Interviews were coded by 8 members of the research team. A Rapid Qualitative Analysis was conducted to identify themes. Caregivers, youth, and CHWs all endorsed the value of CHW models for this population. They also almost universally suggested multiple adaptations are needed for the model to be effective. Four main categories of themes emerged related to intervention adaptations: (1) Why adaptations are needed for LGBTQ youth, (2) Who should serve as CHWs providing care, (3) How CHWs should be trained, and (4) What content needs to be included in the intervention. Broadly, findings suggest the relevance of having CHW models for LGBTQ youth of color to address stigma and discrimination experienced, access to culturally and linguistically relevant services, and the need for caregiver support of LGBTQ youth. CHWs need increased training in these areas.Lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth of color experience high rates of mental health disorders, yet they experience challenges to accessing mental health services. Community health worker (CHW) models of care have potential to promote equitable mental health services among LGBTQ youth. Our aim was to understand how CHW models could be adapted to better support LGBTQ youth of color in accessing mental health services. Semi-structured qualitative interviews were conducted with LGBTQ youth of color ( Significant mental health disparities exist for lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth , is one promising strategy to work with families of LGBTQ youth. CHWs have been identified as an important workforce to enhance service equity for communities of color . Qualitative interviews were conducted with LGBTQ youth, caregivers of LGBTQ youth, and CHWs to identify: 1) provider characteristics essential to promoting effective and engaging care, 2) CHW training needs when serving LGBTQ youth, and 3) intervention components that should be incorporated into CHW models such as family navigation.This study leveraged ongoing community-academic partnerships with CHWs embedded within healthcare systems in Massachusetts  and community settings in California  included LGBTQ youth (n = 16), caregivers of LGBTQ youth (n = 11), and CHWs (n = 15) in Massachusetts and California. All caregivers, CHWs, and youth participants reported being racially and/or ethnically minoritized . All caregivers identified as the LGBTQ youth’s biological mother. See Tables Inclusion criteria for the study included that participants either identify as 1) currently serving as a CHW, 2) caregiver of a child ages 10–21 who identifies as a sexual or gender minority, or 3) youth between the ages of 18–21. All participants needed to be English or Spanish speaking. Given the focus on making adaptations for LGBTQ youth of color, purposeful sampling was conducted within community partnerships that served racially and ethnically minoritized populations. Additionally, efforts were made to have representation across sexual orientations and gender identities. Participants , with bilingual researchers conducting the interviews in Spanish. Participants received a $50 incentive for the interview. All interviews were audio-recorded and transcribed verbatim. All study procedures were deemed exempt by [masked] Institutional Review Boards.Youth and caregiver participants were recruited from medical centers in an urban area in Massachusetts and non-profit agencies in the central coast of California serving LGBTQ individuals, to have representation of all participant types from medical and community settings. CHWs included family navigators recruited from medical centers in Massachusetts and Purposeful sampling was used with an effort to have variation across race, ethnicity, language spoken, and youth gender identity and sexual orientation. As recommended for qualitative research in implementation research, this variation was used to find shared and different patterns across cases . These questions were asked to understand areas to target within CHW intervention. After these broad questions, the definition and role of CHWs was introduced and follow-up questions were provided regarding perceptions of this role. Emphasis was placed on how CHW models should be adapted specifically in regards to (1) who should serve as CHWs , (2) CHW training , (3) and content that CHWs should be able to address . Broadly, CHW-specific questions explored their experiences working with LGBTQ youth and their caregivers and the types of training they received or desired to support this population  to identify common themes that emerged from the interviews , which were then entered into a matrix. The researchers completed a practice transcript to establish consistency in summaries and met throughout the course of the study to avoid drift in the way interviews were summarized. RQA is an especially valuable approach to compare responses from different participant groups to identify where themes converge and diverge , (2) Who should serve as CHWs providing care , (3) How CHWs should be trained , and (4) What content needs to be included in the intervention . The themes  within categories focused on similarities and differences relating to the experiences and challenges within and across stakeholder groups.Qualitative themes were organized under categories informed by the FRAME in regards to adapting CHW-models for LGBTQ youth. The categories of themes addressed the following areas: (1) lack of CHW training and experiences related to working with LGBTQ youth and their families, and even those with some experience communicated difficulty providing support due to a lack of training related to the LGBTQ community . When recalling one experience working with an LGBTQ youth, a CHW expressed, “…I found myself not knowing what pronouns to use… feeling uncomfortable in the situation because I didn’t want to offend her.” Despite having limited experiences, the CHWs expressed a desire to provide support to working with LGBTQ youth and their families ; however, as one CHW explained “good intentions” alone are not enough to qualify someone to work with LGBTQ youth, “You could approach someone with all due respect but still disrespect them because of your own lack of knowledge.” Similarly, youth and caregivers described the need for care models and providers that aligned with CHW-models . When describing the ideal characteristics of service providers, a Latinx, bisexual, genderqueer youth expressed:“Something that I guess I can think of out of my head is that I would hope that they could know, I guess knowing that homophobia and sexism and misogyny is deeply entrenched into the community. And having that cultural background and awareness, I feel like would be really crucial in being an intervening type of thing.”A primary theme was the experiences with stigma and discrimination often intersect with culture and religion. A CHW described, “I think it's more just what is—from their culture, religion, and stigma because a caregiver has a lot influences on them in some ways of how they can express. They feel okay to talk or not, so I think that would be one of the challenges for the youth.” A Latinx, lesbian, non-binary youth explained, “…there is so much machismo in the community that does not allow me to be my full self.” Additionally, youth and their families described being discriminated against due to their race and how racism intersected with heterosexism, and cissexism. As one mother of a Black trans-male youth said:… like police, they identify him now as a Black male. And to me, that—I worry about that because he’s been pulled aside from the police before just walking with his friends and searched for no reason. So, I worry about that."“Overall, CHW, caregiver, and youth participants identified that CHW services for LGBTQ youth would need to be responsive to how “We, the promotoras, have this gift because we are people, they see us... as a family, like we go, uhm, to go help them, support them so that's why they open up, that's why they express themselves, ask for help because they know that we are the same, that we have gone through the same thing, perhaps the same more at the beginning when they arrive in this new country, then they feel with that confidentiality that they can count on us and that knowing they telling us their problems, that we are going to have that support and that help for them." [translated]“Nosotras, las promotoras, tenemos ese don porque somos personas, nos ven... como una familia, como que nosotros vamos en, ehm eh, a llegar a ayudarlas, poyarlas entonces ellos por eso se abren, por eso ellos se expresan, piden ayuda entonces porque, que ellos saben que nosotros somos iguales, que hemos atravesado lo mismo, quizás los mismos más al principio al llegar a este país nuevo, entonces ellos se sienten con esa confidencialidad de que pueden contar con nosotros y que sabiendo ellos contándonos a nosotros sus problemas, que nosotros vamos a tener ese apoyo y esa ayuda para ellos.” [original]Given that CHWs are community members and often share similar cultural and religious backgrounds to the individuals they serve, CHWs are uniquely well-positioned to build trust across youth and caregivers, while navigating and addressing these challenges. As one CHW noted:adaptations to family navigation might be especially relevant for transgender youth, who face additional systemic challenges stemming from stigma and discrimination within school and healthcare systems. As one Latinx, transgender youth recalled, “The violence is so prevalent that it’s fearing for our safety, you know. And when I was in high school, and my, uh, town, it was, like, predominately Latinx, Hispanic, and I did not say I was trans.” Many caregiver and youth participants communicated that several school systems did not accept the youth’s identities  or provide accommodations . In health systems, transgender youth described experiencing discrimination in the form of misgendering, but also experienced difficulty in getting access to gender affirming care , which are critical to a transgender youth’s sense of self and identity. Youth and caregivers suggested that family navigation could help coordinate care across systems that impact the youth.Specifically, youth and caregiver participants identified how relatable” providers that understand the cultural group they are serving was an important characteristic shared across all groups: “…I would say, I would be more connected with a person of color because we still have some share, struggling like, racism, or… classism” .Youth, caregivers, and CHWs agreed that CHWs providing support to LGBTQ youth and families should be knowledgeable about the LGBTQ community, share an understanding of the culture and language of the family receiving support, be open-minded and nonjudgmental, and be an active listener. Indeed, having “gender or sexual identity of the CHW should be, based on whether the role was meant to work with the youth or caregiver. Accordingly, youth and caregivers described LGBTQ youth providers as “peer partners” that provide mentorship as the youth navigates the community and related difficulties. An Asian, gay male youth, for example, noted:“… it would be more, makes sense if [the CHW] identify in our LGBTQ plus communities, because it's just really hard for a straight person to actually sympathize with what I'm saying. That's how I feel because maybe they can listen to us, but they wouldn't have the whole idea about it. They wouldn't actually experience, living experience.”There were differences in perspectives on what the “You understand them more and what they are going through because it’s the same culture.”Particpants also expressed the need for caregivers of LGBTQ youth to receive CHW support from someone who could build trust with a caregiver, educate them about the LGBTQ community , and, preferably, share the same culture but was not necessarily a member of the LGBTQ community. As described by one CHW, CHWs desired greater education with respect to the LGBTQ community. Only 5 of the 15 CHWs interviewed for this study reported having any experience working with LGBTQ youth and/or their families. Of those who did have some experience, they reported discomfort due to their lack of knowledge and experience with this population. One CHW, for example, noted, “one time I found myself not knowing what pronouns to use… feeling uncomfortable in the situation because I didn’t want to offend her”. Indeed, general LGBTQ education such as the use of pronouns, gender identity, and sexual identity were all identified by youth, caregiver, and CHW participants as necessary education for CHWs to receive when working with LGBTQ youth and/or families.“For me it has been difficult because as a mother, if I had a daughter, I want to see my daughter. And suddenly, getting used to the fact that he is not just another girl, he is a boy; his appearance changed because he started his testosterone treatment, and seeing his physical changes, that was hard for me too.” [translated]“Para mí ha sido difícil porque como madre, si yo tuve una hija, yo quiero ver a mi hija. Y de repente, acostumbrarme a que él no es una niña más, es un boy; su apariencia cambió porque él empezó su tratamiento de testosterona, y verle los cambios físicos, eso fue duro también para mí” [original].Transgender youth and caregivers of transgender youth specifically noted the importance of CHWs receiving additional education about the transition process to better provide youth and families with information, resources, and support. Caregivers of transgender youth were especially interested in receiving this education and support, as knowing what to expect and how to best support their children through the process was an important piece of the support they’d hope to receive from CHWs. One caregiver, for example, expressed:CHW education of the process can facilitate more effective support for transgender youth and families, especially with respect to the expectations and navigation of the transition process.training CHWs to build trust and an understanding between the CHW and youth, especially around confidentiality and mediation was expressed across CHW and youth participants. When asked to describe training needs, one CHW noted, “I think just like going into the room, feeling comfortable that you’re not going to like offend or disclose any information that you shouldn’t.” Relatedly, a non-binary, lesbian youth stated,“It's very common for youth to feel-- LGBTQ youth, specifically, to feel kind of afraid to get services when they know that their family may or may not be supportive… So I feel like, being open to that fact and trying really hard to establish good relationships with the youth before they immediately jump into ways that they're trying to help…safety has always been my main priority, and that's often why I don't reach out to certain resources or certain people.”Importantly, CHWs expressed wanting to more effectively navigate this type of communication to promote trust and safety for the LGBTQ youth they serve.provide education to caregivers and be knowledgeable of and refer families to available resources . One caregiver of a non-binary, Latinx youth, for example, expressed her own struggle to understand LGBTQ terminology by noting:“And just trying to understand the differences between sexuality and gender identity like that, that is like completely new to me. So trying to understand that and explain that, not that I would have to, but even if it came up, I don’t even know how I would try to explain it. I don’t have the language or the understanding sometimes.”Overall, youth, caregivers, and CHWs agreed that family navigation for LGBTQ youth should “… I feel like I’m the one doing all the research… it’s probably out there, but…I don’t know where to begin.” Youth expressed frustration with having to provide this education to their caregivers, family members, and other members of their community .Indeed, education about gender identity and sexual orientation was identified as a need for caregivers. As one Latinx caregiver of a gay male youth shared, promotoras within community agencies, all CHWs voiced a desire to learn more about the available resources and services. Specifically, it was important for CHWs to be able to link families to culturally appropriate services, as many participants noted that services available for LGBTQ youth were often not culturally or linguistically appropriate. Specific to transgender youth, youth and caregiver participants suggested it would be helpful to receive information about navigating complicated aspects of transgender healthcare, such as details on medical insurance coverage, hormone treatment and surgical procedures, as well as support with the social transition.Although family navigators embedded within medical centers expressed more familiarity with the resources available for LGBTQ youth compared to advocate across systems  for the youth. As one caregiver of a transgender youth noted, CHW should be:“aware of the law as well, and… the law protects, um LGBTQ children especially… their privacy, rights, and all these things because it’s just so, it’s so difficult… I've known instances of teachers who, who actually say something about an, an LGBTQ kid in their class, in the classroom and they are actually outing them out and um... So... that's something that, that has to be addressed.”Both caregivers and CHWs, especially family navigators, emphasized that CHWs should be aware of current LGBTQ issues, policies, and legal rights in order act as an “I think a lot of times, because we're connecting with the head of the family for the most part, we play more of the role of a bridge between the family and providers. But I think there could be like a three directional bridge or model if you will. It's being that strength conductor between the caregiver and the child, the child and the caregiver, the child and the provider...”Moreover, CHWs, caregivers, and youth noted that family navigation for LGBTQ youth might need to help mediate caregiver-child relationships and facilitate effective communication within the family. As one CHW shared:This study highlighted the role CHWs could play in enhancing access and culturally appropriate care for LGBTQ youth of color and their families. However, based on qualitative responses across participants, it was clear further adaptations are needed to traditional CHW models of care  to meet the unique needs faced by LGBTQ youth. Whereas, CHW models are able to address many concerns faced within communities of color, including lack of insurance, limited availability of linguistically appropriate providers, and distrust of medical systems (Barnett et al., Interestingly, CHWs and caregivers identified similar areas of training and education they would like regarding understanding sexual orientations and gender identities. Youth participants identified that it would be helpful if their caregivers received this information from individuals other than themselves, as this placed additional stress and pressure on them. As such, one role for CHWs could be to provide psychoeducation to caregivers related to sexual orientations and gender identities, and how to provide support to youth (Olson et al., Related to the content of CHW interventions, findings suggest that family navigation or other models where CHWs serve as bridges to services would be helpful in navigating the complex systems of care impacting LGBTQ youth and their caregivers, including schools, medical care, and mental health services. Having strong support models is crucial given the difficulties that LGBTQ youth of color face when engaging in mental health services, including potential barriers to engagement related to factors of stigma surrounding sexual orientation, issues surrounding cultural attitudes, and lack of knowledge regarding services (Moore et al., The present study reached LGBTQ youth of color, a highly marginalized population. It further diversified exploration by including caregivers of LGBTQ youth as well as CHWs embedded within community volunteer networks and medical centers. However, even with the strength of reaching this diverse population, limitations should be considered when interpreting the findings of the current study. Participants self-selected to participate in the study, and it is likely that the caregivers and CHWs who agreed to be interviewed may be more supportive of LGBTQ youth than is typical. Notably, the current sample was recruited from communities within liberal states with relatively adequate resources and is, therefore, not representative of the perspectives of individuals within less liberal and less resourced areas. This is especially notable given that many states are passing policies, which specifically discriminate against LGBTQ youth and their caregivers. Youth and their caregivers in states where anti-LGBTQ legislation is being passed likely need different types of interventions based on what is not only available, but also legal in the localities where they live.In recent months, the U.S. has witnessed a wave of anti-LGBTQ legislations that are impacting school instruction Diaz, , banning


While cultural sociology has recently made a comeback in research on social inequality both in the context of poverty studies and studies of immigrant integration, it has rarely investigated how particular constructions of the problem of socioeconomic mobility are themselves culturally situated. The article addresses this neglect by investigating the problematization of disadvantaged lives within the relational framework of Bourdieu’s cultural theory of the state. Here, the state exercises symbolic violence by transforming one arbitrary cultural standpoint in social space into a universal standard, or a taken-for-granted “doxa,” against which other cultural positions can only come off as deficient. The article extends this perspective by addressing the role of official statistics in this process. Taking Germany’s official monitoring of the socioeconomic integration of immigrants as its case and drawing from document analysis, interviews, ethnographic observation, and data from the German General Social Survey, the article shows how such statistical instruments of the welfare state in fact tacitly universalize a model of the good life particular to civil servants, the very constructors of the monitors, as a benchmark for immigrant integration. Exponents of cultural sociology have more recently made a conscious effort to extend cultural analysis to a broader gamut of social phenomena mobility. For the welfare state, Steensland  has madeTaking their insights as a cue, this article focuses its inquiry on a case in which official perspectives of the state as well as social-scientific methods of inequality research intersect. In Germany, administrative bureaucracies on the municipal, state, and federal level have resorted to social-scientific expertise and quantitative research methods in order to monitor the social advancement of the immigrant population. In so-called “integration monitoring systems,” compilations of socioeconomic indicators derived from official statistics are used to compare the population segments of migrants and non-migrants in order to effectively govern the institutional incorporation of first- to third-generation immigrants. The statistical parameters include level of education, unemployment rates, income, health, household size, area of living space per household member, rate of real estate ownership, fertility rate, civic engagement, and political involvement. In line with much of social inequality research and the sociology of immigrant integration, policies oriented by these statistics seek to close the gap between both population segments, or, in other words, to eliminate the systematic effect of a migration history on these socioeconomic indicators. An analysis interested in the cultural grounding of the epistemological apparatus of observing social inequality and socioeconomic mobility would have to attend precisely to such a statistical monitoring instrument.erasures as they standardize the matrix through which images of immigrants are filtered.And indeed, I argue that the indicators of the monitoring instrument tacitly impose a class-culturally particularistic ideal of a typically “bourgeois” life. They do so first and foremost through their choice of variables. Inevitably, the fact that a certain dimension is measured already bestows significance on the dimension itself. The specific configuration of indicators inadvertently produces a “grid” of a particular biographical standard. Thus, normative implications emanate not only from measuring and publicizing statistical “norms” as captured by the means or medians of various parameters; they are also, and perhaps more fundamentally so, conveyed by the very fact that some aspects are deemed “worthy” of measuring in the first place. Alternative conceptions of the “good life” that would lead to entirely different measurements are thus eclipsed or manifest themselves only as deviations from the statistical averages of the selected indicators. Epistemologically, then, the statistical perspectives of the monitors exhibit not just biases but Beamte im höheren Dienst), i.e., the occupational group that in Germany includes department heads of administrative bureaucracies and university professors. In many regards, then, the very people who construct indicators of integration are unwittingly universalizing their personal ideas about the good life as a standard for successful integration. The cultural heterogeneity even of the national mainstream is thus obscured, and the presence of alternative or subcultural ideals and aspirations is removed from the statistical picture.The argument builds on the relational perspectives of Pierre Bourdieu, specifically his more recently published theory of the state, which he developed in a lecture course at the Collège de France between 1989 and 1992 , categories employed, statistical methods used, and tabulations published”  for indicators, which include levels of education, unemployment rates, income, health, household size, area of living space, rate of real estate ownership, fertility rate, civic and political engagement, and others see Table.Such indicators generally compare averages between the native population and the immigrant population, except where such comparisons are not applicable . For such comparisons, the monitors employ a distinction between persons with and persons without a “migration background,” the first including all people not born as a German or with at least one parent not born as a German. Negative discrepancies between both segments are interpreted as an integration deficit.Although these monitorings generally feature information on the distribution of immigrants according to legal status of residency, occupational qualifications, and country of origin that reflect current immigration policies, the integration indicators themselves very rarely make such distinctions.In exploring how such quantitative perspectives shape the construction of the problem of immigrant integration, I investigated several units embedded within the case of Germany , the German General Social Survey. This data set provides large enough Ns to allow for the segmentation into occupational meta-categories. I construct simple tables instead of conducting regressions with the usual controls. I do this for a fundamental reason. Following Bourdieu, the analyses are concerned with the structure of social space and the various forms of habitus it brings forth. Here, combinations of education, income, geographical location, sex, ethnic origin, and even age are seen as crucial determinants  in an “executive committee” for integration. As the current head of the integration department  remembered, the indicators were (and still are) born out of discussions within this group:On the federal level, the selection of indicators likewise occurs in close coordination and conversation with civil servants from other ministries and departments who maintain their own indicators. Here, too, the federal statistical office is intricately involved in the process. As the responsible civil servant put it: “The question is: what are meaningful indicators from our perspective?” Indicators from other sources are, as she phrased it, “read against the grain.”Referat) responsible for designing the monitoring painted a similar picture of concerted deliberation: “We wanted to do a bit more [than the joint-working group of German states]. And since we had the human resources, we sat together, really in the sense of a ‘brainstorming,’ thought about different things, looked at different data sources whether there was something relevant to be found.”In Westlanden, the head of the unit . This stood in stark contrast to the self-critical stance administrators generally took towards other aspects of the monitoring such as the overly broad and homogenizing classification “migration background” or the stigmatizing effects of the “deficits” highlighted by the indicators .after voices from outside the administration questioned the indicator’s pertinence for measuring integration. As the head of the statistical office recalled: “We were asked, ‘is this a goal of integration that foreign women are giving birth to as many children as Germans, can that really be an indicator of integration,’ and we said, ‘well, when it comes down to it, no.’” The episode signifies how particular selections of indicators that were taken for granted within the executive committee did not make immediate sense to other actors and stakeholders.To be sure, as interviews with civil servants in Stadthausen revealed, they had grown increasingly skeptical of the indicator “fertility rate” – but only Amtsleiter or Referatsleiter). In devising instruments for quantitatively monitoring integration, they often enlist the expertise of university professors, some of whom have established considerable renown as sociological consultants for integration policy. All of these actors generally belong to the same occupational category, so-called civil servants with executive duties (Beamte im höheren Dienst), a group that includes university professors, who, in Germany, are state-employed. Indeed, as higher civil servants, the responsible administrators within the bureaucracy themselves have an academic background, usually in one of the social sciences, in social work, or in law, and some even have a doctorate degree. As I argue, it is the habitus of this segment of social space that is implicitly universalized in measuring the extent to which lives are “integrated” in German society. At stake are cultural practices that, as I will show in the following, are prototypically “bourgeois” but are not reflected as class-cultural particularisms. On the contrary, civil servants are guided by an intuitive and self-evident “doxa” in selecting indicators, settling on a compilation which to them seems largely uncontroversial and which indeed is presented in this way in the publications. In fact, the reports explicitly disavow ethnocultural notions of assimilation and often stress the value of diversity and the preservation of one’s cultural identity. This makes them an especially pertinent case for analyzing processes of unwittingly transforming a particular cultural standpoint into a universal standard. In many ways, they represent a “least likely case” for cultural biases, given the heightened sensitivity to cultural impositions.In conclusion, the people responsible for the construction of integration monitoring instruments are heads of bureaucratic departments  on the municipal, state, and federal level ” rather than religion; a “close affinity to aesthetic culture ”; finally, a central understanding of family as a private, autonomous, and emotionally constituted unit with “few children and a sustained effort at their education”  went hand in hand with the ascent into Bürgertum. Without the latter it was difficult to achieve the former. The demand for full equality as citizens was a demand that Jews could raise and gradually achieve only when they had become bürgerlich in their language and education, social manners and customs, their hygiene and their manner of dress” , with the latter comprising all occupations which, as opposed to the propertied bourgeoisie (Besitz- or Wirtschaftsbürgertum), derive their social position and life chances primarily from their academic credentials . What is more, most of the monitoring reports on the municipal, state, and federal level provide justifications in the text for including a specific indicator. These often quite normative statements serve well to highlight the implicit ideals that inform such statistical perspectives on integration. Westlanden’s monitoring, for instance, pictures education and work as keys to an “independent life” and a “secure occupational position” that “guarantees a reliable income [and] makes life-planning possible.”As indicated above, bourgeois mentality is characterized by a particular regard for routine, continuity, steadiness, moderation, and predictability, the hallmark of Max Weber’s modern In emphasizing continuity, planning, regularity, and stability in this way, the attendant indicators in such sections do more than problematize the financially precarious and indigent circumstances of the disadvantaged. They at the same time implicitly devalue more alternative, non-committal, and “bohemian” lifestyles that are marked by experimentation, indulgence, and even contrarianism.An indicator which compares the percentages of those owning (rather than renting) real estate among persons with and without a migration background further conveys this tacit regard for constancy and steadfastness (see Table 1). The mere selection inevitably suggests the relevance of this aspect of life, and the negative discrepancy between persons with and without a migration background wittingly or unwittingly indicates which of the two living arrangements is to be preferred. It is evocative of bourgeois norms of sedentariness, settlement, and commitment. Such valorizations implicitly hold a very particular and bourgeois life model to be the normative standard. In turn, lifestyles characterized by mobility, flexibility, and few attachments, whether they are purposefully chosen or not, are implicitly marked as aberrant.not even half” (my emphasis) of the proportion among native Germans. Promoting an increase in real-estate ownership is thus listed in the action plan of Stadthausen’s integration department. Another municipality in Westlanden includes the rate of fluctuation in its monitoring reports, which has even led to a political campaign advertising the city as a “location to stay” (interview with head of the integration department). Likewise, during a network meetings of integration officers in Westlandian municipalities, the mayor of the hosting municipality gave a welcoming address in which she noted that they wanted the people who migrate to their city “to put down their roots here” (fieldnotes).Normative commitments to such ideas of sedentariness also came through in several of the civil servants’ comments and actions. For instance, the Stadthausener monitoring notes that the percentage among migrants owning real estate for personal use “is However, in segmenting the population of German nationals in Germany into different occupational groups using data from the General Social Survey (ALLBUS), we find that such long-term commitments are particularly characteristic of the very people who construct integration monitorings.There is a specific phenomenological relationship to time at stake with many of these indicators. It is the typically bourgeois penchant for long-term planning, the methodical and rational pursuit of distant ends, deferred gratification, and an investment into the future.Even such innocuous and uncontroversial indicators as the use of preventive health measures among persons with and without a migration background implicitly cast such temporal perspectives as the normative standard (see Table 1 for examples). Again, data from the ALLBUS indicates that this is associated with class. Table 2 shows the percentages of people within the different occupations who have visited a doctor for preventive care or vaccinations within the last 3 months. Civil servants with executive duties have the highest proportion of those within an occupation who have visited a physician for such reasons.8The typical founder who is being advised by our agency... comes here and makes a business-plan and goes on for I don’t know how long in deliberating [legal titles such as] ‘LLC’ or ‘registered merchant’…and does every conceivable thing first. Some of the ethnic groups function differently…Here one doesn’t go to the classic consultancy agency for business start-ups. One simply goes ahead and opens the business.Civil servants also exhibited such valorizations of foresight and future-planning in interviews. The head of Stadthausen’s department of economic affairs, who is also a member of the executive committee responsible for the monitoring, was palpably bewildered that immigrants showed comparatively little inclination to avail themselves of the free consultations his department offers to business start-ups:The comment also exemplifies well how such differences are generally attributed to ethnicity or migration background rather than to class.Bildungsbürgertum “invented” the idea of the private family circle secluded from public, i.e., economic or political, affairs . As they do so, they highlight the relevance of the family and inadvertently valorize a specific model of family life over others. Inevitably, in the context of an integration monitoring focused on integration deficits, the generally larger family structures of migrants are implicitly problematized in their juxtaposition to the more “nuclear” structures of non-migrants. This resonates with bourgeois ideals. In fact, the 19th-century s Kocka, , p. 44.Moreover, the focus on the number of children further validates the calculative time-perspectives typical of the educated bourgeoisie. Again, it is precisely in this class segment where birth control originated . In the context of discussing the process of selecting indicators, we have already seen that civil servants unreservedly point to a “civic sense of responsibility” and an expectation of “contributing to society” in justifying such a focus.bürgerliche Vereine, once again mirrors this ambivalence. In themselves, they are an embodiment of core values of the 19th-century bourgeoisie cultural assimilation in stressing the “preservation of one’s cultural identity.” Yet, statistical indicators of the integration monitors impose a starkly uniform “culture” of civil servants. What is implicitly affirmed under “diversity,” then, is the paradoxical notion of a “bourgeois diversity.” What is tacitly imagined, it seems, are people utterly uniform in their values and aspirations. Integration statistics essentially portray a view of immigrants as “inconvenienced civil servants.” This example thus calls for closer attention to the ways in which stylizations of the problem of “disadvantaged” lives are steeped in a particular class-culture and overdetermined by relations of observer and observed in social space.In fact, given the state’s monopoly on symbolic violence, such stylizations may obfuscate the actual extent to which such bourgeois conceptions of the good life have lost traction even among the broader middle-class. There are indications that the particular ideal conveyed by integration statistics may hark back to a society that no longer exists and to subjectivities that are increasingly on the wane. As argued above, the monitorings implicitly subscribe to a model of life characterized by stability, long-term planning and commitment, risk-aversion, and sedentariness. In contrast, sociologists have argued that today’s economy fosters and even demands subjectivities that are first and foremost marked by flexibility: i.e., a disposition towards short-term rather than long-term commitment; high tolerance – even affirmation – of risk, change, and mobility; and more fleeting, superficial ties to people and places (see, e.g., Sennett, Immigration itself is surely related to these developments. Highly qualified migrants, especially, are likely to correspond closely to such subjectivities, making them highly mobile and perhaps only temporary residents of their host-country. Indeed, some of the tectonic forces that drive migration – greater economic and political interdependencies, technological innovations in transport and communication – are certainly also crucially involved in the emergence of new subjectivities that make a virtue out of the economic repercussions of such changes.It is for this reason that the perspectives of the integration monitoring may be to a large extent quixotic, even paradoxical. They implicitly aim to assimilate migrants to an ideal subjectivity which may actually be eroding due to similar circumstances that fuel at least some forms of migration. And indeed, studies have pointed to a continuous “dissolution of the middle” in Germany, be it in economic terms (e.g., Grabka & Frick,


Moderator analysis revealed that measurement instrument and subjects had an impact on the effect of Solomon’s paradox and there was a non-significant effect size of culture and conflict type. Future research should explore the diverse forms of Solomon’s paradox across more diverse cultural contexts  to better understand the phenomenon and help people cope with life’s problems more wisely.Solomon’s paradox is a widespread phenomenon regarding how we think, which asserts that people reason more wisely about other people’s social problems than they do about their own. This means that we are more likely to make rational decisions when decision-making on the behalf of others than for ourselves, which has practical implications in the field of interpersonal conflicts and social dilemmas. However, it remains unclear whether Solomon’s paradox exists across cultures, and the magnitude of its effect size. A meta-analysis was conducted, examining six studies and 20 effect sizes, to gain more insight into this phenomenon, considering the influencing effects of culture, measurement instrument, conflict type, and some other moderating factors. The results showed that Solomon’s paradox does exist in interpersonal conflict ( There was even a popular saying: If you have any questions, ask Solomon, and he will tell you what to do. Many people traveled far to seek his counsel. However, he also made many wrong and even foolish decisions when dealing with his problems. Eventually his extravagance and poor choices in his later years led to the downfall of his dynasty. This phenomenon, of being a wise advisor to others but a poor decision-maker in personal issues, was named Solomon’s paradox by Solomon’s paradox defines the human trait of being better able to reason wisely about the conflicts or dilemmas of others than those we face personally, and represents a fundamental and widespread social cognitive bias. The existing research indicates that people’s perceptions of themselves are often less accurate than their perceptions of other people , anotherResearch into Solomon’s paradox has had important practical value, shedding light on how to better navigate the fields of social dilemmas and interpersonal conflicts. However, there are still some shortcomings in the existing research, and the details of the effects of Solomon’s paradox are still controversial. Findings on the effect size of Solomon’s paradox have varied greatly , yet eve2.2.1.The current study began with a comprehensive search for relevant literature published in Chinese or English. The CNKI, Wanfang Data, and CQVIP databases were used to find journal articles and dissertations written in Chinese, while PsycINFO, PubMed, and Web of Science Core Collection were searched for journal articles and dissertations written in English. The initial database search looked for abstracts only. Meanwhile, the researchers also combed the reviews and references of the relevant articles dated until January, 2023. Keywords used in the search of the Chinese databases included “智慧” and “冲突,” while the English-language search used “wisdom*” and “conflict *” as keywords. A total of 4,840 results were returned from the searches. These 4,840 studies were subsequently screened thoroughly by three researchers working together to determine whether they fit the following criteria, as outlined in 2.2.We assessed each study to determine if it examined whether context, that is, self-conflict versus others-conflict, affect one’s level of wise reasoning. Other possible moderating factors, such as participant demographics methodological differences, or publication characteristics, were also taken into account.M and SD of experimental and control groups, sample size, and demographic characteristics of participants, including their age and gender. Two psychology postgraduates encoded the selected articles and dissertations individually. Coding disagreements were discussed with the intervention of a third person to determine the final results. The included studies and their associated characteristics can be found in the The following data were extracted for all included studies: first author, study area, cultural region, measurement tools, 2.3.I2 and with a p value for Q statistics. I2 values represent the degree of heterogeneity, indicating low (≤ 25%), medium (50%) and high (≥ 75%) heterogeneity . An item would be given a score of “0” if the answer was “NO” or “UNCLEAR”; if the answer was “YES’,” then the item was given a score of “1”. Two reviewers independently evaluated the methodological quality of each included study, using the 11 AHRQ criteria and calculating an overall score for each to determine the article quality. Article quality was rated as follows: low quality = 0 to 3; moderate quality = 4 to 7; high quality = 8 to 11 . Discrepd was used to calculate the effect sizes of each outcome measure using the formula developed by d could not be coded directly from the study, they were converted. d = 0.20 is a small effect, d = 0.50 is a medium effect, and d = 0.80 is a large effect.Cohen’s 3.3.1.Nother = 2,377, self-condition group Nself = 2,401). Regarding study region, eight independent samples were from United States , indicating that the final estimated results of the meta-analysis were stable.3.4.I2 value was greater than 50% , p < 0.001; see d could be categorized as small , and the moderating effect of age was also not significant . The results of the subgroup analysis showed that: (1) the effect size in Western culture was larger than in Eastern culture, but the moderating effects were not significant ; (2) in the wise reasoning dimension, the effect size of “considering other people’s perspectives” was larger, but there were no significant differences overall; (3) there were significant differences of the research tools used, with the effect size of the Wise-Reasoning procedural questions larger than that of the SWIS ; (4) the effect size was smaller among working adults than among college students ; (5) the effect size was larger for general social relationships than for intimate relationships, but there was no significant difference in the type of interpersonal conflict ; and (6) there were significant differences between sample sizes, with smaller sample sizes resulting in larger effect sizes for Solomon’s paradox . See First, meta-regression analysis was used to analyze the moderating effects of gender  and age (average age) on Solomon’s paradox. The results showed that the moderating effect of gender was not significant (4.d = 0.317). This finding adds strong evidence that Solomon’s paradox is true, while also affording us a better understanding through which we can improve wise reasoning abilities in interpersonal conflict. However, reference to existing studies  examined whether Solomon’s paradox exists and its effect size. It also took into account possible moderating variables in terms of participant, methodological, and publication characteristics. Our results show that one’s ability to reason wisely about conflicts or dilemmas that they are involved in is lower than when considering conflicts or dilemmas of others, with a small to moderate positive effect . This result suggests that Solomon’s paradox may be in a “compromise state” between existence and non-existence within current Chinese culture . This is a particularly interesting result as it can be seen as the Solomon’s paradox of Solomon’s paradox studies. Although the SWIS uses the reconstruction of conflict events to explore respondents’ wise reasoning levels in the face of interpersonal conflict, which has higher ecological validity, it seems, however, that the practice of asking subjects to respond to items using a self-rating scale inevitably traps them in the first-person dilemma. Therefore, by adding observer evaluation , the wise reasoning procedure may more effectively avoid the limitation caused by individuals always evaluating themselves in various situations – which is in fact benefitting from the understanding of Solomon’s paradox. This result also has important reference value for broader psychological measurements. Self-rating scales are often more convenient and efficient, and are more conducive to clinical use and application. However, when measuring key psychological qualities of individuals, it is better to combine evaluation indicators of third-party observers to avoid Solomon’s paradox in the measurement field, to avoid the respondent being influenced by biases such as self-enhancement or accurate self-awareness. “Considering other people’s perspectives” had the highest effect size in terms of measuring the subdimensions of the instrument. When resolving conflicts with others, individuals can think more flexibly when they take the perspective of both sides of a conflict, and switch sides from time to time . When dealing with their own conflicts, as an involved party, it is often not easy for an individual to ignore their own position in the situation to deal with the conflict impartially, especially if it is accompanied by high emotional intensity. An intervention study on wise reasoning also showed that participants reflecting in the third person showed a significant increase in wise reasoning about interpersonal challenges, and these effects were particularly pronounced for intellectual humility and social-cognitive aspects of wise reasoning . A limited number of studies can jeopardize the validity of statistical conclusions and publication bias, as the number of studies may render insufficient statistical power for detection of an effect. Furthermore, the limited number of studies included in this review also made it impossible to investigate certain moderators . Another limitation of the present study is that we focused only on Solomon’s paradox in an interpersonal conflict context. As mentioned above, Solomon’s paradox exists across a wide range of social dilemmas, not only between people. Future research should be more targeted and comprehensive. Furthermore, we hope to see more studies exploring Solomon’s paradox in different cultural contexts in the future, as the limited understanding we have now does suggest that this asymmetry in thinking and decision-making does appear to affect people cross-culturally, existing across people, groups, and countries.One major limitation of the current meta-analysis is the low number of studies included .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Evolutionary game theory, with its explicit incorporation of frequency-dependent selection into evolutionary thinking, was one of the great leaps forward since Darwin's insight . AdaptatGame theory can therefore be used to solve problems where the pay-off for adopting a given strategy depends on the strategies adopted by others, and there is no obvious ‘best thing’ for an individual to do. This underlying idea applies whether the focus is on economic behaviour in humans, or on evolution in populations of organisms that do not necessarily have the capacity for rational thinking. Although the formal origins of game theory lie in economic behaviour, in hindsight, it does not seem surprising that the leap to evolution would be made: in his classic textbook , p. vii Published 50 years ago, ‘The logic of animal conflict’ by John Maynard Smith & George Price  is the pv stands for the value of the resource and c stands for the cost of an escalated fight. It assumes that whenever two hawks or two doves meet, both are equally likely to win. Therefore, their expected pay-offs are (v − c)/2 and v/2, respectively. If a hawk and a dove meet, the dove flees with zero gain while the hawk gets the whole resource v. Note that c > v, namely, the cost of conflict exceeds the value of the resource.In the pay-off matrix, Now think in terms of the frequencies of strategies within a population. A homogeneous population of doves can be easily invaded by a few hawks, who win all contests without a fight. Conversely, a homogeneous population of hawks can also be invaded by a few doves. Although a dove has no gain from fleeing from a competitor, it is still better than the negative pay-off hawks get from escalated fights, which take place constantly in a nearly all-hawk population. Therefore, neither strategy alone is stable in the long run. Evolution will lead to a mixed population of both hawks and doves.Maynard Smith & Price  laid outBox 1.Perhaps the single most influential concept introduced in Maynard Smith & Price  is that I) ‘must have the property that, if almost all members of the population adopt I, then the fitness of these typical members is greater than that of any possible mutant; otherwise, the mutant could invade the population, and I would not be stable’  a Nash equilibrium .stable’ ,12). Phr. PhrI) ‘stable’ . For testable’ Since the seminal work of Maynard Smith & Price , evolutiet al. [Evolutionary game theory also plays a key role in studying a variety of conflicting interests between the sexes. One example relates to the conflict between different optimal mating rates for females and males: Kovalov & Kokko  show thaet al.  present et al. [Evolutionary game theory provides insight into the way humans and other animals make decisions in social interactions, and into the underlying mechanisms. Wang et al.  combine et al.  reviews Laboroides dimidiatus and its ‘client’ fishes, Bshary & Noë [et al. [In biological market interactions, individuals have multiple options to cooperate with a single or multiple partners, such as the interactions on the ‘mating market’ between conspecific males and females, between plants and pollinators, and between ants and lycaenid butterflies. Focusing on the biological market interactions in a marine cleaning mutualism between the marine cleaner wrasse ry & Noë  review h [et al.  review t [et al. ) by whicet al. [Escherichia coli strains in continuous culture while preserving their spatial distribution. By tracking the frequency changes of the three strains over two weeks, they found that the evolutionary dynamics differ greatly from the cyclic dominance pattern predicted by classical evolutionary game theory models, but can be explained by simulations that consider the relevant ecological factors.While evolutionary game theory models are generally constructed to focus on the fitness consequences of social interactions, results from studying social interactions in humans and other animals as well as those revealed by comparative economics studies show that there is much potential in integrating the proximate and ultimate aspects of social behaviours in future evolutionary game theory models. Kuhn et al.  combine et al. [Evolutionary game theory is a versatile modelling framework that can be naturally connected to other major modelling approaches, such as the Lotka–Volterra equations commonly used in ecology, and the Wright-Fisher or Moran process models frequently used in population genetics. Traulsen & Glynatsi  present et al.  review tet al. , humans Evolutionary game theory has come a long way since it was first hinted at in models of sex allocation  and sinc


Purchasing produce at farmers markets represents one method by which individuals can purchase and have access to healthful and seasonal fruits. Despite the extension of nutrition assistance programs to local farmers markets, fruit and vegetables consumption has remained below the recommended guidelines, specifically in rural geographical locations.The purpose of the study was to explore the aspects of the Link Up Illinois Double Value SNAP Nutrition Incentives Program (DVCP) and its effects on food selection at rural farmers markets for individuals enrolled in nutrition assistance programs.The current study uses a qualitative methodology in order to uncover barriers local health departments and farmers markets face to implementing the DVCP in their communities and to discover the perspectives of low-income individuals who utilize the DVCP. This paper explores the organizational and community member perceptions of the DVCP and its administration. Semi-structured interviews and one focus group were conducted with health educators from county health departments, DVCP stakeholders, farmers market managers, local farmers, and residents who used the DVCP. A purposeful sampling method was used, intentionally selecting individuals with lived experiences of the research objective. Data were analyzed using a three-cycle coding process, then categorized into overarching themes until thematic saturation was reached.There were a total of 19 individuals who participated in the study. Five themes and four subthemes emerged from data analysis, including organizational capacity, exposure to the DVCP, purchasing power, DVCP advancements, and values.These findings contextualize the facilitators and barriers of multiple stakeholders when implementing nutrition assistance programs at farmers markets. Other similar “double value” programs can utilize these lessons when seeking to increase participation of underrepresented populations at local farmers markets. The 2020–2025 Dietary Guidelines for Americans recommends individuals to eat healthfully throughout the lifespan to reduce the risk of chronic disease. Yet, national surveillance data and other research  unfailinDisparities in food access are highest in rural communities partly due to a sparse food retail environment, transportation issues , and household economic concerns . As suchIn Illinois, the Link Up Illinois Double Value SNAP Nutrition Incentives Program  allows recipients of all three food assistance programs—SFMNP, SNAP, and WIC—to receive double the value of federal nutrition benefits spent at participating farmers markets throughout Illinois , 22. Alt2.2.1.In this qualitative study, data were collected using semi-structured interviews with various stakeholders who contributed to the operation of regional farmers markets across southern Illinois. Additionally, a focus group was conducted with individuals in Jackson County who have access to, and who use, the DVCP at the largest regional farmers market. This congressional district was selected purposively for its primarily rural location  and higher than average percentage of persons in poverty .2.2.All activities were approved by the human subjects committee at the institution where the research was conducted prior to engaging in study activities. Health educators from eight regional health departments with oversight of distributing WIC, SNAP, and SFMNP benefits to local residents were selected purposively , 24 fromThe Health Belief Model   version 24. Two researchers participated in the coding of the qualitative data, the lead author and a paid external qualitative researcher. A three-coding cycle process was used as described by Saldana , using al coding . The firl coding , 28. Patl coding , an indel coding . The aut3.3.1.n = 8) were, on average, 35 years old , female (87.5%), white (50%), employed part time (50%), and SNAP recipients (87.5%). Most had completed some college or technical school (62.5%). The remaining participants held positions at the farmers market  or an administrative role with DVCP (co-op grocer). A total of 19 individuals participated in the study. The average participant age was 42 years old . The majority were female (89.5%), white (68.4%), and college educated (63.2%), with 56.2% reporting full-time employment status. Of these participants, 11 were individuals with an administrative role in nutrition at a health department or DVCP, and farmers market, with an average age of 48 years old , most of whom were full-time employees (81.8%) with graduate professional degrees (54.5%). Focus group participants . Likewise, a health department administrator suggested “permanent funding”  for the DVCP, and another mentioned “expanding the program to all counties or statewide,”  indicating the need both to sustain and grow the DVCP. Nevertheless, numerous barriers to implementing the DVCP were cited, the most frequent being “governmental partnerships” at the regional, statewide, and federal levels, as well as those related to governmental programs such as SNAP and WIC. One participant identified “a need to build relationships and partnerships with the SNAP program and doctors’ offices [because] surprisingly, a lot of the doctors do not know what WIC is” . Participants mentioned other needed partnerships, including “the development of a food council, [partnerships with] faith-based organizations, collaboration between doctor offices [and] grocery stores, and partnerships with the public housing authority” . Participants strongly believed that building relationships and improving communication among multiple organizations would minimize nutritional barriers experienced by low income individuals .A subtheme of organizational capacity was (lack of) support. Farmers markets administrators experienced a limiting scope, one commenting, “We have frequent staffing issues that prohibit implementation, [such as] the uncertainty of funding [state and grant], and the lack of staff to effectively collaborate” . Another administrator similarly noted, “I would love for my organization to offer a program such as the DVCP; however, it is hard fighting for programs with leadership inconsistencies and frequent staff changes” . Community support was also a consistent attribute, with participants who held administrative roles describing the need for more individuals to take advantage of the DVCP. Finally, participants discussed the need for financial support, noting the instability of funding for the DVCP and the need to sustain the program with local funding through county partnerships and collaborations.In some areas where health departments lacked capacity to implement the DVCP, they adopted similar approaches to reduce the nutritional gap in their communities. For example, in one county, a health department administrator collaborated with a local business owner to provide “fruit and vegetable dollars” to local community members and also partnered with two farmers to implement “Farmers Market Dollar Days” in the parking lot of her organization This individual also provided program education  in addition to providing recipes along with the premade produce bags for participants. These two elements reminded community members to engage in healthy eating activities, while providing awareness of the program and produce options at the market. Thus, although some participants may not have had the capacity or support to assist with the implementation of the DVCP, they nonetheless made efforts to improve community nutrition using grassroots methods.3.3.The second theme, exposure to the DVCP, was exemplified by participants’ experiences with the DVCP, whether they had participated in the program or simply had heard of it. It also encompassed their general experiences with fresh fruits and vegetables and familiarity with farmers markets. For example, one participant commented, “This program (WIC) has allowed participants to explore new fresh fruits and vegetables, learn about the farmers market, and discover the DVCP .” One focus group participant, however, noted that some local residents may not have equal opportunity to experience this type of program:Single mothers or working parents…don’t all have the luxury of waking up as early as 8:00 am to get the kids ready and go to the outdoors market. They unfortunately have to go to work or take their kids to a doctor’s appointment due to their schedules throughout the week .Similarly, advertisement of the DVCP was a sizable barrier. Participants with knowledge of the DVCP claimed that many individuals eligible to receive the program’s benefits remain unaware it even exists. For instance, two participants mentioned that area college students and individuals with lower incomes, two groups that could benefit from utilizing the DVCP, do not visit the farmers market as much as they might otherwise had they known of its existence.Likewise, when discussing necessary improvements to the DVCP, participants mentioned the need for an increased social media presence to promote program expansion. One participant suggested, “They could make a Facebook page for it and promote it. The farmers market is on Facebook but does not post things like the [DVCP] program. They should work together and post together” . Another participant agreed, stating, “I love Instagram, and they can promote it like a business or tweet! Twitter is fun and you can capture every second” . In these instances, participants implied both the farmers market and DVCP were not collaborating enough to attract individuals to the market and were not using social media appropriately to communicate incentives and programming.Participants also commented that the DVCP would “fill a gap” to improve community nutrition by increasing local access to fresh produce. They suggested that implementation of the DVCP program would likely result in a significant increase in fruit and vegetable consumption and, to overcome barriers, partnerships with local faith-based institutions and the formation of a food policy coalition—which would specifically “assess and address food access and issues”—could be established. Stakeholders suggested that community support would be critical to promote exposure for the DVCP. One participant argued that “strengthening community support for the program, whether it’s selling a bumper sticker or a reusable shopping bag or something like that, [would result in] proceeds [going to the DVCP]” . This specific participant urged the community to “step up and step in” to assist other community members by getting the word out so individuals could take advantage of the DVCP.3.4.Purchasing power was the third major theme identified and was reflective of DVCP recipients’ personal experiences when using the DVCP. One participant spoke about the many benefits of the program mentioning that “it helps put food in [her] fridge” . Participants described their ability to purchase affordable, healthy food, because of the DVCP. Another DVCP recipient shared, “When I cook, I use that program; you know, it’s a real help… [with] a lot of things we cannot afford…It really helps” . Three subthemes emerged from this theme: affordability, attractiveness, and variation. The subtheme of affordability related to DVCP recipients’ decisions regarding whether it made sense to purchase fresh produce. Overwhelmingly, participants listed price as the number one determining factor when making the decision to shop for healthy food. One explained, “If the price [were] really high, then I would not buy it. I would buy something less healthy” . Another DVCP recipient spoke to affordability, mentioning:(Price) is super-important, because if I don’t have enough money from my job or from my SNAP benefits… [and] I can’t afford the fresh fruits and vegetables, then I’m probably just going to be eating ramen for that time period .Some participants indicated they conflated attractiveness with quality and that they were less likely to purchase produce if they found it to be visually unappealing. One participant explained, “[Quality] is definitely important for me, especially for my fruits. I do not like bruises on any of them. I probably will not buy it if there are any bruises or if they look spoiled” . Another participant spoke to the attractiveness or quality of the fresh fruits and vegetables, stating:I think quality is really important because if a fruit or vegetable [is] gross, then I won't touch it or get it. I would have to go to another store just to find fruits and vegetables. Sometimes I don’t have the extra money to spend on gas to travel to another store. If I don’t have the extra money, then I won’t buy fruits or even vegetables that paycheck .The final subtheme is related to the assortment or variety of fresh produce in the local community. Focus group participants were asked, “What are your thoughts on the selection of fresh produce in the local community when shopping?” Participants were not impressed and debated whether their community might have an unfavorable selection and lack of variety. One participant stated, “I wish there [were] more access to different kinds [of fruit]. Like more or what’s wild, you know, [like] dragon fruit? Because sometimes strawberries may be a little boring, so you kind of want something different” . Another noted, “…sometimes they do not have what I want, but I understand that it might not be in season, but it’s still always the same stuff” .3.5.Individuals spoke about program advancements related to incentive distribution. One participant suggested, “I kind of wish they would put it on the [LINK] card…They give us paper coupons, when they could just upload it onto the card” . Another participant added, “We all use our phones… I know that she mentioned social media because we always get notifications from every app that we have, [but] why [does not] the program make an app instead of coupons” ? Similarly, another participant agreed, “They should make an app for the market to track the program and the number of users; if people get a notification that the market is open and to visit certain stands that accept the market, they would be in big business” !Further suggestions included expansion of the program to include additional benefits and added educational opportunities about the fresh produce. One participant mentioned, “I would give more—triple it instead of doubling the incentive. Maybe more people will use it” . With regard to education, another participated stated, “I wish they would tell me how to make the vegetables that I’ve never cooked. Sometimes I want to buy the foods but do not want them to go to waste” . For example, one innovative technique suggested was the use of meal kits. One participant claimed, “I would have them develop a cheaper meal-prep kit; it should at least be an option… I know there are ones at [local chain grocer], and they are almost $20, so if it [were] even half that price, that would be helpful” . Another participant commented on how meal kits would promote ease of use, stating, “I do not have time to sit there and try to come up with a recipe or try to find a recipe, so if they had those meal kits, it would be a lot easier” . The recommendations of education and recipe availability suggest that individuals may be more susceptible to cooking fresh produce if they receive more information at the time of purchase.3.6.The final theme, values, described participants’ normative beliefs regarding fresh produce, including preparation, cooking and shopping for fresh produce. One participant expressed a desire to bring back family traditions that had disappeared throughout the years:My grandmother used to have this large garden in her backyard, and on Sunday mornings, we used to go in the back and pick fresh greens and vegetables for dinner. We don’t do that anymore, and I would like to start again. My first step in doing so would be purchasing fresh fruits and vegetables at the market. I want my family to get familiar with fresh vegetables early and one day be able to start our own garden in the back yard .Another participant mentioned how her sibling influenced her own shopping habits at the farmers market:My greatest influence is my sister; she goes every year, more than twice a month. She cooks for her kids and husband with most of what she purchases at the farmers market. I think that seeing her be able to use the program and her telling me how much money she has saved influenced me to just visit .Finally, friends’ shopping behaviors were also highly influential in participants values related to the farmers market. One individual stated:If it wasn’t for my friends dragging me out on a Saturday morning, I wouldn’t have learned about the farmers market, let alone the [DVCP] program. At first, I thought it would be a waste of time going there, but I’m glad I did. Saved money, they’re a good influence. We cook our healthy meals together too, and we go every weekend it’s a great experience .Collectively, these data suggest participants normative beliefs had a strong effect on behavior change, as such this direct influence from peers is needed to gauge individuals’ interest in both fresh and healthy food and the DVCP.4.This study explored barriers local health departments and farmers markets face when implementing or deciding whether to implement the DVCP in their communities, as well as the perspectives of DVCP recipients and how they presently use the program. Of the individuals interviewed, most had a minimum understanding of DVCP goals. Although administrators were well-informed of their community’s nutritional needs, they faced many organizational barriers, such as the lack of consistent leadership and employees to sustain the DVCP. In one instance, a participant collaborated with community members  to develop a program (similar to the DVCP) that offered discounted fresh fruits and vegetables, education, and “farm fresh” meal kits. Nonetheless, the organizational capacity of participants’ organizations varied considerably, thus ultimately determining what the participants were able to do regarding developing partnerships outside of their respective organizations.Participants suggested that the development of partnerships in the respective counties were critical to improving the nutritional environment and increasing access to fresh produce, specifically grocery store collaboration and community support. One recent study revealed that a cooperative agreement between the consumer food environment  and community members was a powerful component in improving the community food environment in rural or small counties . UltimatAlthough local health department administrators mentioned that the DVCP would fill a gap to improve the community nutrition environment, one participant thought it was insufficient due to underuse by community members. Two barriers potentially exist which contribute to the underuse of the DVCP and farmers market use—marketing/promotion and education. Most participants revealed that word of mouth has been the primary reason for visiting the farmers market and learning about the DVCP. Focusing efforts on analyzing the target audience or potential DVCP recipients and promoting the program directly to individuals who qualify for the program could significantly impact DVCP use. The second barrier, education, plays a momentous role in individuals’ knowledge of the production and consumption of fresh fruits and vegetables. For instance, participants noted that they were interested in consuming more exotic fruits  in southern Illinois. This comment implies that individuals might lack a fundamental understanding of both what local farmers can grow and the main concept of a farmers market, i.e., that consumers can buy directly  from the farmer. On the other hand, some participants commented that they wished to receive additional recipes and meal kits for in-season produce. Ironically, one of the local health department administrators offers both an education course  with educational lessons on meal kits to their local patrons. Similarly, another participant’s concerns about the attractiveness of produce suggests that DVCP recipients may not fully comprehend the limitations of small independent farmers . Perhaps if the local rural farmers market offered extended educational outreach, pre-made fresh produce bundles, and recipes for “meal-kits,” the program might be more attractive to DVCP recipients.The findings from this study should be interpreted with some limitations in mind. First, this study is limited in scope and used qualitative methods with a sample comprised of diverse individuals involved in local farmers markets who were sampled via convenience. Additionally, this study focused solely on one Congressional district, comprised of eight local health departments and two stakeholders involved in the DVCP in southern Illinois. To assess the administrative scope of the DVCP, participants were recruited from nine locations. Another limitation was whether organizational employees had the knowledge and experience in the subject of this specific inquiry. Some participants did not understand some questions presented and could not provide a response upon receiving clarification of the question. Furthermore, for the focus group, participants self-selected to participate in the study, and the condition of the weather during farmers market hours could have had an influence on participants’ ability or desire to sign up for the focus group. Given time constraints, only one focus group was conducted. Ultimately, the findings from this qualitative research study must be interpreted with caution and cannot necessarily be generalized to other geographical settings.4.1.To promote health equity, nutrition assistance programs are implemented in low income and rural communities to increase access to fresh and healthy and foods. Before the implementation of such programs, it is important first to conduct community assessments. Community assessments are generally performed by community-based researchers and practitioners to provide a method for examining strengths and resources, as well as concerns of a particular population or community . CommuniLastly, researchers should consider using a systems-thinking approach to improve the community nutrition environment. Systems thinking helps researchers find the most important places for an intervention that might change the long-term behavior of a system. Using systems-thinking tools might help inform researchers, practitioners, and policy makers to ask the right questions toward understanding the best places to “leverage change” in a system. Leverage points include “places within a complex system… such as a company, program, [or] economy” “…where one small shift can produce big changes in everything”  (p.5). C5.This study revealed that the DVCP is a valuable program not only to its recipients but also to local health department administrators, the latter of whom would be willing to implement the program given enough support and organizational capacity. As such, this study is the first step in better understanding what partnerships are needed between local farmers, farmers markets, and/or farm stands and local organizations to implement the DVCP and make it appropriately marketable to its intended constituents. Building capacity has the potential to improve the nutrition environment for lower-resource individuals who may not be able to access the DVCP. The results of this study can ignite future research that might ultimately influence policy to change organizational and political perspectives regarding solution-orientated change.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Southern Illinois University Carbondale Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.DR conceptualized the study, conducted interviews, and focus groups, and served as primary author. SD and JM assisted with methodology and data analysis. DN and MM advised on nutrition-related and health department-related concepts, respectively including recruitment. AK-D was primary advisor for the study and contributed to authorship and led revisions. All authors contributed to revisions and approve of the final article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Medical terminology can be challenging for healthcare students due to its unfamiliar and lengthy terms. Traditional methods such as flashcards and memorization can be ineffective and require significant effort. To address this, an online chatbot-based learning model called Termbot was designed to provide an engaging and convenient method for enhancing medical terminology learning. Termbot, accessible through the LINE platform, offers crossword puzzles that turn boring medical terms into a fun learning experience. An experimental study was conducted, which showed that students who trained with Termbot made significant progress in learning medical terms, demonstrating the potential of chatbots to improve learning outcomes. Termbot’s gamified approach to learning can also be applied to other fields, making it a useful tool for students to learn medical terminology conveniently and enjoyably. Medical terminology is a crucial aspect of clinical thinking and application, and its learning process can be challenging and frustrating for many medical professionals and students. However, familiarizing oneself with medical terminology can be immensely beneficial, not just for medical students but also for the general public. It can help one prepare better before visiting the hospital and make it easier to communicate with medical professionals. For example, it can aid in determining which outpatient department to visit and what type of specialist doctor to consult. Moreover, knowing medical terms can also help individuals engaged in related careers, such as writing medical articles, translating medical content, or working in medical insurance. It can give a clear understanding of one’s health problems and help medical professionals to diagnose and treat them effectively. In conclusion, while the learning process of medical terminology can be challenging, the benefits it offers make it a valuable investment of time and effort. By familiarizing oneself with the basic medical terms, one can take an active role in their healthcare and improve their overall health and well-being.With the widespread availability of smartphones, mobile learning has become a popular trend, allowing learners to study at their convenience anytime and anywhere. The oral aspect of mobile learning has been noted as particularly important . DigitalThe crossword puzzle strategy is a form of active learning that engages students by having them fill in crossword games created by the teacher. According to Kazimoglu, digital games foster motivation by providing players with solutions that allow them to progress to the next level, contributing to the growth of the video game industry . These gKumar et al. emphasized that, while online crosswords may not be a substitute for traditional crosswords, they still offer valuable teaching opportunities, as they can pique students’ interest and encourage them to learn . Bailey Patel and Dave observed that students appreciated the use of crossword puzzles in their learning, as it allowed them to engage in important learning activities. The strategic use of crossword puzzles can simplify the delivery of content and provide opportunities for students to discuss and review fundamental concepts in their university studies .Crossword puzzles are an effective tool for memorizing vocabulary and promoting active learning and critical thinking skills.Research question: Can the use of Termbot aid in improving students’ medical terminology?Chatbots are computer programs that simulate human conversation using text or speech recognition. They are designed to make users believe they are communicating with a real person in real time. Advancements in technology have enabled chatbots to employ advanced artificial intelligence algorithms and natural language processing to provide intelligent and meaningful responses. The early chatbots relied on simple pattern matching and string processing, but modern systems have evolved to use more sophisticated knowledge-based models to generate human-like responses. Especially during COVID-19, chatbots have played an important role, as in . It is aTo make learning medical terminology more engaging and effective, this study presents a novel approach that uses JavaScript, jQuery, and HTML to develop a chatbot system with crossword puzzles, named Termbot. Termbot can be accessed via the LINE platform and is aimed at providing students with a convenient and interactive way to practice and memorize English medical terminology.LINE, a freeware app for instant communication on various electronic devices, is widely used in Taiwan, including by students. Termbot leverages this popular platform to offer an entertaining and effective learning experience for students. As students complete the crossword puzzles, Termbot records their incorrect answers and categorizes the students into different groups, allowing the teacher to provide targeted remedial instruction based on the needs of each student. This unique feature sets Termbot apart and represents a significant contribution of this study to the field of medical terminology education.This study employs an experimental method to assess the impact of Termbot on students’ learning of medical terminology. The sample participants were divided into two groups: the experimental group and the control group. The experimental group received instruction on the use of Termbot, while the control group received traditional teaching methods. The researchers compared the results between the two groups to determine the effectiveness of Termbot on students’ academic performance.Sixty participants were recruited for this two-month study, with 30 anonymous nursing students assigned to the experimental group and 30 anonymous nursing students assigned to the control group. The experimental group was given access to Termbot for practicing medical terminology at any time, while the control group did not have access to Termbot. After two months, all 60 participants took a posttest for the online medical terminology exam.Termbot, a chatbot based on crossword puzzles and developed using Python, has been introduced in this study. It is designed to be used on the LINE platform, which is known for its user-friendliness and diverse messaging options, including flex messages. LINE is a popular instant messaging app that provides a wide range of functions, such as shopping, mobile payments, news, and live broadcasts.The Termbot system comprises two major modules, namely the database and the processing engine, as illustrated in To set up Termbot on the server side, Python version 3.8.13, Ngrok, and a LINE Developers account are required. The system also uses other packages, including line-bot-sdk version 2.3.0 and flask version 2.2.2.Termbot can be accessed on various devices, including smartphones, iPads, laptops, and personal computers, offering students a convenient and accessible way to practice their medical terminology. After the teacher inputs medical terminology and clues, the chatbot automatically generates crossword puzzles for the students to complete. The architecture of Termbot is shown in The Termbot system stores all medical terminology in a relational database named PostgreSQL . As a gaThe fields of the tables are described as follows:The “Student” data sheet contains all the relevant information about the students, including their unique identifier “student_id” and their name recorded in the “name” column.The “Teacher” data sheet records information about teachers, including their unique identifier “teacher_id” and the class they teach, recorded in the “class” column.The “Vocabulary” data sheet records information about the vocabulary used in the class. The “book” column indicates which book the vocabulary is from, and the “lesson” column indicates the specific lesson in which the vocabulary is used.The “Puzzle” data sheet records information about crossword puzzles created for the class. The “timestamp” column records when the puzzle was created, while the “auto_manual” column indicates whether the vocabulary used in the puzzle was sourced from the books or typed in manually by the teacher. A value of 0 in the “auto_manual” column indicates that the vocabulary was sourced from the books, while a value of 1 indicates that the vocabulary was typed in manually by the teacher.The “Homework” data sheet connects puzzles with students. The “puzzle_id” column is used to identify the puzzle, while the “class_id” column identifies which classes the puzzle is related to. The “valid” column indicates whether the puzzle is still valid or not.The “Wrong” data sheet records information about student mistakes. The “wrong_word” column is used to record each student’s wrong answer.Termbot is a chatbot designed to be used on the LINE platform, which serves as its user interface. Below are the functions offered by Termbot.Students have access to three main functions on the initial screen: “Today’s homework”, “Practice by book or lesson”, and “Help”. The “Today’s homework” function allows students to view the crossword puzzle homework assigned by their teacher, as shown in On the initial screen, the teacher has access to six main functions: “Auto-generate”, “Manual generate”, “Assign & Reassign”, “Generate report”, “Delete Puzzle”, and “Help”. The “Auto-generate” function enables teachers to select the textbook and lesson to be practiced by students, and the system will automatically generate the crossword puzzle questions and answers. The teacher then confirms the puzzle before sending it back to the students, as shown in The field of crossword puzzle generation has seen a growing interest among researchers in recent years. Several studies have proposed crossword puzzle generators for different applications. For example, Bonomo et al. used genetic algorithms and the wisdom of artificial crowds to generate crossword puzzles . YampolsThis study utilized usability testing to assess the effectiveness of Termbot in meeting the needs of users. Fifteen volunteers were recruited to participate in the evaluation process, which is crucial for enhancing the users’ experience . The usaThe System Usability Scale (SUS) questionnaire was used to assess the usability of Termbot. The SUS questionnaire was created by John Brooke in 1986 and is a widely used method for quickly evaluating the usability of product system interfaces, desktop programs, and website interfaces . The queData was collected using Google Forms, and a total of 15 questionnaires were received with an average total score of 83.25, indicating that users were satisfied with the system.As previously stated, 30 students were part of the experimental group, and 30 students were part of the control group. The students in the experimental group utilized Termbot for a minimum of 2 h a week for medical terminology learning after class, while the students in the control group used traditional independent learning methods without the aid of Termbot. The results of the experiment indicate significant progress made by the students in the experimental group compared to those in the control group. The statistical analysis results are presented as follows.t-test was conducted to compare the mean difference between the control group and the experimental group. The control group consisted of 30 individuals with an average test score of 54.23, while the experimental group consisted of 30 individuals with an average test score of 53.33, as shown in t-value obtained from the test statistic was 1.2749, and the p-value was 0.2074, which did not reach the significance level of α = 0.05. This means that the null hypothesis could not be rejected. The results of the analysis suggest that there was no significant difference between the performance of the control group and the experimental group.In this study, an independent-sample t-test was used to compare the difference in the means between the two groups, and the results showed that the t-value was −10.5072 and the p-value was 0.0000, which is significant at the α = 0.05 level. Thus, the null hypothesis was rejected, and the alternate hypothesis was accepted. These results demonstrate that learning medical terminology through Termbot was effective in helping students improve their test scores compared to traditional learning methods.After two months of learning medical terminology, the 60 nursing students took the posttest again. The results showed that the students in the experimental group made significant progress, with an average test score of 82.69, as shown in The findings suggest that using Termbot to practice medical terminology is effective in improving students’ medical terminology knowledge. These results are consistent with the study’s expectations and provide evidence that the use of Termbot as an educational tool can significantly enhance students’ learning outcomes. The results highlight the potential of using technology in education and support the importance of incorporating digital resources into the classroom.Returning to our research question—Can the use of Termbot aid in improving students’ medical terminology? The answer is affirmative. Our results indicate that Termbot can indeed assist students in studying medical terminology. The results of the satisfaction survey of the experimental group students were overwhelmingly positive, as shown in The results of the analysis show that there is a significant difference between the means of the control group and the experimental group, with the experimental group having a significantly higher mean score. This is consistent with the results of the study by Seidlein et al. on Gamified E-learning in medical terminology: the TERMInator tool .The control group students were motivated to use Termbot for medical terminology practice after seeing the significant progress made by the students in the experimental group. To further improve Termbot, the developers plan to refine the RBT-based evaluation system ,37.Chatbots have played a crucial role during the COVID-19 pandemic, particularly in combating misinformation, as demonstrated by the tool discussed in . This toTo promote the usage of Termbot, the authors recommend two strategies:Offering incentives and rewards: Providing incentives and rewards can motivate students to use Termbot and strive for success. These incentives and rewards could include certificates, prizes, or recognition.Providing regular feedback: Regular feedback on students’ progress can help to build their confidence and motivation to continue using Termbot. This feedback can also help to identify areas where they need to focus their attention and improve their learning outcomes.In this study, Termbot, a crossword puzzle chatbot designed for online learning, was developed to provide an interactive and engaging way for students to learn English medical terminology. By incorporating the fun of crossword puzzles, students find learning medical terminology to be more enjoyable and effective. During their interactions with Termbot, students can use the provided online crossword puzzles to improve their understanding of medical terminology. The results of this study showed that students who used Termbot demonstrated significant progress in learning medical terms. This information can also be useful for teachers, who can use it to identify areas where students need additional support.Termbot has proven to be an effective tool for enhancing student learning not just in medical terminology but in other subjects as well. This versatile application is designed for professionals, students, or anyone who wants to increase their knowledge or refresh their memory. Termbot is designed for convenient use, allowing users to access it at any time and place, whether they are on the go, at home, or at work. This study highlights the feasibility, convenience, and effectiveness of mobile learning. However, the limitation of the study is that it is difficult to control the frequency and duration of students’ use of Termbot.In conclusion, Termbot is an excellent choice for self-learning, and future research will focus on expanding the available user interfaces and integrating them with a recommendation system to make it even more effective ,39. The