyzed the main factors contained in the three basic dimensions. Based on the existing relevant literature, the questionnaire items are compiled. The items of the questionnaire are in Questionnaire S1.A total of 3473 valid samples were completed. The questionnaire included five age groups, there were 146 in the “20–29 years old” group, 829 in the “30–39 years old” group, 1088 in the “40–49 years old” group, 1105 in the “50–59 years old” group and 305 in the “60 years old and above” group. We conducted a survey in the form of online questionnaire. The samples were recruited in China’s first tier cities . Before the investigation, we trained seven investigators of the research group and unified the investigation methods and standards. Seven investigators went to seven survey cities to distribute online questionnaires face-to-face. The purpose of face-to-face distribution was to improve the survey quality. The network questionnaire was selected to facilitate statistics and avoid errors due to manual input. Finally, a total of 3551 samples were completed from 24 March to 23 April 2020, and after deleting 78 questionnaires of participants who did not meet the recruitment conditions, 3473 valid questionnaires were retained.We used a self-made questionnaire to investigate the current situation of women’s fitness in urban China. The questionnaire items mainly come from the results of previous studies. We obtained the description of the current situation of women’s fitness in urban China. The questionnaire contains 40 items. The items of the questionnaire included age, occupation, educational level, family circumstances, health status , women’sWe conducted statistics and analysis on the data through SPSS-AU and Excel statistical software. Reliability analysis was used to analyze the reliability of the questionnaire . Factor Women’s fitness motivation is the internal driving force for women to stimulate and maintain fitness and make action-oriented fitness. As shown in Women’s fitness demands are the time, place, environment, etc that women lack in their fitness practice. As shown in Factor analysis and cluster analysis were used to analyze the fitness demands of different types of women. Five factors are extracted from the scale, they are self-realization fitness motivation, family needs fitness motivation, family support environment demand, public policy demand and social support environment demand . Self-reThere is an interaction between women’s fitness demands and family fitness demands. Our research found that in terms of personal background, older women have a higher demand for a family support environment . The famFrom the perspective of women’s individual fitness, our research found that older women have a higher demand for a social support environment . HoweverFrom the perspective of women’s individual fitness, women’s demand for public policy is weak . HoweverWomen’s fitness demands are the time, place, environment, etc that women lack in their fitness practice. According to women’s fitness behavior , fitness“Environmentally supported group” refers to women who love fitness and have a strong demand for fitness environment, such as family series fitness activities, economic support, etc. Women with a supportive environment have the strongest fitness motivation. Their fitness forms are greatly affected by their families. Their overall fitness behavior is better than that of the other two types. They like to participate in sports activities with their families. When exercising alone, they choose “walking, fast walking, running”, “aerobics and dance”, “indoor”, and “small ball”. When participating in fitness activities with their families, they choose “ball games”, “swimming”, “outdoor”, and “skipping rope”. The family fitness environment of the environmentally supported type is good, and words such as “happy fitness” and “parent–child activity time” often appear. Environmentally supported women have significantly higher fitness demand than the other two types. They need more leisure time and economic support and tend to participate in family sports activities.“Policy guaranteed group” refers to those who love fitness and hope to obtain a policy guarantee to promote their fitness performance or competition. The family fitness environment of policy guaranteed women is the best of the three types of women. Their number of fitness times per week is the highest, and there are fewer women of this type who never exercise. The fitness time and intensity of each sports activity are better than they are for the other two types. Women in this group like to exercise alone and do physical exercise in parks and gyms. Their family fitness environment is good. When participating in fitness activities with their families, they choose “walking, fast walking, and running”. This type of woman has a high demand for policy guidance, support, and guarantees.“Key supported group” refers to women who need fitness because of weak fitness motivation, family inhibitory environment and need special attention and help from the society and the government. The fitness motivation of key supported women is weak. This type of woman is mostly born in an inhibitory family fitness environment, and their family fitness consumption expenditure is less. The proportion of this type who exercise more than three times a week is small, and approximately 20% of them never participate in physical fitness activities. Most of them tend to exercise alone and to participate in spontaneous sports activities, such as square dancing and Tai Chi. The demands of key supported women are lower than that of women in the first two groups. Many aging women can be found among the key supported women, which needs the focus of society. Our research found that their fitness motivation needs to be stimulated, they need fitness guarantees, and they need to age healthily.The frequency, durations, and fatigue of participating in fitness activities every week can reflect the enthusiasm, habits, and regularity of women who participate in fitness activities. According to the questionnaire survey, women who often participate in fitness are in the minority. Women have enough exercise time to participate in fitness, but their exercise intensity is low. A survey conducted in 2019, Taiwan, China, also showed that women’s sports participation is characterized by insufficient exercise intensity and low participation rate . CombineThe factors affecting women’s fitness demands include both internal and external environmental factors. Women’s internal factors mainly come from women’s fitness motivation and fitness behavior. If women are short on fitness motivation, their fitness demands will not be engendered . MeanwhiThe differences of urban women’s fitness demand in China mainly come from their occupation, monthly income, and family stage ,10,11. WThe current situation of women’s fitness in urban China is characterized by low frequency and short duration. The internal factors affecting women’s fitness demands include fitness motivation and fitness behavior. The external factors affecting their fitness demands are their social environment and family environment. The differences in women’s fitness demands mainly come from their occupations, monthly income, and family stage. According to the research results, we make the following suggestions. First, the society improves women’s fitness cognition and enriches their fitness experience to stimulate their fitness participation behavior. Second, the society and women’s family give full play to the role of sports organizations to meet women’s diverse fitness demands. Third, the government ensures the supply of basic fitness services and promotes women’s fitness participation by relying on various national fitness activities.In this study, a questionnaire survey was used to explore the fitness demands of women in urban China. However, there is a problem of insufficient scale both in terms of sample size and sample area. Our follow-up studies will expand the sample size and sample area on the basis of this paper. We will deeply explore the influencing factors of women’s fitness demands, the differences between rural women and urban women, the differences between different types of women, and the differences between women and men in fitness demands. In addition, this study lacks in-depth discussion of the influencing factors of women’s fitness demands from the perspective of psychology. For example, the choice tendency of women’s fitness behavior and the strength of fitness motivation are directly affected by women’s psychological factors. Examining the topic of women’s fitness from the perspective of psychology will help researchers collect research data more carefully. Future research should develop our results along the following three aspects. First, the method of stratified sampling should be used to include women in both urban and rural areas in the sample selection range, and the sample size should be expanded. Second, the influencing factors of women’s fitness demands should be studied from the perspective of psychology. This includes studying the relationship between women’s fitness demands and life cycle, and the relationship between women’s fitness demands and emotions. Third, solve the problems of how to effectively supply the fitness demands of different types of women.


The term “normal” is culturally ubiquitous and conceptually vague. Interestingly, it appears to be a descriptive-normative-hybrid which, unnoticedly, bridges the gap between the descriptive and the normative. People’s beliefs about normality are descriptive and prescriptive and depend on both an average and an ideal. Besides, the term has generally garnered popularity in medicine. However, if medicine heavily relies on the normal, then it should point out how it relates to the concept of health or to statistics, and what, after all, normal means. Most importantly, the normativity of the normal needs to be addressed. Since the apparently neutral label “normal” can exclude, stigmatize, and marginalize people who are defined in contrast to it as abnormal, health professionals should think twice before using the term with patients. The present critical perspective advocates against using the term “normal,” as long as no understanding of a person’s individual normality has been attained. It advocates for the right to autonomously determine one’s own normality. For health professionals I do not see worthwhile benefits of subscribing to the concept of  “normality” and imposing it on their patients. But I do see many risks. We use it constantly, like our favourite mug, but our understanding of it remains volatile, like the scent of the freshly brewed coffee in our mug. In the following, I will critically discuss the subject of normality with the aim to make people think about the normal, its fallaciousness, and its dangers.The term “normal” is culturally ubiquitous, but its conceptual essence has not been fully unveiled Stephens . If a coIn times of crisis, typically an uptick in prevalence of the term “normal” can be observed. Just compare pre-pandemic and pandemic numbers or use Google-Books-Ngram-Viewer to see the increase during and especially after political crises. In these cases, the term “normal” is mostly applied to social, political, and economic conditions. This should not obscure another field of application, namely persons and their qualities.The present opinion piece addresses this particular field of application. As the coronavirus spreads, the use of the term “normal”—primarily being applied to social conditions, such as a return to normality as indicated by an end of curfews—spreads as well, and this risks to reinforce the acceptance of the concept of normality, also when applied to persons. This is unfortunate because, as will be shown later, the label “normal” often stigmatizes, marginalizes, and sometimes even pathologizes persons who are not considered normal.Ethical analysis distinguishes between two types of statements. Descriptive statements make factual claims about how the world or a person is. Normative statements make prescriptive claims about how the world or a person ought to be. Normative conclusions  need to rest on at least one normative premise. Of course, as with descriptive premises, the normative premise is always debatable, but the point is that an ought (i.e. normative claim) cannot solely rest on an is (descriptive claim).Interestingly, the normal appears to be a descriptive-normative-hybrid. It seems to unnoticedly bridge the gap between the descriptive and the normative, a gap which philosophers have been struggling with for eons. In “The Normal and the Pathological,” Canguilhem articulates this convergence: “the concept of normal is itself normative” , which, by nature, represent mere descriptive statements about the distribution of measured qualities and which lack any intrinsic normative significance. For the normal distribution, normal refers to the situation where most of the sample data clusters around a single value (the mean) with observations far apart from this value being rare, but it neither describes one part of a binary normal-abnormal condition  or as an “subjective notion,” socially and normatively constructed . Irrespective of this genuine contestability of the concept of health and the underlying notions of normality, if medicine heavily relies on the normal, then it should point out how the normal relates to the concept of health or to statistics, and what, after all, normal means. Reflection on the normal should be incorporated in classification systems and in medical curricula. The normal should be an object of critique. Its determination should not be left to the diagnosing health professional. Most importantly, the normativity of the normal needs to be addressed. However, normality in medicine is currently not clearly defined in the medical literature Chadwick . Only ifNormality, once established, is rarely made explicit but still powerfully permeates our daily lives. Any person-related reference to normality, simultaneously, qualifies abnormality. Facing this ineluctable truth, an individual might experience fear of denormalization, which often results in marginalization and stigmatization, and, hence, has strong incentives to adhere to the normal. In fact, any form of normality entails conformity pressure. “Normal” is no neutral label. On the contrary, it is—in its negative form: the abnormal—being used in a variety of discourses as a metonym for social exclusion. The normal and abnormal are powerful tools in the hands of those who construe its essence.“Normal” is a generic replacement term that, mediated through persisting related beliefs, discriminates against certain—often historically excluded—groups in various mutually constitutive discourses. These discourses are interconnected and, therefore, discrimination at the intersections can be amplified Crenshaw . InterseThis is illustrated by the following few findings on the normative and exclusionary operation of normality that are related to medicine. The normal implicitly determines social judgements about the acceptability of certain kinds of biological variation Amundson . The bodGiven these effects of the normal, shouldn’t we allow only one form of normality, that is each person’s individual normality? With respect to health, Goldstein outlined that “disease can be determined only by means of a norm which permits taking the entire concrete individuality into consideration, a norm which takes the individual himself as the measure; in other words, as an individual, personal norm”  that the concept of normal relies on logical coherence, and that exposing its contradictions will fatally undermine its functionality”  “normality” and imposing it on their patients. But I do see many risks. Medicine’s persistent recourse to normality not only—in many instances—fails to honour the paradigm of rigorous science, it also—more importantly—fails to honour the lived experiences of those systematically excluded by the social, cultural, and medical authority of the normal.


Background: Spirituality is a multidimensional construct which includes religious, existentialistic, and relational issues and has different layers such as faith as the core, related attitudes and conviction, and subsequent behaviors and practices. The perceptive aspects of spirituality such as wondering awe are of relevance for both, religious and non-religious persons. These perceptions were related to perceiving the Sacred in life, mindful awareness of nature, others and self, to compassion, meaning in life, and emotional wellbeing. As awe perceptions are foremost a matter of state, it was the aim (1) to empirically analyze the frequency of wondering awe perceptions  and (2) to qualitatively analyze a range of triggers of awe perceptions.Methods: Data from 7,928 participants were analyzed with respect to the frequency of Awe/Gratitude perceptions , while for the second part of the study responses of a heterogeneous group of 82 persons what caused them to perceive moments of wondering awe were analyzed with qualitative content analysis techniques.Results: Persons who experience Awe/Gratitude to a low extend were the youngest and had lowest wellbeing and lowest meditation/praying engagement, while those with high GrAw-7 scores were the oldest, had the highest wellbeing, and were more often meditating or praying (p<0.001). Gender had a significant effect on these perceptions, too (Cohen’s d=0.32). In the qualitative part, the triggers can be attributed to four main categories, Nature, Persons, Unique Moments, and Aesthetics, Beauty, and Devotion. Some of these triggers and related perceptions might be more a matter of admiration than wondering awe, while other perceptions could have more profound effects and may thus result in changes of a person’s attitudes and behaviors.Conclusion: Emotionally touching experiences of wondering awe may result in feelings of interconnectedness, prosocial behavior, mindful awareness, and contribute to a person’s meaning in life and wellbeing and can also be a health-relevant resource. These perceptions can be seen as a perceptive aspect of spirituality, which is not exclusively experienced by religious people but also by non-religious persons. Spirituality is a complex and multidimensional construct which includes religious, existentialistic, prosocial-humanistic, and relational issues  and, froawe as a first-order level of experience from wondering which is described as a reflective second-order experience; they considered awe as an immediate experience that may motivate more reflective experiences. Empirical studies have shown that pausing in specific situations with feelings of wondering awe (and subsequent feelings of gratitude) is of relevance for both, religious and non-religious persons; all may perceive moments of wondering awe or admiration, yet to differentiated degrees  was developed as a measure of a person’s perception of the Sacred in daily life, and thus, the items measure experience rather than particular beliefs or behaviors . In contTo assess participants’ well-being, the WHO-Five Well-being Index (WHO-5) was used . RepreseThe frequency of participants’ spiritual/religious practices such as meditation or praying was assessed with a 4-grade scale ranging from “never” (0) to “at least once per month” (1), “at least once per week” (2), and “at least once per day” (3) as described .n=5,395), frequency of spiritual practices , and perception of the Sacred .Data of 7,928 participants were used to assess their Awe/Gratitude perceptions. Within this larger sample, different subsamples recruited as different cohorts and at different time points were analyzed with respect to participants’ wellbeing  as well as internal consistency (Cronbach’s coefficient α) were computed with SPSS 23.0. The significance level of ANOVA and correlation analyses was set at For this study, free-text responses were analyzed using qualitative content analysis techniques  referrinTo get some degree of heterogeneity, healthy participants, both female and male, from different age cohorts and with different religious/spiritual backgrounds  were invited by email in a larger European research network  and subsequently informed about the purpose of the project, voluntary participation, and usage of short anonymous quotes for a publication. Eighty-two persons send back their written statements. Identifying information and respective mails were immediately deleted to assure anonymity of responses. Nevertheless, their gender, age, and religious background  were recorded to describe the sample. Among them, 56 were female and 26 were male, with a mean age of 52.9±13.3years (range 29–82). Thirty-three were Catholics and 21 Protestants, and 28 had other spiritual/religious backgrounds (incl. Buddhists and Yoga practitioners).For this study, data from 7,928 participants were used . Among tParticipants experienced the beauty in nature or were “captivated by the beauty of nature” much more often than they had explicit feelings of “wondering awe” or were pausing “spellbound at the moment”; becoming “very quiet and devout” at certain places and thinking about all the things one is grateful about were experienced “in-between” . A quiteThese seven items can be combined to one factor, the GrAw-7 scale, which has a good internal consistency also in this large sample  and explains 58% of variance. The mean score of this factor is 65.3±19.7 . Also, the age cohorts differ significantly , with the lowest GrAw-7 scores in the younger ones (<21years: 56.4±22.4) and the highest in the older ones . Persons with a nominally Christian background have higher scores than those without (66.4±19.5 vs. 62.8±20.8), yet this difference is rather weak (Cohen’s d =0.18). However, persons with other religious affiliations had the highest GrAw-7 scores (70.6±18.3); compared to Christians the difference is weak, too (Cohen’s d=0.22). Thus, the religious orientation had a small but significant influence on the GrAw-7 scores .Women have significantly higher scores than men  and in a subsample of 2,613 persons strongly with the perception of the Sacred in daily life . Frequency of meditation and praying was assessed in 3,886 persons, and the GrAw-7 scores were moderately related with both spiritual practices . As there is an obvious association between perception of the Sacred in life and frequency of spiritual practices, one may assume that particularly religious brothers and sisters (n=371) and yoga practitioners (n=833) with their specific lifestyles and spiritual practices will have higher GrAw-7 scores than the other persons. In fact, religious brothers and sisters, which are the oldest (mean age: 60.5±13.7years), had similarly high scores compared to yoga practitioners , which were much younger (mean age: 49.4±10.3years), while the scores of the other participants (mean age: 44.8±16.7) were significantly lower .In a subsample of 5,370 persons, the GrAw-7 scores correlated moderately with participants’ wellbeing , moderate (45.6–85.0), and high (>85.0)], those with low GrAw-7 scores had the lowest age, lowest wellbeing, and lowest spiritual practices, while those with high GrAw-7 scores were the oldest, had the highest wellbeing, and were more often meditating or praying .As shown in the empirical data, the frequency of the different indicators of perceived awe differs, with more frequent perceptions of beauty in nature in general than staying “spellbound” at the moment. This would mean that moments of fascination are experienced more often than the more specific perceptions of wondering awe. To analyze the different causes and triggers of a wide range of awe perceptions, a heterogeneous group of persons was invited to describe what caused them to perceive moments of wondering awe. Here, the statement of 82 responding persons was analyzed with qualitative content analysis techniques.Nature, Persons, Unique Moments, and Aesthetics, Beauty, and Devotion .More specific situations and observations related to nature were described, too:“Most of the time I feel that in or through nature. When I come to the pond one morning and see the empty hulls of the hatched royal dragonflies and then they buzz over the surface of the water. When I see the little frogs watering the flowers. To watch the young tits leave the box and flutter out into the world. The colors of a sunrise that are almost too beautiful to be true. The sea” .“As a rule, these impressions are associated with nature in the broadest sense. It can be a beautiful landscape, or the observation of wild animals. I am an enthusiastic rider and when these impressions are still connected to my horse, i.e. when riding, then I often find the feeling overwhelming!” .Related to the aforementioned general topic, these perceptions were attribution by several persons to the Sacred in the whole creation, either stated directly or indirectly:“When I see the divine shimmering out of people/animals /plants/beings or the divine in their actions” .“When I take the ship to a German North Sea island in autumn and the weather is rough and stormy, I am amazed because of the greatness of God” .“I am amazed again and again by the creative work of nature and that of man. When I see how things have developed which are unbelievably creative, it often touches me deeply .One woman interpreted her nature-related perceptions as a hint of God’s presence, particularly in depressive states.“In deep personal despair and fear, in the feeling of hopelessness, the perception of a robin, a sunrise, sun-drenched leaves of trees - small light events that have always filled me with astonished awe, because for me they are powerful signs of the no-ifs-and-buts validity of Jawhe’s almost incomprehensible promise [to be there for me]” .One other woman stated that unique perceptions after her work with others reminded her that she is part of “something bigger,” without clearly referring it to something transcendent:“After intensive work - with others, moment of rest, ex. food, and the idea that I am embedded in something bigger” .Outstanding, inspiring people may also trigger perceptions of admiration or even awe. There are several statements that refer to this category. These persons can be impressive because of attitudes, behaviors, and actions, because of their life experiences, or because of outstanding skills:“I am full of amazement when a person acts ‘superhumanly’, such as when a Palestinian father releases an organ of his brain-dead son to the son of an Israeli father. I am in awe when people forgive circumstances (such as the murder of a family member) without a trace of retaliation. I am awesome when people behave altruistically by putting themselves in danger and saving people and animals. I am in awe of the wisdom of old people” .Older persons and persons in difficult situations can cause moments of respect, admiration, and awe:“Also with older people who transmit wisdom or younger people in conversations” .“At patient encounters, when amazing human encounters take place, e.g. how someone deals with an extremely difficult illness: how someone thinks about the world and life and death” .Important persons can also be members of the own family that helped to care for the children despite own burden:“Today, on my father’s birthday, I think of him with awe and gratitude. In the time of his loneliness as a (widower) he respected us, his growing daughters and helped to understand the maturing life” .Also admiration of the unique skills of specific persons, either artists, musicians, or poets were categorized here:“With a 25-year-old pianist in the large concert hall, who played the hardest pieces by heart for 2h. The musician was still so young and played so confidently and at the same time so humbly, devoted, selflessly… out of the silence - no one who was listening interfered with coughing, etc.”.“Perhaps most of all with music, for example when I see a musician I admire ‘live’ and feel that what he/she does is really great” .“It is also triggered when I hear beautiful music or singing. A great pleasure and astonished pause even with beautiful texts, especially poems, e.g., Rilke” .The birth of a child was stated as a trigger of awe by some persons, not because of specific abilities or behaviors, but because of their simple presence and unique “wonderful” part of their life:“I was able to attend a birth. Amazed awe to hold a little new living being ‘human’ in your hands! You cannot do that, it’s a gift” .“Immediately after the birth of our first child, there was such an unexpected moment of ‘wondering awe’. This lasted extremely for a few minutes and then more and more weakly for several days. This feeling was also present at the birth of the second child, but weakened more quickly” .Also living with the own children and attending their development causes moments of wondering awe:“Such moments are also familiar to me in everyday life with my child. Reaching for a toy for the first time, discovering your own toes and fingers, but also now (he’s now 8) watching my child, hearing how much wisdom, sincerity, clarity and compassion there is in this little person” .Not only birth can be a trigger of awe, but also being with dying persons. These encounters were touching because the dying persons shared their experiences, and respondents were able to assist them:“In the face of dying/death - when a whole life is decided. Death as something great” .“In the great moments of meeting patients, when they have invited me into their life, which was often enough determined by suffering, misery, despair, fear of death, and succeeded in helping them to give them a little bit of hope, discovered a little joy, a little gratitude in looking back at their life. This given premonition of being loved nonetheless has changed these people” .Nevertheless, these moments are also a time of self-reflection, and one person was appreciating the confidence of specific persons and their acceptance of being dying:“Whenever I feel that death is in wait in a room, I am amazed at the YES of the person concerned. Then I ask myself: - Are you capable of this?” .This subcategory holds statements “from a distance” about man as a miracle in general. It is a matter of rather cognitive “wonder” how complex the creation and man specifically is:“The human organism - with all the intermeshing of the most varied of processes - to be aware of this causes me to be amazed again and again. Or the development of a little human being - getting up at some point, the emerging speaking and understanding of contexts” .“As a doctor, when I visualize what always happens so automatically and yet finely tuned unconsciously through our body, cells divide, food is digested” .Times of crisis triggered moments of awe in some respondents. These can be, for example, a matter of wondering surprise against own professional expectations in terms of healing processes:“If a child is born in an emergency, it has to be reanimated and all parameters are more pessimistic. And then, after a few days and repeatedly for weeks and months, the news comes that the child is healthy and well” .One medical doctor described an own moment of crisis when she perceived simple moments of admiration as a hint that God is still at her site, even in times of inner darkness:“The astonished reverence was for this inviolability of the promise and the inventiveness of God founded in love, and that they [she refers to unexpected observations in nature] were also for me at the bottom of life. The question - why did you leave me - but it also implies knowing about you. And that was enough” .“Moments in everyday life, looks, words” , while there are also more specific situations. One statement indicates some kind of resonance between therapist and patient:Specific situations can trigger such feelings as described by some participants. Several triggers of the aforementioned category, particularly “Birth of the own child” or “Accompanying the dying” or “Crises,” could be attributed also to this category. A general statement addresses “During rhythmic embrocations on patients when something like non-verbal communication is taking place. There is silence and calm in the room, and something begins to oscillate between patient and practitioner” .Specific times of silence at certain places and also during daily life activities were mentioned, either related to God or not specifically addressed:“Monastery - meeting God in silence” .“It can also happen spontaneously in everyday life, especially in times of silence or meditation” .insights”  refer to a perception of interconnectedness which may link this topic to the subcategory “Perceiving the Sacred in Creation,” too.This category refers to situations and moments which raised specific “unexpected” understanding or “insights”  that thereby triggered moments of wondering awe. These ““In the holm oak forest of a hermitage: silence, old trees, fog, just being in there as a person, and feeling, I am part of creation” .“The main reasons were the awareness of undeserved gifts. But also the awareness of being carried and chosen by God” .“Amazed awe occurs when I see larger connections in the world or in my life. Sometimes it happens as a spontaneous insight. Mostly when I read texts or take part in philosophical seminars” .“There is always amazement and thanks when I look at my life and so many unbelievable connections that emerged in it” .Some participants reported moments of admiration and even awe when they perceive music, poetry, ballet, or sacred buildings which have impressed or inspired them, or during specific ritual and ceremonies that have touched them. The sacred buildings are both, a place of admiration and veneration and a place to practice specific rituals.Here, examples are categorized that go beyond simple admiration of artists as concrete persons, but refer to music or poetry itself which is touching:“When I walked into the Museum of Modern Art in New York and there was a real Matisse hanging in front of my eyes in real size and colors. To really see this in REAL was overwhelming” .“The incredible beauty of a Bach oratorio. The deep touch that I feel when I hear the Brahms requiem and even more when I sing it. Unexpected changes in harmony that completely surprise me and open completely new doors to the piece [of music] and maybe also to myself. A poem that uses language in such a way that the old words suddenly create something completely new. When language can surprise me, leave the usual path and create something new with inner contexts or its sound and rhythm that is unexpectedly beautiful. Dance. Mainly ballet or artistry” .Specific sacred buildings were mentioned either in terms of the beauty of the building itself or its effects on the person. These can be related to perceptions of connectedness, too. However, it can be also an aesthetical experience of inspiring peace, calm and beauty.“When I came to the Sagrada Familia in Barcelona and was amazed at the format, the colors and the naturalness of the shapes” .“Large church buildings ” .“Cathedrals especially when they are embedded in the quiet of a landscape. And the sacred can be felt far beyond the narrow confessional references” .Depending on the spiritual background, specific spiritual/religious rituals were mentioned that have triggered feelings of awe by three persons. In case of a yoga practitioner, this feeling was also related to remembering a unique teacher of his tradition, in terms of devotion. However, in that respective situation, it was the ritual which triggers the devotion of the school’s guru .“Every time in Eucharistic adoration. When receiving the sacraments” .“In front of an altar during a satsang [spiritual ceremony with chantings] while looking at a picture of Swami Sivananda [the deceased guru of this yoga school] during a puja [ritual of veneration]; in deep meditation” .Findings of the empirical part of this study underline that the frequency of Awe/Gratitude perceptions is varying strongly. Persons with low Awe/Gratitude perceptions were the youngest and had the lowest wellbeing in the sample, while those with high Awe/Gratitude perceptions were the oldest and had the highest wellbeing. Those who were experiencing awe only rarely (low scores) have wellbeing scores that would indicate depressive states (WHO-5 scores<13). The causal pathways of this association are unclear. Both concurrent pathways might be true: Persons with low wellbeing (or depressive states) experience awe less intensive, while persons who are unable to stop for moments of wondering awe (because they are too busy) might be “happy” but not satisfied with their life. Such associations were already described , 2021e, During the COVID-19 pandemic, the perception of Awe/Gratitude was related best with positively perceived changes in terms of Nature/Silence/Contemplation and Relationships, while it was only marginally associated with participants’ perceived burden – and is thus not a buffer against burdening situations . InteresR2=0.12), but not Awe/Gratitude. It seems that the perception of Awe/Gratitude is a relevant dimension related to a person’s meaning in life and prosocial behavior, while it is not a direct aspect of their quality of life. It is rather an ability to nevertheless perceive the positive aspects in life – despite restrictions (in terms of the COVID-19 pandemic or illness).During the pandemic, GrAw-7 scores were much lower in tumor patients . Therefore, the number of participants is not the same for the respective correlation analyses. As responding to the DSES-6 requires a theistic religious belief, the scale was used only to underline convergent validity of the GrAw-7 scale (which does not require belief in God) in a subsamples of participants. Further, the data are cross-sectional, and thus, the causality of interactions remains unclear. Despite the relatively large sample size, we cannot guarantee that the data are representative for the general German population. Particularly, the two specific subsamples of religious brothers and sisters and of yoga practitioners were exclusively recruited as “positive perception” samples which are not representative for the general population.With respect to the qualitative approach, the participants were invited to respond by email. Although it was assured that the responding emails were directly deleted and no identifying data were recorded, some may have been reluctant to send their responses back. One may further assume that particularly persons have responded who have an interest to state their usually positive experiences, while those who may assume that their experiences are either “too small” to report, not important enough or even negative might not have responded. Therefore, the number of participants was raised in order to achieve a larger set of different awe perceptions. Further, it cannot be excluded that persons from other cultural or religious societies may perceive moments of wondering awe differently than the German sample and that they may state other triggers, too.Nature, Persons, Unique Moments, or Aesthetics, Beauty, and Devotion. Some of them have a transcendent  connotation, and others are concrete. The experiential and perceptive aspect might be crucial instead of adopting inherited experiences of others or adopting religious concepts for which no personal experience is available (belief systems). Here, the concept of transcendentality could enhance the view (What is the “spiritual” aspect of perceiving moments of wondering awe? First, touching experiences that transcend the conventional experiences can induce processes of inner change . These tthe view , as mindthe view . With rethe view .For healthcare professionals, this indicator of spiritual sensitivity could be an approach to implement the underlying ability to perceive the nevertheless beautiful and unique moments even in difficult life situations, both in their patients and in themselves, in terms of a coping process and to draw attention to what is still valuable and special in life. Mindful approaches, such as yoga and meditation, but also autobiographical narratives, art, and writing, could be useful. Perceiving moments of wondering awe will not directly influence a person’s wellbeing, but probably in terms of interaction processes that enroll different interacting variables .According to the data protection regulations, the dataset cannot be made publicly available. Data are however available upon reasonable request.Ethical review and approval was not required for the study on healthy human participants in accordance with the local legislation and institutional requirements. Participants were informed about the study purposes, guaranteed confidentially, and they consented to participate by filling the anonymous questionnaires, which were applied in most cases online. Neither identifying personal details nor IP addresses were recorded to guarantee anonymity.AB designed the study, set up the online survey, undertook all analyses, and wrote the manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be seen as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To describe the experiences and expectations of Spanish women regarding breastfeeding and the support they receive from healthcare professionals, family, and friends during the breastfeeding journey, A qualitative study using an empirical-phenomenological approach was conducted. Primiparous women that had already given birth were interviewed using a purposive and snowball sampling. In-depth interviews were conducted between 1 January and 30 April 2020. The interviews were transcribed verbatim and analysed using Haase’s adaptation of Colaizzi’s phenomenological method. We recruited 14 women who had recently become mothers. Three major themes describing experiences of infant feeding by maternal lactation were identified—institutional influences, establishing breastfeeding, and cessation of breastfeeding—as well as the following 10 categories: hospital routines, lactation concerns (amount and infant nutrition), antenatal breastfeeding decision, embarrassment to breastfeed, and normalisation of breastfeeding. Prior education and support were identified as key elements in possible breastfeeding support strategies. The World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF) recommend that breastfeeding is started within the first hour after birth, is continued exclusively for the first six months of life, and then maintained along with supplementary feeding until age two or older . HoweverThe benefits of breastfeeding (BF), especially exclusive breastfeeding (EBF), have been widely recognised ,9,10,11.However, rates for EBF continue to be low worldwide—only 36% of babies under 6 months receive EBF ,14. BreaThe United Nations Children’s Fund (UNICEF) provides country-disaggregated data on any breastfeeding, and these rates vary widely between low- and middle-income, and high-income countries ,18,19. SAt a national level, Spain does not have a breastfeeding monitoring system, which makes it difficult to collect official data on the breastfeeding situation. However, according to the latest update of the 2018 National Health Report, in 2017, 81.1% of new-borns had been fully or partially breastfed in the first 6 weeks of life .In Spain, there is no official system suitable for monitoring breastfeeding , but datAn increasing number of studies suggest that parents are influenced by multiple sociocultural factors that interact to guide their infant feeding decision . It has Regarding the support of professionals in health institutions, the existence of specialized professionals who provide continuous breastfeeding support varies greatly among centres. While some have qualified personnel dedicated exclusively to these tasks, in most public centres, breastfeeding support is part of the activities carried out by professionals on a daily basis and depends on the availability of time in their working day. This means that breastfeeding support is often limited to offering a small piece of advice .Women are more likely to initiate and maintain breastfeeding behaviours when encouragement by medical professionals is combined with breastfeeding support by family, friends, and partners A qualitative study of women’s experiences of group-based or individual peer support found that women preferred a group-based approach that normalised breastfeeding and provided flexibility and a greater sense of empowerment and self-control . One-to-The aim of this study is to describe the experiences and expectations of Spanish women regarding breastfeeding and the support they receive from health professionals, family, and friends during the breastfeeding journey.We conducted a qualitative study using in-depth interviews. An empirical-phenomenological approach was used to obtain detailed descriptions of the experiences of new mothers that were breastfeeding their infants.Participants were recruited through purposive and snowball sampling . The samThis study received the approval of the Clinical Research and Ethics Committee.The objectives of the present study were explained to all participants, and voluntary participation and oral informed consent were obtained before each interview. The use of numbers in place of names for each participant  and eliminating any identifying information from the transcriptions ensured confidentiality. All audio recordings and transcriptions were stored with password protection on a protected computer. Throughout the study, we followed the COREQ Standards for Reporting Qualitative Research guidelines.All in-person in-depth interviews were conducted at a time chosen by the participant between 1 January and 30 April 2020. The interviews were recorded with the participants permission. Data for each participant were collected, including age, civil status, duration of breastfeeding, and any education they received.All interviews began with an open question that asked, “Please tell me how breastfeeding your infant has been for you”. Subsequently, follow-up questions were used to motivate the participants to share their story, such as: “how did you feel the first day you breastfed?”, “How do you feel now?”, “What challenges have you faced with breastfeeding?”, “Do you think you were able to resolve them?”, “Did you receive help from healthcare workers?”, and “Do you think something should be changed in the healthcare system to help women breastfeed?”. Further probing questions were added, such as “Please, tell me about that?”, to improve the depth of the interview.Data collection was conducted at the same time as the analysis of the interviews. The interviews were conducted in the homes of the women interviewed by three different researchers. The audio recordings were transcribed verbatim by two researchers and revised by a third to ensure improved accuracy. The interviews, original transcriptions, and the data analysis were conducted in Spanish. During the data analysis, all the authors agreed with the annotations of the transcribed texts. All texts were translated to English by a native translator, and backtranslated to Spanish by an independent translator to ensure the meaning was retained, and the researchers validated the final text.The transcriptions were analysed by Haase’s adaptation of the Colaizzi method ,28,29. TThroughout the process, the criteria for methodological rigour of credibility, dependability, confirmability, and transferability were observed .Credibility was achieved by in-depth interviews followed by peer debriefing ,30,31. TAll authors participated in the validation of the results. Each step of the analysis was questioned to check any alternative interpretations. The analysis was discussed until an agreement was reached.Our sample consisted of 14 new mothers (between 1 month and 1 year breastfeeding) collected between January and April 2020. Ten had tertiary level education, and four had secondary level education . All womThe interviews lasted between 25 and 65 min. Three major themes describing experiences with infant feeding by maternal lactation were identified : “institData saturation was reached with interview number 12, and 2 more interviews were conducted to confirm theme redundance.“The beginning was very difficult, because of the caesarean and not being able to do skin to skin due to hospital protocol.”(M2)“In private hospitals, they have their protocols and, sometimes it is very difficult to make them respect the wishes of a labouring woman and a new mother.”(M4)“In the hospital they didn’t help me, on the contrary, they forced the infant onto the breast as per their routines, and both of us cried.”(M6)“The healthcare professionals in the hospital gave my infant various bottles of formula without my consent while I was in the recovery room, completely interfering with breastfeeding.”(M8)“In the hospital and with the medicalisation of processes it was not possible for everything to go as well as it would have at home.”(M10)“In the hospital after the caesarean they admitted me to the ICU for 8 h without being able to see my daughter because I had high blood pressure and they pressured the father telling him that if he didn’t sign consent to give formula they would leave her without food for the whole time I would be in ICU.”(M3)Hospitals are complex environments in which different routine proceedings are conducted daily; the maternity wards do not vary much from this for safe growth of the new-born. However, some mothers complained that the structures imposed by hospital policies interfered with their experience of breastfeeding their infants.“It is a marvellous experience, and the connection with my infant, my experience in the hospital was good, everything had a protocol, and it made me feel safe.”(M14)Only one mother considered these routines as calming processes when it came to breastfeeding.“At first in the hospital it was very difficult, because of the caesarean wounds and because the infant was admitted to the ICU and they separated us. They gave the infant formula in neonates, and a dummy without even asking me.”(M3)Some mothers found that the physical separation from their infant owing to admission to the neonatal intensive care unit created a challenge for breastfeeding.“At one month, they admitted me to the hospital with a generalised infection, and following milk culture detected infection with MRSA, a super-resistant bacterium. I had to pump milk and have intravenous antibiotic therapy.”(M13)Other mothers were not able to be physically present with their infant due to their own health condition. This type of situation was considered challenging, above all for the initiation of breastfeeding.“In the hospital where my son was born, the help to initiate breastfeeding was some posts on the ward, 0 lactation consultants, their presence on the ward should be compulsory just like doctors, nurses, nurse aides, etc.”(M1)“I did not receive help from the staff of the hospital where my daughter was born.”(M7)“In the hospital they recommended we supplement, and I pump milk to produce more.”(M9)“In the hospital after childbirth there was little help.”(M11)“In the hospital I didn´t have the needed support, there were many contradictions between the different professionals that cared for me.”(M13)“The lack of interest from the healthcare professionals on the hospital ward ensured no one helped me.”(M2)Some mothers reported that healthcare professionals did not encourage them to breastfeed their babies outside of the habitual feeding hours, which discouraged them and even made them consider formula.“In the hospital, I received help and support from the lactation consultant nurses.”(M14)“In the room, the nurses always placed my son on my breast when they entered and helped me with breastfeeding.”(M4)“I gave birth in the hospital where I received a lot of support by nursing staff to initiate breastfeeding, correcting posture, etc.”(M5)“I believe that the training of staff in public hospitals is terrible and has to change for the good of our children.”(M8)“Some nurses in the hospital were kinder and more patient with me than others when teaching me how to breastfeed.”(M3)“I am convinced that I have been able to continue breastfeeding due to the help I received from the nurses in the neonate unit of the hospital.”(M5)“Initially I had problems because in the hospital they gave us formula because he didn´t latch well.”(M9)Although when they spoke specifically about the nurses, they were considered as one of the most positive influencing factors in the experience of breastfeeding, with nurses considered as calming, informed persons that provide all the support in this initial process.“It was a frustrating time, difficulties facilitating breastfeeding in the hospital, lack of time and family support, problems with a tie and latch. I tried everything: supply line, syringe, skin-to-skin, hospital pumps... Finally, I couldn´t anymore and gave up. They lack support protocols in the hospital.”(M13)“The start was very hard due to fissures, mastitis, drops of milk... As well as the insecurities of a first-time mum, but now I enjoy it. I would like to be able to maintain it for a time, but I don’t know if I will be able to balance it with work.”(M2)“Frustrating and difficult due to difficulty with latch and endless feeds that meant I didn´t sleep sufficiently.”(M7)“Now, without pain and confident in myself, I enjoy breastfeeding, but my infant keeps asking every hour and 45 min throughout the night, and I am exhausted, I am considering stopping after 9 months as I don’t sleep.”(M8)The first weeks after childbirth were stressful when mothers faced the challenges of breastfeeding, with problems including insufficient milk, poor latch, or physical exhaustion due to the frequent feeding of the infant.“The start was hard because of problems with the latch that caused significant fissures, for which I started using nipple shields.”(M6)“In the hospital they supported me a lot with breastfeeding, but I didn´t achieve a good latch, and it ruined my nipples.”(M1)“My experience has always been pleasant. I feel very fortunate to have had “easy” lactation without problems with latch, or of any type.”(M7)Mothers worry that their babies cannot correctly latch, which is a demotivating issue and one of the principal causes of considering stopping breastfeeding as the only nourishment for their babies.“I lived attached to the breast pump to save milk for them to give him when I am working. If it wasn´t for this, I would have stopped breastfeeding a while ago.”(M2)“I restarted work at 6 months full-time with 5 24 h on call a month, for which I used my breast pump for a lot of time, almost up to 18 months of my son’s life.”(M4)“He latched on the third day and bye-bye fissures..., etc. I also want to comment that when my breast was hard and tight in the hospital, they taught me to use a pump, and this also helped a lot.”(M11)“My infant was a guzzler, and I had little milk despite putting him to the breast frequently with good latch and position, help arrived when in the hospital they taught me to use a breast pump, and this made breastfeeding change for the better.”(M9)In this subtheme, the correct use of breast pumps comes into play, and if the nurse showed them how to use it or, on the contrary, they did not receive any teaching by any healthcare professionals in the use of this apparatus.“At first it took me a while because of engorgement and fissures, but by two months he already latched well, and milk transfer was good. I weighed him every week.”(M4)“My experience has been good, and the infant latched well from the first moment and gained weight well.”(M10)“In my case, I have bad memories of breastfeeding because the infant did not finish eating well, did not latch well, and cried a lot because of hunger.”(M6)Another important subtheme is the correct supply of milk, and this is perceived by mothers as a common occurrence and the most stressful for mothers. In the hospital environment, often the establishment of breastfeeding is achieved with the achievements of both the mother and her babies: The mother, as the producer of milk, and the babies, when we consider their success, showing they are capable of obtaining sufficient human milk as measured by weight gain.“My experience at first was a little traumatic for me because my daughter didn’t latch correctly because of flat nipples and her tongue tie. She ended up losing significant weight, and I had to help with formula until she recovered her weight. Once she did, I returned to exclusive breastfeeding.”(M13)“The start was very complicated: nipple shields, formula supplements, and finger feeds, and supply line, poor latch, 12% weight loss, tongue tie... But with the help of the professional hospital team and the support of my partner, it all paid off, and by two months I was exclusively breastfeeding without any problems.”(M5)An indicator that an infant is obtaining sufficient nutrients through breastmilk is often the beginning of the successful establishment of breastfeeding as a fundamental pillar in the feeding of their babies, because, if the mother believes that her child is feeding well, it is due to the success with exclusive breastfeeding without the need to offer any kind of supplementation.“In my family, it’s seen as totally normal and natural. In fact, during my pregnancy I was asked a lot if I was going to breastfeed, but none of those questions came from my family–they just assumed I would.”(M12)The cessation of breastfeeding may occur for different reasons. In our discussions regarding the main reasons, the first reason was the decision made during the antenatal period on whether to breastfeed; in second place, it was feeling embarrassed breastfeeding in public; and lastly, it was the negative attitudes by people towards mothers that breastfeed in public. The normalisation of breastfeeding is needed to avoid unnecessary abandonment of breastfeeding.“Despite having read up on it, it was full of surprises. From the start, it didn´t go well enough, leading to use of nipple shields, leaving them even though I read everywhere that it wasn’t easy and shortened breastfeeding, something that didn´t happen in my case; mastitis, a lot of pain, understand and live with each of the stages and then able to honestly enjoy it. It takes a lot, and I think that it is idealised, it is not at all rosy.”(M4)“I think we will tend to idealise breastfeeding and that nobody is really prepared for the setbacks. Nobody tells you that maybe you should give formula during those first days to be able to rest, it won’t interfere with breastfeeding, they tell you the opposite, also the use of the dummy, but really, my experience tells me that I was able to start with mixed feeding in some feeds, use a dummy, and still exclusively breastfeed my infant for seven months. Nobody tells you that if you can’t, it doesn´t matter. You can try again later. And above all that you are doing a GOOD job.”(M10)Women tend to choose to breastfeed during the prenatal period based on their knowledge of breastfeeding; nevertheless, the reality of breastfeeding does not always coincide with their preformed ideal, and this incongruence between their ideal and the reality can stifle the woman’s confidence in breastfeeding and push her to wean.“With my son, I didn´t put him on the breast initially, partly because of the visitors in the hospital and I felt embarrassed to pull out my breast in front of them.”(M1)“It is an experience suffered and sacrificed for the mother; sometimes, you feel embarrassed breastfeeding with people around and especially at first.”(M2)“The insecurity and embarrassment that one may feel breastfeeding is unfair, and many mothers wean because of that, and due to misinformation, I see it constantly.”(M13)Feeling embarrassed breastfeeding in public was an important sub-theme, especially the embarrassment of the women and their families and/or society in general. Some women felt they need to ask permission before nursing in front of their friends and some family members.“In general, people comment that you should pick up a child a lot, nor let them sleep with us, much less breastfeed in public.”(M2)“Criticism always affected me, and I felt a lot of shame nursing in public.”(M8)“I breastfed him very occasionally because of the short time and only in private because I was told by whoever saw me not to do it, and I was embarrassed, and in the end I stopped.”(M6)Some women expressed reluctance in terms of feeding their babies in public, emphasising the need to be discrete and carried out in a hidden manner, and even if recognising that breastfeeding is acceptable in public, it should be in a way that does not appear offensive to other people.“For my first son, I stopped breastfeeding at 8 months only because of social pressure.”(M10)“I weaned them at one year because they fell asleep nursing all the time, and, honestly, I was very tired of people telling me I had to stop breastfeeding.”(M6)Some women reported having felt negative attitudes and perceptions from others towards breastfeeding; whether due to breastfeeding or for the duration of breastfeeding.“I breastfed everywhere. Always when my infant was hungry. I breastfed until I felt it was ok to do so, despite the opinions of those that said I should stop earlier and those that said it was early. I think that making mothers feel bad for their lactation choices is horrible.”(M13)“I am proud that I was able to normalise breastfeeding around me and able to help other mothers through different paths.”(M5)“Breastfeeding needs to be normalised. It seems to scare people to see someone breastfeeding!!”(M14)“A lot more information and normalisation are needed, and above all, more help in the hospital. It helps to insist that yes, you can breastfeed.”(M1)Facilitating a sensation of it being normal for women to feed their children via breastfeeding was considered essential by all the women, both in the promotion of breastfeeding as in the initiation and duration, and, of course, the acceptance of the whole breastfeeding process by the woman.The aim of this study was to explore experiences of first-time mothers with infant feeding via breastfeeding. Our findings indicate that the experiences of infant feeding were modified by institutional influences, the period of breastfeeding establishment, and by their own cessation of breastfeeding.The results show us that the hospital environment influenced the infant and the mother’s experience of feeding her children; while some mothers felt influenced by the processes and technological environment, others felt appreciative of the role that nurses played in informing them regarding infant feeding with breastfeeding ,33,34.The importance of healthcare professionals as educators in the promotion of breastfeeding is recognised by some mothers and considered a part of their role ,36 and aSimilar to our study, some authors have found that mothers experience a change in reality once they bring their babies home, and they find themselves facing a lack of skills and information regarding lactation, such as correct latch and ability to assess if babies are correctly feeding, as well as constant worry if they are providing their infant with sufficient breastmilk ,38.The hospital environment places healthcare professionals as experts and mothers as beginners in breastfeeding. All the mothers in our study regarded the nurses as experts, especially in terms of breastfeeding support . AdditioThe study by Thomson and Dykes  describeA large difference exists between expectations and reality. This tension reflects the problems inherent in the maternal ideal of trying to satisfy two very demanding tasks: on the one hand, to breastfeed her infant and, on the other hand, to fulfil the role of the working mother and caretaker of her home . We mustPrevious studies ,47,48 haThe authors believe that, in addition to improving knowledge and resources that should be offered to mothers, it is essential that health institutions promote changes in care protocols that facilitate breastfeeding. Specifically, it would be highly advisable that the centres adhere to the Baby Friendly Hospital initiative to follow a process of appropriate change and based on current scientific evidence, implementing practices, such as skin to skin in all cesarean deliveries, when the situation allows, and strengthening support for those women who are especially in vulnerable situations.The authors are surprised that the reasons for abandoning breastfeeding do not include the incorporation to work, possibly attributable to the work situation of the sample evaluated.The use of in-depth interviews allowed mothers to explore their own experiences with breastfeeding with minimal interviewer influence.One potential limitation in this study was the time passed from hospital discharge to the interview, which ranged from 15 days to 1 year. This time difference may have resulted in different perceptions of their experiences breastfeeding, as the babies were in different stages of their development and growth. We should also recognise that this is a small study, and we cannot generalise the findings, although, in qualitative research, a small sample size allows for the full exploration of participants’ experiences and in-depth analysis , and theThis study explored the experiences and expectations of Spanish women regarding breastfeeding and the support they receive from health professionals, family, and friends during the breastfeeding journey. Specifically, it explored the possible causes for stopping breastfeeding.Previous education and support were recognised as key points for possible strategies, and it is important for health systems and key decision-makers to provide resources to the healthcare professionals that have contact with mothers who wish to breastfeed. These resources should be compulsory and centred in the education of mothers regarding the full breastfeeding process.These improvements in education and training would support the provision of appropriate care by healthcare professionals to help mothers in theirs and their babies’ breastfeeding journey.Providing a realistic image of breastfeeding could contribute to building a community culture of support for mothers, understanding that, for breastfeeding, the decisions made previously have longer-term influence in the maintenance and cessation of breastfeeding.