DrugsNot4Me campaign were understood, experienced, and engaged with among a group of street-involved young people in Vancouver, Canada.Due to the popularity of public service announcements (PSAs), as well as the broader health and social harms associated with illicit drug use, this study sought to investigate how drug prevention messages found in the Government of Canada’s Qualitative interviews were conducted with 25 individuals enrolled in the At-Risk Youth Study, and a thematic analysis was conducted.Findings indicate that the campaign’s messages neither resonated with “at-risk youth”, nor provided information or resources for support. In some cases, the messaging exacerbated the social suffering experienced by these individuals.This study underscores the importance of rigorous evaluation of PSAs and the need to consider diverting funds allocated to drug prevention campaigns to social services that can meaningfully address the structural drivers of drug-related harms among vulnerable youth populations. During the past half-century, public service announcements (PSAs) to promote healthy behaviors have become increasingly popular, including PSAs focused on preventing drug use among youth, which target both young people and their parents . PSAs caAcross various settings, the literature on the effectiveness of drug prevention PSAs reveals mixed results , 3. SomeMany PSAs focused on preventing drug use among youth use fear-based appeals in an effort to motivate behavioral change. Fear-based appeals can be defined as messages that aim to motivate behavioral change by frightening or threatening target audiences with negative outcomes if unhealthy behaviors are initiated or continued, and recommendations are not followed , 12. To DrugsNot4Me campaign. Given the continued popularity of fear-based appeals, we also sought to investigate the potential effect of the campaign in preventing the initiation of more severe and potentially harmful forms of drug use among young people experiencing social, economic, and institutional marginalization. Despite the campaign’s perceived target audience of youth who are at high risk of initiating drug use but have yet to, we chose to discuss the campaign with street-involved young people who had already begun engaging in heroin, crack cocaine, and crystal methamphetamine use. While we recognize that this campaign was not specifically aimed at our study population, it was important to elicit these young people’s perspectives on the campaign because they were at one time part of a particularly “high risk” segment of the broader Canadian youth population targeted by the campaign. On the one hand, these young people arguably stood to benefit the most from an effective drug prevention mass media campaign; on the other, this group of young people would also likely be the most negatively impacted by an ineffective drug prevention mass media campaign. Additionally, we were interested in investigating the wider impacts of the DrugsNot4Me campaign on individual and collective understandings of youth drug use, from the perspective of marginalized young drug users themselves. Whether or not they had initiated more severe and potentially harmful drug use prior to first exposure to the DrugsNot4Me campaign, we asked youth to reflect on how the PSAs could shape their understandings of themselves and their lives in the context of current or past experiences of addiction, as well as broader public understandings of the “problem” of youth drug use.The present study sought to understand how one group of street-involved young people in Vancouver, Canada understood, experienced, and engaged with the images, ideas, and information found in two video PSAs released as part of the Canadian Government’s DrugsNot4Me, a drug prevention PSA campaign that primarily targeted youth. From 2007 to 2012, a total of CDN $29.8 million was budgeted for the Government’s Prevention Action Plan, which included the DrugsNot4Me campaign  ca” [The video PSA dot] ca” .Mirror follows a young Caucasian female. The majority of the PSA takes place in her bedroom, and depicts her physical and psychological demise over time as a result of substance use. Her transformation is signaled by progressive changes in physical appearance , as well as her behavior, which becomes increasingly angry, erratic, and desperate. The PSA includes a musical rhyme, reminiscent of a children’s nursery rhyme, in which a female voice sings: “One, two, kicked out of school. Three, four, snort some more. Five, six, need my fix. Seven, eight, it feels too late.” At the end of the rhyme, we are shown a before-and-after image, in which the still healthy and attractive teenage girl sees her emaciated, dirty, and distressed “addict self” reflected in the mirror. Her reflected self has sores on her arms and mouth, implying the use of more severe drugs such as crystal methamphetamine and crack cocaine. The PSA closes with a scene of the young woman smiling and laughing as she leaves her house, accompanied by two other teenagers. A male voice completes the scene with the same narration as above .The video PSA DrugsNot4Me campaign, rather than as part of a prospective evaluation. Participants ranged in age from 20 to 32 years, with a median age of 25 years. Of the participants that self-identified as a single race or ethnicity, ten (40%) self-identified as White, five (20%) as Aboriginal, two (8%) as Southeast Asian, and one (4%) as Black/African-Canadian. Of the participants that self-identified as more than one race or ethnicity, five (20%) self-identified as Aboriginal and White, one (4%) as Aboriginal and Black/African-Canadian, and one (4%) as White and Black/African-Canadian. Each interview lasted approximately 1 h and was conducted by two female researchers (LT and DF) at the ARYS frontline office in downtown Vancouver between April and June of 2015. All participants provided written informed consent and received a thirty-dollar honorarium for their participation. The study was undertaken with ethical approval granted by the Providence Healthcare/University of British Columbia Research Ethics Board.Study participants were recruited from the At-Risk Youth Study (ARYS), an ongoing prospective cohort study of street-involved and drug-using youth in Vancouver, Canada . Twenty-DrugsNot4Me video PSAs prior to the interview, and were shown both Fast Forward and Mirror several times throughout the interview process. However, the interviews revealed that the DrugsNot4Me campaign had a high level of exposure among the study participants. Of the 25 study participants, 23 (92%) indicated that they had been exposed to the campaign prior to the interview, while two (8%) indicated that they had no previous exposure. Participants indicated that they had been exposed to the campaign via multiple channels of communication  and in multiple locations .The study participants were not required to have seen the DrugsNot4Me video PSAs with video PSAs from other campaigns they had been exposed to. Finally, we asked young people for their recommendations on how to improve drug prevention PSAs, as well as their ideas about alternatives to drug prevention PSAs for addressing youth drug use.During interviews, we asked young people to describe their exposure to the campaign, and reflect on how it did or did not impact their own drug use-related decision-making across time. We asked them to tell us how the visual and audio components of the PSAs contributed to the specific stories being told and how the PSAs could impact individual and collective understandings of youth drug use in Canada. We also asked youth for their perspectives on the use of fear-based appeals in drug prevention messaging, and to compare the DrugsNot4Me campaign); this framework was then refined by the research team through the addition of new codes that captured more complex analytic categories . NVivo software was used to facilitate data coding and management.All interviews were audio-recorded and transcribed verbatim, and transcripts were checked by the lead author to ensure accuracy. Following transcription, a coding framework was generated that captured broad, emergent themes What really irks me about both of these ads though, is Overall, findings of the present study indicated that the Fast Forward). It is important to note that during the time these PSAs were on the air, marijuana was essentially being decriminalized in Vancouver, revealing a discrepancy between the Government of Canada’s DrugsNot4Me campaign and the drug policy climate in Canadian metropolitan urban settings like Vancouver. Since the campaign, the presence of medicinal marijuana has increased dramatically in Vancouver, and is easily accessible to most adults. Yet, of the latest series of drug prevention PSAs released by the Government, one continued to focus on the potentially dire consequences of marijuana use among young Canadians  a lot. ‘Cause she’s from [a] well-off family. And like, that’s what happened to her. She started crying when she saw that commercial. It like, blew her out of the water. [It] gave her like, [a] kick in the ass. Yeah, she got really scared. I think [the ad is] sad. My friend really relates to that ad , sucks to live it. The [ads] just feel no hope for that girl, is what I’m getting. And that she’s fucked and you better not get to that point because there’ll be no hope for you as well. And there’s so may people that, in their addiction—whether it’s been a year or twenty years, they feel that way. And I feel like this is just backing that up. This is like, [a] really alienating ad, right here. It’s really making it seem like, there’s Similar sentiments were reflected in other participants’ accounts:Mirror, participants noted:makes society scared of everybody that’s on drugs. You shouldn’t be afraid of it. I think you should just be more aware of it. More information on [the context of youth drug use] would be more helpful than to like, just put an ad on. Like, freak out people, you know? [The ad] separation, making them appear to be in a different category. Like, the segregation of people who are on drugs. It’s just saying, ‘Don’t use drugs.’ It’s not saying that, you know, ‘But if you do use them, here’s how we can help.’” This ad is not solution-based in any way. It shows a problem, and [says], you know, prevent a problem by not doing it. But what if someone was to look at this ad and they are in that place in their lives? How is this going to be bettering [for] where they are in their addiction in any way? It’s just kind of creating a When asked to think about the impact of the PSAs more broadly, participants articulated a concern regarding the potential of the PSAs to create public fear surrounding youth drug use, and reinforce stigma and discrimination towards vulnerable young people who were not able to “just say no” to drugs. Regarding DrugsNot4Me campaign was not designed to address the needs of young people who were already engaged in more severe forms of drug use. Nevertheless, study participants consistently characterized the video PSAs as “problem-based” rather than “solution-based” and commented on how they promoted abstinence without offering useful information about how to access support for those young people struggling with addiction or the decision to use more severe and potentially harmful drugs. Though intended as a resource, the link to the DrugsNot4Me website featured at the end of the PSA was viewed as insufficient by participants. To this effect, one participant explained about Mirror:drugsnot4me.com. If I got to learn more about that resource it would be more beneficial to me. Yeah, I would’ve liked to see more about what happens when I go to that site—what kind of help there is available to me. [Without it] I’m left with a story and a link. [It’s hard to] separate myself from the girl and imagine myself getting the help. [When she] goes onto the porch [of her home] and she’s with her friends—that’s great, but how did she get the help? And choosing not to use won’t just miraculously change your life. You can be sober and clean and still feel dead on the inside and still have all of the issues that you had when you were using. [The ad] said When it comes to preventing youth drug use, almost all study participants argued that there are more effective alternatives to drug prevention PSAs that use fear in an attempt to influence or change individual behavior. With regard to developing more effective PSA campaigns, participants suggested that PSAs should be more informational and educational, providing facts about illicit drug use rather than emphasizing emotional storylines. It is important to note that the we didn’t make this up to sell you an idea. This is an actual person that’s gone through this. Maybe like, [if the ad] wasn’t fictional. That might help too—if it was like, actual people who’d gone through some of the things. ‘Cause that might resonate more with [people] than this fictional political ad created by the Government, you know what I mean? If it was like, ‘Oh, we interviewed some addicts and this is what they had to say’ and stuff like that. This is a real person—Study participants also suggested that the PSAs could be improved through the use of “real people with real stories”:experience being in and out of rehabilitation programs. And I feel like those people would have a lot of the similar ideas or thoughts that I have towards this and be able to really make an actual effective ad and program for people. I think it would be more effective for them to hire onto their advertising team and their campaign team people who are recovered addicts. People who work in the addiction industry. People who have, like, One participant suggested this community-based, participatory approach to creating a drug prevention mass media campaign:DrugsNot4Me campaign] on [is] helping the already addicted. More supportive housing, more mental health advocates. ‘Cause that’s what I see right now is the problem. The Downtown Eastside is [full of] drug addicts and, you know, drug addicts with mental health issues. ‘Cause I’m one of those people that have both. I would really want to focus on the drug addicts and not the could-be drug addicts. So what I would spend the money  would be more useful going towards services for youth than the ads. I’m sure there are a lot of youth who don’t even pay attention to them or don’t fully understand them. I didn’t have access to things like a peer support worker or Coast Mental Health or anything like that [but] for me, it was the youth center [in the rural community where he grew up]. That was where I really started to take on like, leadership responsibilities and [started] volunteering and stuff like that. I think the money [used for the One participant in particular strongly emphasized the importance of providing community spaces and services targeted at vulnerable youth who have not yet initiated drug use, but are highly vulnerable to drug use. Briefly, he noted that while access to these kinds of spaces and services exists in downtown Vancouver, it is limited in other parts of the Lower Mainland and the Province of British Columbia. He described how a community center in his home town, which provided specific programing for youth (including leadership and volunteering opportunities), played a significant role in allowing him to move away from drug use and towards other opportunities:DrugsNot4Me drug prevention PSA campaign had an extensive reach. Indeed, this study provides evidence of its success in reaching some of Canada’s most vulnerable and marginalized young people. However, the results of the present study indicate that for this group of young people, the PSAs were simplistic and lacked information, and, for some, were even emotionally harmful. Importantly, many called for funding of drug prevention PSAs to be diverted to housing, mental health, and harm reduction programs. Our findings therefore support previous work which emphasizes the overall ineffectiveness of drug prevention PSAs, including those which use fear-based appeals [The Canadian government’s  appeals , 9–11.lived experiences or lived realities of suffering can be powerfully shaped by social, structural, and environmental factors beyond individual control [DrugsNot4Me campaign reduces drug use and its harms  to personal choice. Reinforcing this personal choice narrative can deepen the stigmatization of those young people whose “choices” are powerfully constrained by broader social, structural, and environmental factors. This includes forms of self-stigmatization, through which young people blame themselves for not being able to “just say no” to drugs [The findings of the present study are also consistent with previous work indicating that PSAs can have negative repercussions for vulnerable populations , 13–15.  control –30. By eto drugs .emotional impact campaign content can have on audiences, particularly when addressing issues related to vulnerable populations; rather, they focus on audience recall and understanding [The potential negative impacts PSAs can have on vulnerable populations has led to arguments for the rigorous evaluation of PSAs and mass media campaigns in an effort to mitigate, or altogether avoid, these outcomes. However, despite the existence of policies around mandatory standardized post-campaign evaluation for media campaigns of $1 million or more in Canada, evaluative strategies often overlook the importance of pre-campaign evaluations, and neglect to measure the standing . Furtherstanding –37.DrugsNot4Me campaign was on the air from 2009 to 2012. From 2007 to 2012, the Government of Canada budgeted CDN $29.8 million for its Mass Media Campaign, as a part of its Prevention Action Plan [DrugsNot4Me campaign, but also the Government’s latest campaign, released in October 2015, which featured two PSAs about the harms of marijuana and prescription drug use targeted at parents [Given the high costs associated with the production and dissemination of drug prevention campaigns, as well as the dire situation of many young people who use illicit drugs in Canada, the findings of the present study have implications for resource allocation. The ion Plan . From 20ion Plan , 39. Theion Plan , 13, 14. parents , 22.The need to consider the social, structural, and environmental contexts of health behaviors when designing a public health communication campaign is emphasized in various studies –6, 40–42For many of our participants, the creation of drug prevention PSAs and mass media campaigns were not considered the most effective use of resources. Rather, participants suggested an alternative approach worthy of consideration: that funding for PSAs be reallocated to social housing, mental health, and harm reduction programs, as well as other community supports and services specifically designed for youth. Better supports and services for young people in the places of their childhoods are needed so that the “decision” to initiate more severe and potentially harmful forms of drug use does not come to seem like the only “decision” congruent with every day lived experience in the context of entrenched social, economic, and institutional marginalization , 43.The present study has several limitations that warrant discussion. First, the thematic analysis conducted for the present study was focused on only one PSA campaign, and as such, the findings of this study may not apply to other drug prevention PSA campaigns or those on other health issues. Second, the findings revealed by this study are specific to the study participants and are not representative of the wider street-involved youth population in Canada or elsewhere. Third and relatedly, it is important to recognize that the campaign did not directly target our study population, street-involved youth, but rather youth who are potentially at high risk of initiation into drug use. As such, this study cannot speak to the impact of the campaign among its direct target audience. And finally, it is important to acknowledge the limitations of the interview process and the ways questions are framed, as well as the existence of power relations embedded in the research process, particularly when working with youth, that may influence responses to favor researchers’ interpretations .DrugsNot4Me campaign were understood, experienced, and engaged by participants in a way that reflects the lived experiences or realities [In conclusion, the images, ideas, and information found in the ealities , 30 of sealities . The obv


The five most common categories were related to health, sugar, dairy, packaging, and additives. Thematic analysis of responses from the laddering method identified three major themes: concerns about the types of beverages mothers would like to provide their preschoolers, the healthiness of a beverage, and the sugar content. Conclusions: Mothers’ perceptions of beverages are sophisticated and need to be included in the design of health communication strategies by health promoters and government agencies to influence mothers’ beverage selections for their preschoolers.Background: The prevalence of obesity among Australian pre-school children is a major concern with links to poor health outcomes. One contributing factor is excess energy intake. Sugar-sweetened beverages are energy-dense, nutrient-poor, readily available and have been implicated in the increasing prevalence of obesity. Furthermore, preschooler beverage consumption may develop into dietary habits that track into adulthood. There is little research on factors influencing parents’ decision-making when serving beverages to their preschoolers, or on mothers’ perceptions of preschooler’s beverages. The aim of this study was to explore mothers’ perceptions of commonly consumed preschooler beverages. Methods: The Repertory Grid Technique and the Laddering Technique methodologies were utilized in interviews with 28 mothers from Melbourne, Australia, to explore beverage perceptions. Results: A large number of diverse perceptual categories (‘constructs’) ( The high prevalence of overweight and obesity among young children is a major public health concern and is linked to poor health outcomes in childhood and adulthood, including non-communicable diseases such as Type 2 diabetes ,2, sleepMothers are generally considered as the primary household gatekeepers . They arMothers’ perceptions or beliefs are likely to influence the types of beverages they provide for their preschoolers . UnfortuMore broadly, two studies of women’s fruit and manufactured snack perceptions ,24 are rThe present study was underpinned by the theoretical framework of the Food-Related Lifestyle Model . This frIn summary, there is a gap in the research literature in regards to mothers’ perceptions of preschoolers’ beverages. Therefore, the overall aim of this study was to investigate the beliefs and perceptions of commonly available preschoolers’ beverages held by mothers in Melbourne, Australia.Two distinct methods were used in this study to provide a rich, in-depth exploration of the topic. The first method used was the RGT which is an established method based on Personal Construct Theory (PCT) ,31,32,33The second method used in this study was “Laddering” . It is bMothers of children aged two to four years residing in two geographical areas in Melbourne, Australia were invited to participate in the study. The two areas were purposefully selected to represent different levels of socio-economic status according to the Australian Bureau of Statistics’ Socio-Economic Indexes for Areas (SEIFA) . We aimeEthics approval was obtained from the Human Research Ethics Committee at Deakin University, on the 10 April 2017, reference HEAG-H 35_2017. Consenting participants were invited to attend an interview at the recruitment venue or at Deakin University, and in-depth interviews were conducted. To review and streamline the procedure eight pilot interviews with mothers of preschoolers were conducted. These data were not used in the final analyses.Each of the interviews were divided into two sections involving the administration of the RGT and then the Laddering Technique for the constructs that the participants considered important to them. Participant’s socio-demographic characteristics were collected using a short questionnaire at the conclusion of the interview. These included maternal age, educational background, occupation, postcode, ethnicity, marital status, and whether the participant was the main shopper. To determine the mothers’ perceptions of children’s’ beverages, thirteen images of drinks commonly consumed by Australian preschoolers in the 2011–2012 National Nutrition and Physical Activity Survey (NNPAS)  were selThe beverage images were printed on A4 sized paper and presented in sets of three (triads). Mothers were asked which beverage was different from the other two and why. The mothers were advised that there were no incorrect or correct responses and that the researchers were only interested in the mother’s own perceptions. The response to each triad (termed ‘constructs’ in PCT) were recorded in written form on five-point bi-polar scales . In judgIn the second part of the interview, the participants were asked if each of the constructs they had provided was important to them, and if so, why? Once the participant had provided a response, she was asked ‘why?’ again for further clarification. The laddering technique is qualitative in nature and the why questions are open-ended to explore the underlying motivations and values of the participants. Those participants who answered “no” to any constructs, i.e., they did not think it was important to them, were not asked the laddering questions for those constructs.Descriptive statistics were used to summarize the participants’ socio-demographic characteristics .The constructs were grouped into similar categories according to the frequency of their key words  43,44].,44.43,44Each mother’s ratings of all the beverages were analysed using WebGrid Plus . In thisIn the resulting perceptual maps, beverages that are in close proximity to a construct indicate that the participant perceived the beverage as having that particular attribute. Conversely, beverages that are far from a construct tend not to possess that construct in the mother’s mind .The mothers’ reasons for the importance of specific constructs, obtained from the laddering technique, were analysed via thematic analysis ,35. The Twenty-eight mothers of preschoolers aged two to four years participated in the interviews. Six further women who had expressed interest declined to participate for varying reasons , and their demographics were not collected. The duration of the interviews was 20–55 min, with an average of 37 min. The majority of the mothers (25/28) were aged over 30 years and all but one were married or in a de-facto relationship. Over two thirds (19/28) had a bachelor’s degree or higher and 61% (17/28) were born in Australia with the remaining from ten different countries. Over four fifths (23/28) were primarily responsible for the procurement of foods for the household, and a further four participants shared this responsibility. Although mothers were recruited within organizations in the targeted area some lived in neighbouring suburbs of differing socio-economic position (SEP) based onSEIFA . In totaThe number of constructs elicited per participant ranged from five to 12. The total, 28 participants provided a diverse range of 312 constructs about preschoolers’ beverages. These were grouped into 22 categories . The sixEach mother’s repertory grid data yielded a unique perceptual map of their constructs of the 13 beverages. There was great diversity within and between the maps. One example of a map of intermediate complexity is shown in Three main themes were identified, named as: ‘Influences of beverage selection’, ‘Drive for healthiness’ and ‘Reasons for sugar avoidance’ . Six minThe mothers were particularly concerned about the drinks their preschoolers consumed. All mothers considered certain beverages necessary or ideal for preschoolers such as water, milk and some mentioned juice, and they reasoned that these choices were important for health.The milk and some orange, like a fruit juice, they good because, and their taking. They need a water a little bit, but the cokes and other thing they not good for kids. Water is most important for them.”“ID: 110, low SEPThere was also consideration of the purpose of the beverage by three mothers, of whether it quenched thirst or warded off hunger. Four mothers recognised that their children had limited appetites, or sometimes no appetite, and if a caloric beverage was provided, the child would not be able to consume a more nutritious food or beverage.Four mothers mentioned their children’s preferences, but most mothers decided they knew best. In an attempt to control consumption of undesirable beverages four mothers would ensure the beverage was inaccessible, for example supermarket shopping without her pre-schooler.I don’t want the kids drink much soft drink although they really like it. So like if I take them to the supermarket and they see it and want to buy it. If I don’t buy it they will not drink it. Usually I don’t take them to the supermarket.”“ID: 117, high SEPIn contrast, two mothers mentioned that their children influenced the beverage they received through their behavior.If she does not get juice when she asks for juice then the tantrum is not worth it.” “ID: 106, high SEPEleven mothers acknowledged that the social and food context were considered when selecting a beverage for preschoolers. Therefore, a sugar-sweetened beverage might not be suitable for breakfast but acceptable for a birthday celebration.When we go to McDonalds we buy these things (pop-top fruit drink or soft drink). If we have a birthday or something.”“ID: 127, low SEPAll the mothers wanted their children to have a good, disease-free, physically active and emotionally balanced life. Most acknowledged that both food and drink were important for good health, which included oral health, being physically fit and having strong disease immunity. Four mothers commented that it was important to develop habits that achieve healthy outcomes.I want him to grow healthy. I am trying to do everything I can in my power to make sure he has a healthy, well-balanced diet, to grow up healthy, and physically fit.”“ID: 122, high SEPHalf of the mothers were also concerned about avoiding certain substances, like additives, or caffeine for health reasons, and the unknown consequences of these items.…because the long-term effect of those additives on health are not always known and I think especially for young kids you don’t want really want them consuming these artificial additives if you’re not really sure how it will affect them short or long-term.”“ID: 105, low SEPTwenty-six mothers were concerned about sugar in their preschooler’s diet. Generally, they felt their preschoolers consumed enough sugar in food, so additional sugar from drinks was excessive. One mother was concerned that sugar had worse consequences than fat in food.I think particularly for drinks, it should, it is always one of those areas where if you are going to cut down on sugar just not having sugary drinks is the one of the easiest ways to do that”“ID: 101, high SEPTwenty-four of the mothers also worried about the short and long-term effects of sugary beverages causing conditions like hyperactivity, tooth decay, and diabetes. In contrast, two mothers believed that sugar was important and that it had a place in a child’s diet.I think that sugar provides something to the body. I am not sure because I am not a doctor but I think that sugar still provides something to us, we need maybe a little bit because if we use too much we may be diabetes later. If you don’t have sugar you will lack the nutrition or something like that.” “ID: 117, low SEPThree mothers differentiated between different types of sugars, for example: natural, added and artificial sugars.I prefer natural sugar because it is natural, you still have to keep track of how much she’s having, but at least if it is natural it is better for you.”“ID: 115, high SEPThis study combined two methodologies, RGT and Laddering Technique, to provide rich data and in-depth exploration of mothers’ perceptions of preschoolers’ beverages. This is in contrast to most previous studies that have only focused on one attribute, health ,17,18,19The utility of the Food Related Lifestyle Model’s was generally supported by the elicited perceptions which were complex and multi-faceted. For example, mothers mentioned their preference for serving milk over formula because of its convenience, a higher order attribute. Mentions of their preference for organic beverages because of their naturalness represent another higher order quality factor. References to lids on beverages are examples of concrete attributes that were linked to freshness and convenience . Similarly, references to the calcium content of milk can be seen as a concrete attribute but also as part of a shopping script: knowing and checking which beverages provided this nutrient. Finally, the avoidance of sugar-sweetened beverages to avoid child hyperactivity is a good example of a perceived consequence. Although perceptual maps have been derived from previous studies of food perceptions ,47 and pSome of the perceptual categories shown in The three major motivational themes derived from the thematic analysis of the laddering responses are consistent with previous research. The ‘Influences on Beverage Selection’ theme is about the contexts and maternal strategies that affect beverage purchasing and the control of the child’s behavior by the mother or the child. These include the use of sugar-sweetened beverages as treats, the avoidance of situations such as supermarkets in which clashes between the mother’s and child’s purchase wishes might occur (‘pester power’) ,53,54,55The ‘Drive for Healthiness’ theme highlights the nutritional trade-offs mothers may make between different beverages and foods according to their nutritional properties, for example, providing a chocolate-flavoured milk for its calcium content despite its sugar and additives. The theme is also linked to the development of healthy beverage preferences and life-long healthy habits ,57,58,59The ‘Reasons for Sugar Avoidance’ theme is topical, with over 200 articles in the “Newsbank” database of Australian newspapers  listed iSome products’ attributes such as taste and financial cost have been reported to be primary influences over adult food ,68,69,70The present findings clearly show that preschoolers’ mothers hold a great variety of perceptions about beverage attributes. When researchers pre-select certain perceptual attributes with little empirical foundation , these may not reflect the diversity or priorities of perceptions and beliefs of the target population . Any heaA limitation of the study was that the mothers were relatively well-educated and generally of high SEP so the findings may not reflect the socio-economic diversity of the Melbourne population. For example, mothers of low SEP may have perceived cost to be more important. However, the participants were ethnically diverse with 11 nationalities being represented and this allowed a broad range of perceptions to be elicited. The large number and variety of constructs identified in the study suggests that many perceptions of preschoolers’ beverages important to the mothers were found. It remains for future research to examine the likely influences on these perceptions, for example, children’s responses to beverages and mother’s own preferences, and the extent to which they influence preschoolers’ dietary behaviours. Twenty-two categories of mothers’ perceptions of young children’s beverages were identified, indicating that mothers hold multiple, diverse perceptions. The perceptions ranged from ‘concrete’ attributes, e.g., packaging, to more abstract ‘higher-order’ perceptions, e.g., nutrition. These perceptions reflect the utility of the Food Related Lifestyle Model . Themati


Chronic health conditions in children can have a significant impact on their quality of life. The aim of this study was to explore the subjective experience of children and young people being treated for chronic, non-infectious uveitis associated with a systemic disease such as juvenile idiopathic arthritis.A semi-structured interview was conducted with 10 children and young people aged between 6 and 18 years of age and their parents.Preliminary thematic analysis indicated that both the treatment and complications of the disorder have a significant impact on the quality of life and emotional well-being of patients, not only in terms of the discomfort experienced but also in perceptions of social isolation, anxiety and sense of injustice.This study shows that themes including “impact on school”, “social factors” and “emotional reactions” are important domains influencing health-related quality of life (HRQoL) in children with chronic uveitis. Inclusion of questions relating to these domains should be considered in future uveitis-specific tools examining HRQoL in these patients. The importance of measuring health-related quality of life (HRQoL) in children with chronic health conditions is widely acknowledged , 2. MultUnderstandably, the HRQoL of children with visual impairment can be significantly reduced , 4, 6. IChronic anterior uveitis (CAU), the persistent inflammation of the anterior segment of the eye, is the most frequent extra-articular manifestation of JIA. Often clinically silent, CAU can lead to visually-disabling complications including cataracts, glaucoma, band keratopathy and macular oedema, both as a result of chronic disease activity and treatment, which can be burdensome , 14. TreThis study aims to develop an understanding of the subjective experience of the impact of both uveitis treatment and its complications on the HRQoL of children, incorporating parent perceptions, with a view to ascertaining if any important additional topics are worth considering for inclusion in future PROMs of QoL in children with uveitis.This cross-sectional interview study was sponsored by the University Hospitals Bristol NHS Foundation Trust and approved by the South West Research Ethics Committee  were equally represented in the sample. The severity of the uveitis was determined by the treating ophthalmologist using the Standardisation of Uveitis Nomenclature (SUN) anterior chamber (AC) cell grade, AC flare and vitreous haze together with ocular co-morbidities and the number of systemic therapies in preceding years , 18. NinA Consultant Clinical Psychologist conducted a 30 min, audio-taped, semi-structured interview covering six principal domains and a general section with each participant. The six domains included: treatment received, ocular complications, impact on school activities, impact on out-of-school activities, social impact and emotional reactions. The general section comprised further open-ended questions to elicit items that either the children or their parents felt were indicative of the impact of the disease on the child’s life but had not been previously covered. Whenever possible, children and parents were interviewed separately with the interview schedules covering the same domains but with the wording of questions adapted to the appropriate developmental level.The audiotapes of the discussions were transcribed verbatim. Responses were analysed using inductive thematic analysis –21. FirsA total of 10 children / young people were included in this study. Three patients, at their request, were interviewed together with their parents. In the remaining seven cases, the patients and parents were interviewed separately. The results, therefore, represent the outcomes from 17 different interviews.Patient demographics and disease characteristics are shown in Table The study has identified multiple important themes across the six principal domains of “impact of treatment”, “complications”, “impact on school”, “impact outside of school”, “social factors” and “emotional reactions” Table .Table 2T“On some occasions it would take up to two hours to administer the injection because he would cry and scream and throw a general wobbly…he ended up developing a phobia of all things yellow because the sharps bins were yellow and methotrexate is yellow”.The indirect effects of receiving treatment, such as missing school for appointments and treatment were important to both children and young people. Additionally, anxiety about perceived lack of symptom improvement despite treatment was identified as a significant concern by one patient:“I can get agitated as I don’t really see it getting any better”.This lack of perceived improvement also exacerbated avoidance of treatments and caused difficulties between parents and children regarding adherence to treatment regimes. Patterns of non-adherence followed by “nagging” on the part of the parent were described. Unfortunately, adjustment to medication does not necessarily follow and some families indicated that the negative emotional reaction actually increased over time:“She has got more upset about having her injection than she used to be”.There were a number of themes identified in the “impact on school” domain. Upset at missing lessons and subsequent anxiety was a strong theme:“I usually miss out on the understanding of some of the lessons because I wasn’t there for it – it makes you feel worried because I don’t know what I am doing”.The pressure to catch up with missed schoolwork is an additional stress for these children, and parents are aware that progress can be patchy, often in relation to the child’s interests and motivation. There were also practical issues for those experiencing visual problems such as not being able to read the board in class, especially if placed at the rear of the classroom, or not being able to participate fully in Physical Education (PE):“I’m always the last one to get ready for PE and everyone else is waiting on the carpet for me. I feel embarrassed and lonely”.Even when adaptations are made by the school, they are not always successful, with young people commenting on laptop computers not being available at the beginning of each school year or examinations being printed on large sheets of paper that would not fit onto the desk. Furthermore, young people felt that teachers did not always remember the visual difficulties they had and they were reluctant to inform or remind teaching staff as they did not wish to appear different from their peers:“I don’t really tell the teachers about my medical stuff ........I don’t want to sit in another place to other people because that can be embarrassing”.There were fewer themes identified in the “impact outside of school” domain. The most commonly reported adaptations were sitting close to the television and holding hand held consoles or books close to the face. The zoom function on many IT tablets was reported as being very useful. Children and young people reported not being able to see the numbers on buses until they were quite close. Occasionally activities were dropped due to problems with eyesight which saddened young people.In the “impact of treatment” domain, the direct effects of therapeutic interventions such as painful injections, nausea and difficulties swallowing tablets were highlighted. These, in turn, led to both anticipatory nausea in some patients and avoidance behaviour in others, with negative emotional reactions to treatment being a frequently occurring theme:“I was bullied every day in Year 9 [age 13-14 years]...They found out I had had eye surgery and they called me ‘eye surgery gone wrong’. They said I was diseased or contagious and wouldn’t go near me”.In addition to peer rejection, self-exclusion from activities was also reported. In older teenagers, restrictions imposed by treatment also led to feelings of being left out, especially when medication contraindicated alcohol consumption.In the “social factors” domain, the impact of both the treatment and complications of uveitis ranged from not feeling included or being the last person selected for a team or activity, to being actively bullied:“…when I used to go to [hospital] for my cataracts and see the people in there and I was the youngest by at least half a century ...it gets a bit depressing”.Much of the anxiety and worry surrounded possible visual deterioration and the unpredictability of the disease. Fears about the future were apparent, especially in relation to possible careers. Those who had identified potential careers for themselves were particularly concerned about the impact that eyesight problems would have. Some children and young people were explicit about their fear of going blind:“I am scared I am going to go blind”.Many of the children and young people involved in the study expressed distress, anger and resentment of the condition. There were reports of being frustrated and angry about the restrictions and limitations imposed by the condition, feelings often associated with questions about why this had happened to them. In more extreme cases, children and young people reported feeling that life was not worth living.“I used to feel, well I still feel like ‘why me?’ and all that kind of stuff, because it can feel unfair”A range of almost universally negative emotional reactions both to the treatment and complications of uveitis were described. Reactions included anger, fear, embarrassment, isolation and low mood.Our study has identified multiple important themes across all 6 domains. As expected, within Domain 1, “impact of treatment”, the greatest number of themes for any single domain were identified. The themes most strongly represented were negative emotional reactions to treatment, missing school for treatment, side effects and treatment avoidance. Within Domain 2, “complications of uveitis and treatment”, the themes most frequently occurring were concerns regarding cataract removal and poor vision or visual blurring.Domain 3, “impact on school”, also highlighted several important themes, primarily difficulties reading information, upset at missing lessons, teachers forgetting about their condition, anxiety about catching up with missed work and upset at missing friends. It was also apparent that it is more difficult for children to spend free time catching up with subjects that they dislike, leading to additional resentment about missed school. Furthermore, for many children and young people, school is the main opportunity to socialise with their peers, and interruption of peer interaction was raised as an important concern, as was re-integrating into the peer group following periods of absence. The social importance of school was demonstrated in several strong themes coming from Domain 5, “social factors”, including bullying, being excluded and not being chosen as a team member. Such bullying can lead to school avoidance, potentially further impairing the academic achievements of a young person already regularly absent from school due to hospital appointments and illness.The “impact outside of school”, Domain 4, developed fewer themes, with the requirement of adaptations in order to participate in activities and the inability to see bus numbers with ease being identified.In view of the distress and difficulty apparent from the themes discussed above, it is unsurprising perhaps that Domain 6 “emotional reactions” produced some very strong themes, primarily distress and sadness about the illness, fear, anger and worry about deterioration, going blind and the future. This implies that although specific practical and social difficulties are problematic, the combination of these issues, compounded by the frightening nature of a vision-threatening condition, can result in a heavy emotional burden.. There are four QoL items enquiring about feelings regarding the use of medications, missing school for appointments, and “laboratory draws”. One question enquires about the presence of common uveitis symptoms, and there is an item that enquires about visual aids [The only current validated uveitis-specific QoL measure in children, the EYE-Q, comprises 19 items measuring near, far, colour and night vision, photosensitivity, and functionalityual aids . An earlual aids , 11, 22.Other tools, generic, vision and disease-specific, measuring QoL in children have good coverage of these important themes Table .Table 3CThe PedsQL, a validated measure of general HRQoL in children aged 2–18 years, covers 4 core scales: physical functioning, emotional functioning, social functioning and school functioning, with 5 questions in each , 4, 11.The Impact of Vision Impairment on Children (IVI_C) is a 24 question, psychometrically valid vision-specific QoL measure, for use in vision-impaired children aged 8 to 18 years who have no additional disabilities. It includes themes identified in Domains 3, 4, 5 and 6, with a heavy emphasis on the impact on school and social functioning. It has been shown to have construct, face and content validity, as well as internal consistency and good test re-test reliability . A seconA disease-specific tool, the Intermittent Exotropia Questionnaire (ITXQ), is a 3-part, patient-derived HRQoL questionnaire for children with intermittent exotropia (IXT) and their parents, comprising child, proxy and parent questionnaires with 12 questions in each part . It espeThis study has included patients of a variety of ages and with a range of uveitis disease severity. Patients were recruited through a joint Paediatric Rheumatology / Ophthalmology clinic at a tertiary referral hospital and those included had moderate or severe disease. The results may not, therefore, be representative of patients with mild, uncomplicated disease controlled with a single agent. One included patient had Blau syndrome with panuveitis, predominantly anterior uveitis. One of the patients with JIA-associated uveitis had panuveitis and another also had macular involvement Table . It is uThe study has identified themes within three domains  which are affected specifically by uveitis disease and treatment but are not covered by the EYE-Q. Questions which address these domains are included in other generic and ophthalmology disease-specific HRQoL tools for children Table . In the Clinical trials of treatments for JIA-associated uveitis are ongoing, including APTITUDE, a phase II trial of tocilizumab in anti-tumour necrosis factor (TNF) refractory patients  and studMultiple vision and disease-specific measures of HRQoL include questions on domains that this study has shown to be important factors influencing HRQoL in children with chronic anterior uveitis, such as “impact on school”, “social factors” and “emotional reactions”. This study suggests that the inclusion of these domains should be considered in future uveitis-specific tools examining HRQoL in children.


There is a growing body of research on resilience in family carers of people with dementia, but carers’ voices are noticeably absent from it. The aim of this study was to explore carers’ definitions of resilience and their opinions on the factors associated with resilience. Twenty-one in-depth interviews were conducted in Australia with people who were currently, or had previously been, caring for a family member with dementia. Transcripts were analysed thematically and three themes emerged: the presence of resilience, the path to resilience, and characteristics of the resilient carer. Although carers struggled to define resilience, the vast majority considered themselves resilient. Carers identified a range of traits, values, environments, resources, and behaviours associated with resilience, but there was no consensus on the relative importance or causal nature of these factors. Carers also considered resilience to be domain- and context-specific, but did not agree on whether resilience was a trait or a process. These findings highlight both the importance of including carers’ voices in resilience research and the limitations of the extant literature. There is much to be done to develop a field of carer resilience research that is theoretically sound, methodologically rigorous, and reflects the lived experience of carers. A model is provided to prompt future research.  More than 46 million people worldwide are currently living with dementia and the majority are cared for by a spouse, friend, or adult child . AlreadyResilience research began with studies of children who had experienced deprivation or trauma ,11,12,13The problems of definition and measurement also plague the literature on resilience in people caring for family members with dementia ,32,33,34Asking family carers of people with dementia about their own definitions, perceptions, and experiences of resilience might provide important insights into the process and experience of resilience in this population. As Luthar and colleagues  note “thThe aim of this study was to examine carers’ definitions of resilience and the factors they think contribute to their resilience during caregiving. As the research was exploratory, a descriptive qualitative approach was taken.Sixty-one Australian carers from a large, cross-sectional survey of carer health and wellbeing  gave conTo ensure the inclusion of a diverse range of participants and experiences, maximum variation sampling (MVS)  was usedAn interview protocol, including a semi-structured interview guide, was developed by SOD and WM, in consultation with a registered psychologist. To establish rapport, participants were asked to provide a brief overview of their caring experience at the beginning of the interview. The questions then focused on resilience, support, and thoughts of suicide and homicide. For the purpose of this study, the analysis focused only on responses to questions about resilience. The interviews were conducted individually, by telephone, and by a registered psychologist (TT). All interviews were digitally recorded and transcribed verbatim. The interviews ranged in length from 38 to 106 min.The study was conducted in accordance with the Declaration of Helsinki, the University Human Research Ethics Committee approved the study (reference number NRS/20/11/HREC), and all participants provided signed, informed consent. Due to the inclusion of questions on suicide and homicide, a number of risk assessment, risk response, and debriefing procedures were employed. A detailed description of these is available in . The thematic analysis followed the steps identified by Braun and Clarke : data fan = 16) were spousal carers and five lived in rural/remote areas. The 21 participants ranged in age from 37 to 89 years . Ten were caring at home, four had placed the person with dementia into long-term care, and seven were bereaved. The majority Well I suppose I am, yeah. I’ve come through [caring for my son] and I’m still going [caring for my husband].(Participant 9)I’d say so. We’ve had a great life doing all sorts of things, but we’ve had our tough times too. We’ve always bounced back.(Participant 10)I’ve grown out of this [caring experience].(Participant 13)It’s survival rather than resilience” (Participant 11). The other said: “I suppose if resilience consists of getting knocked down and keep on getting up, there might even be an element of stupidity in that” (Participant 2). For these carers, the development of resilience was not necessarily a positive experience, but rather one they would happily have forgone had the alternative been not ‘getting knocked down’. Despite initially saying they were resilient, two male carers went on to question the extent and value of their resilience. One said: “Some carers also said that there were, or would eventually be, limits to their resilience. For these carers, resilience was not ‘all or nothing’, but rather something that was mutable and dependent upon a range of personal, social, and environmental factors. Although these carers were demographically diverse, they shared high levels of insight into their own emotional processes and an appreciation of the unpredictable nature of both caring and life.I don’t think I’ll always be resilient. I think you can be rocked. [Resilience] can be destabilised by a number of things … Life’s good and I would call myself very resilient, but last year I was a mess again … So I think there are things that can destabilise you. I don’t take it for granted.(Participant 19)When I got home, all I did was lie on the couch. I kicked off my shoes and cried my eyes out for hours and hours … The next day I got horribly sick. I think my whole body crashed. I think I was sick for about three days … I think I kept my strength up when [my husband] was around, but when I put him in the facility everything just crashed on me.(Participant 18)There was considerable diversity in how carers thought they and/or others became resilient. Three carers, for example, said their resilience was innate. For these carers, resilience was an enduring personality trait that could not be acquired, but rather was present (or absent) from birth.I think I was born with it.(Participant 5)I think I’ve always had it.(Participant 18)Six carers said that although their resilience was innate, it was possible for others to learn to be resilient. Being ‘born resilient’, however, was clearly the more desirable option.I tend to be resilient by nature. [My friend who is also a carer] learnt to be. We’re both sides of that scale.(Participant 12)I suppose you could probably learn to be resilient. It would probably be a hard road to hoe … [It’s] more something you’re born with rather than something yeah, you know, I think you could learn to become resilient, but it would be a hard job, I think.(Participant 10)I think it’s something you could either be born with or it’s the way you were brought up … I believe you can [learn to be resilient] but I think it, to learn it, I think takes a while … I don’t think you could learn to become a resilient carer just by attending a lecture … I think you’ve got to have ‘hands on’ experience as well.(Participant 13)Eleven carers said that their resilience had been acquired, either through upbringing or during adulthood. For these carers, the development of resilience was an experiential, cumulative process and their comments reflected a sense of pride in having survived and thrived despite difficult circumstances.Well, you’re not born with it, it is something that you have to earn.(Participant 17)I think my resilience was built up by having no Mum and living with my Dad … I lost Mum when I was four and I learned the hard way.(Participant 3)I think it’s my own inner strength that I built up over the years and the knocks that we’ve had. That made me a stronger person.(Participant 4)Approximately half the carers also said that regardless of whether resilience was innate or acquired, it was a necessity. Faced with the relentless demands of dementia care, these carers felt that resilience was their only choice. For them, resilience was about accepting the situation as it was and being resolved to carry on. I think perhaps with dementia you have to become resilient or you won’t survive. You’ll either commit suicide or harm the person that you’re with or collapse in a heap.(Participant 6)I can’t just curl up in a ball … I can’t take to my bed or anything for a couple of days, because he needs looking after … So I suppose that’s why I’m resilient. Because I’ve got to look after him.(Participant 9)You’ve got to be. Yes, I’ve got to be. Maybe not naturally or normally, but no, I must be. I must be prepared to stand up.(Participant 11)Although a few carers identified luck as a part of becoming resilient, the circumstances they described were clearly the consequence of higher socioeconomic status. In particular, their social and financial circumstances ensured better access to the practical and emotional supports that facilitated their resilience.I was extremely lucky having the support I got. I really think that not many people have the support I had.(Participant 5)We were lucky that Mum and Dad were self-funded retirees, that we could afford to put [Mum] in the [aged care facility].(Participant 7)Similarly, four female carers—one the daughter of Greek migrants—said that they were just ‘the resilient one’ in their family or relationship. Their comments, however, clearly reflect the influence of gender and cultural norms on both experiences of caring and expectations about resilience.If anything happens the family ring me and I sort of straighten things out … Organise Dad’s funeral, organise everything … yeah, that’s me.(Participant 8)I’ve been caring all my life. I was the child of migrants and the youngest child. That was just my role.(Participant 15)Carers identified a range of traits, behaviours, and values they felt characterised a resilient carer, as well as a range of environmental factors and resources they felt were available to resilient carers. The traits included being proactive, achievement-oriented, determined, self-aware, self-reliant, fearless, patient, flexible, creative, and resourceful. The values included love, commitment, and care, while the environmental factors included practical and/or emotional support, access to respite care, and outlets or hobbies. The resources included information about dementia and support services, money, and good health, while the behaviours included acceptance, self-care, delegation, preparation, reciprocation, seeking information and support, developing routines and strategies, learning from others, expressing emotions, building skills, reflecting on experiences, persevering, moving forward without forgetting the bad times, walking away or letting go, and keeping things in perspective. Within these comments, however, the relative importance of the various characteristics was not clear, nor was there any consistency in whether carers viewed resilience as a necessary precursor to, or the positive consequence of, these characteristics. The comments did not align in any meaningful way with carers’ perspectives on their own resilience (acquired vs. innate) and there was no discernible pattern in the data regarding gender, stage of care, or relationship to the person with dementia. A lot of people don’t know help’s available. I didn’t at the time. I just didn’t know”—Participant 5; “I could, in a way, kind of cope with the fact that she was diminishing. As bad as that is, I could accept that. But getting people on board to help was incredibly difficult”—Participant 15), all cited at least one characteristic which they possessed that made them resilient, with 19 of the 21 citing characteristics they possessed across three or more of the categories .While a few carers said that a lack of these characteristics (particularly resources and a supportive environment) made their caring experience more challenging . This is a marked difference from Donellan et al.’s research , in whicIt is also interesting to note that when explaining why they considered themselves resilient, several carers in the current study mentioned growth, a feature of resilience that was not included in the definition we provided. There is considerable diversity in the literature regarding whether definitions of resilience should include growth or thriving as a necessary component, or whether a return to, or maintenance of, previous levels of functioning is sufficient. The current study suggests that for people caring for family members with dementia, growth may be an important marker of resilience. These carers also considered acceptance of difficult circumstances to be an important aspect of resilience. This aligns with O’Rourke et al.’s finding that considering change to be a normal part of life is central to resilience  and lendCarers in the current study also considered resilience to be both context and domain specific. For them, resilience in one situation was not a guarantee of resilience in another and resilience now was not a guarantee of resilience in the future. Although this is consistent with much of the literature on childhood resilience, it has not been reflected in the measurement, operationalization, or description of resilience in the literature on family carers of people with dementia, e.g., ,32,35,37Although the majority of carers considered themselves resilient, there was a lack of consensus in their views of resilience as a trait or process. Regardless of whether they thought resilience was a trait or a process, however, the majority of carers spoke in terms of skills and resources they had (or had acquired) prior to becoming carers. This suggests that when considering resilience in family carers of people with dementia, the context within which the adversity occurs is important . It alsoCarers also varied in the factors they thought were associated with resilience and whether they considered these factors to be causes or consequences of resilience. Although their responses support the notion that a broad range of biological, psychological, social, and environmental factors can facilitate or inhibit resilience in carers ,20,22,34Although this study provides an important insight into carers’ perceptions of resilience, it is not without limitations. Firstly, carers were not asked to define adversity. Their narratives do suggest, however, that care-related adversity can be acute and/or cumulative and varies according to the individual. To date, research on resilience in family carers of people with dementia has varied in how it has operationalized adversity, with some studies assuming that all dementia caring is an adverse experience, e.g., ,37, otheSecondly, in-depth qualitative methods do not allow for an exploration of the biological factors associated with resilience. Some compelling research has recently been conducted on cortisol levels in people caring for family members with dementia ,44 and iThirdly, this research was conducted with a small sample of Australian carers. Although MVS was used to increase diversity in the sample, the influence of demographic factors on perceptions and experiences of resilience could not be determined. The data did, however, hint at the importance of gender and socioeconomic status, as well as culture and ethnicity, and larger studies would help to explore the influence of these factors. Similarly, despite efforts to ensure a diverse sample, it is also possible that carers who were more resilient were more willing or able to participate in the research. Finally, this study focused specifically on people caring for family members with dementia. People caring for family members with physical disabilities, chronic illness, or mental illness might have different opinions and experiences of resilience . ResearcIn attempting to situate the current findings in the extant literature, it has become clear that there is much to be done to develop a field of research on resilience in family carers that is theoretically sound, methodologically rigorous, aligned with the broader resilience literature, and reflects the lived experience of carers. Although Windle and Bennett  have proResilience is an emerging topic in the literature on people caring for family members with dementia, but much remains to be understood. This research highlights the importance of including carers’ voices in resilience research. Although the majority of carers in this study considered themselves resilient, they varied in their views of the factors associated with resilience. A theoretical model of resilience that takes into account context, variations in adversity, and the cyclical nature of resilience may provide a useful framework for future carer resilience research.


For instance, premature ageing diseases (progeria) such as Hutchinson–Gilford syndrome were not associated with accelerated aging using this technique, although Werner syndrome might be an exception.4 Additionally, the ‘clock’ is more accurate in children and young adults, which is not the population under study here. Healthy controls had a mean age in Voisey’s study of 71 years, whereas the schizophrenia group had a mean of 52 years-old. An explicit limitation is that accuracy of DNAm for predicting age strongly depends on the sample’s standard deviation of age. Both McKinney’s and Voisey’s studies only provide SEM (not SD), although age range seems large enough. Horvath also suggests an accuracy measure be reported, defined as (median) error, that is, the median absolute difference between DNAm age and chronological age. This ‘error’ is considered a measure of how well calibrated the DNAm is. None of the studies (McKinney/Voisey) provided this information. Finally, the lack of statistically difference in the age acceleration residual between schizophrenia and healthy control groups (p = 0.08) in Voisey’s study could be also attributed to type 2 error due to the relatively small sample size (24 per group). It would have been helpful if the authors of these two studies had provided a power calculation, given the relatively small sample sizes. We think that these methodological considerations should be taken into account when discussing the papers, and undermine one’s confidence in the conclusions.Before offering an alternative interpretation, we would note that Horvath’s6 In order to accommodate the lack of difference in DNA methylation found are these two studies, an alternative explanation is that brain aging could be due to neural senescence. The potential of post-mitotic neurons to enter into the senescent state is increasingly recognized,8 including in schizophrenia.9 Senescent cells would express the aging phenotype, such as a smaller soma and dendritic loss, both of which are described in schizophrenia patients . Notably, Horvath’s clock is not accurate in senescent cells , suggesting that cellular aging is distinct from cellular senescence.More importantly, accelerated aging in the schizophrenia brain has been already reported.Taking all of the evidence together, it seems possible that people with schizophrenia may have both accelerated and cell senescence. The studies of McKinney et al. and Voisey et al. do not rule out either process.


Guangdong experienced the largest dengue epidemic in recent history. In 2014, the number of dengue cases was the highest in the previous 10 years and comprised more than 90% of all cases. In order to analyze heterogeneous transmission of dengue, a multivariate time series model decomposing dengue risk additively into endemic, autoregressive and spatiotemporal components was used to model dengue transmission. Moreover, random effects were introduced in the model to deal with heterogeneous dengue transmission and incidence levels and power law approach was embedded into the model to account for spatial interaction. There was little spatial variation in the autoregressive component. In contrast, for the endemic component, there was a pronounced heterogeneity between the Pearl River Delta area and the remaining districts. For the spatiotemporal component, there was considerable heterogeneity across districts with highest values in some western and eastern department. The results showed that the patterns driving dengue transmission were found by using clustering analysis. And endemic component contribution seems to be important in the Pearl River Delta area, where the incidence is high , while areas with relatively low incidence  are highly dependent on spatiotemporal spread and local autoregression. Dengue fever has spread rapidly within countries and across regions in the past few decades, resulting in an increased frequency of epidemics and severe dengue disease, hyperendemicity of multiple dengue virus serotypes in many tropical countries, and autochthonous transmission in Europe and the USA. Today, dengue is regarded as the most prevalent and rapidly spreading mosquito-borne viral disease among human beingsIn mainland China, the first outbreak of dengue occurred in Guangdong Province in 1978. Since then, dengue outbreaks have been recorded sequentially in Hainan, Guangxi, Fujian and Zhejiang provinces63111213179There was a great increase in the incidence of dengue fever in Guangdong Province in 2014. In 2014, the number of dengue fever cases in Guangdong reached a historically high level and exceeded the total number of cases over the previous 10 years. In this study, we perform an analysis of district-level time series of dengue transmission in Guangdong Province in 2014 using a multivariate time series model2022A total of 45,171 dengue cases were reported from 21 districts of Guangdong Province in 2014. The provincial capital, Guangzhou, has 37,394 cases , followed by Foshan (7.8%) and Zhongshan (1.5%) see . The incth curve .j to district i,In this paper, a multivariate time series model is applied to data on weekly counts of dengue in 21 districts of Guangdong in 2014. In this model, the degree of heterogeneity in real situations is quantified by estimating the random effect value. For model selection in time series models, the comparison of successive one-step-ahead predictions with the actually observed data is used , i.e. fitted value is in turn used as initial value for model update and for calculating all subsequent predictions. In order to capture the effects of significant seasonality, we consider models that differ depending on seasonality parameters . Meanwhile, to describe dengue spread in space, we consider two different models (first order neighborhood (Fo) model and power law (PL) model) accounting for spatial interaction between districts. The Fo model assumes that an epidemic can only arrive from directly adjacent districts, and that all districts have the same coefficient for importing cases form neighboring districts. The PL model is considered as a description of spatial interaction as motivated by human travel behavior can be well described by a decreasing power law of the distance or neighborhood order, which assumes the form d, the less important are higher-order neighbors. Moreover, wij against neighborhood order oij, it is obvious that the spatiotemporal component effects mainly account for nearest neighbors dependence.From the Note that the heterogeneity of the dengue incidence can thus be captured adequately according to random effect parameter In particular, for the endemic component in For each district, the relative contributions of endemic, autoregressive and spatiotemporal factors in driving the dengue prevalence with time is called the “patterns driving dengue transmission” in this district. An intuitive way of quantifying the relative contributions of the three components is provided by It is obvious that three cluster centers and four noises can be found in the decision graph, as shown in Jiangmen, Zhongshan, Guangzhou and Foshan belong to Pattern A (they are in the Pearl River Delta area), have been mainly affected by the endemic component and also have the highest overall number of cases. Especially in the early outbreak period, more than 70% of cases account for endemic component which implies that the socioeconomic, climate and environment might be major factors attribute to dengue outbreak in these districtsThe Fdp clustering method classifies districts independently of the geographic area taking into account only the patterns driving dengue transmission. The majority of cases are clustered in the Pearl River Delta area  and the incidence in these districts is relatively high . These districts belong to Pattern A and their incidence is clearly dominated by the endemic and autoregressive component, while districts that belong to Patterns B and C with relatively low incidence  are highly dependent on spatiotemporal spread and local autoregression.Our analysis of dengue case report data characterizes considerable heterogenous incidence levels and transmission across districts in the dengue outbreak in Guangdong Province in 2014. The degree of heterogeneity is quantified through random effect parameter estimates; moreover, by using the Fdp clustering method, we explore the characterization of patterns driving dengue transmission, which might be useful for improving our understanding of heterogeneous dengue transmission.To analyze the spatial and temporal occurrence of dengue and its association with the heterogeneity of environmental characteristics, we fit a multivariate time series model of dengue virus transmission to spatial time series data from Guangdong and compare maximum-likelihood random effect estimates to account for unobserved heterogeneity. To assess the potential for dengue spread in space, both models, the first-order neighbor model and the power law model, accounting for spatial interaction between districts, have been incorporated in the multivariate time series model. We find that the power law model accounting for spatial interaction between districts substantially improves model fit and predictions. We further note that in the best-fitted model D3, there is a strong decay of spatial interaction for higher-order neighbors, which indicates that the spatiotemporal component effects mainly account for nearest neighbor dependence. But this may be limited by the small number of districts in Guangdong: A second-order neighboring district would include all. A better way of accounting for spatial interaction effects would thus be to explicitly incorporate movement network data2527In this study, we show that the estimated random effect parameters were able to capture the influence of heterogeneity at district level. In particular, there is significant endemic and spatiotemporal variation across districts, while no clear autoregressive heterogeneity is found. Another encouraging finding is the relative importance of the three components in each district and three patterns driving dengue transmission in Guangdong. The Pearl River Delta area in pattern C is highly exhibit a relatively high endemic incidence, which means that a great amount of cases is explained by external factors, such as seasonality/climate, socioeconomic and environment. It seems that the spread of dengue in Pearl River Delta area is more of an endemic than epidemic natureTo conclude, this paper underlines the varying transmission of dengue across districts and characteristics of three patterns driving dengue transmission by combing multivariate time series model and clustering method. However, when analyzing spatially stratified time series the assumption of equal transmission rates or incidence levels across all districts is question. For example, dengue transmission might be influenced by factors such as vaccination status in individuals, vector, or environmental factors, Such factors could be incorporated into the multivariate time series model as covariates if they are observable and available. Therefore, it would be necessary to further enrich the model by entering external processes such as mosquito density as covariates in the endemic and epidemic components, and a better way of accounting for spatial interaction would thus be to explicitly incorporate human mobility data.Km2, with Guangzhou city as the provincial capital; it is one of the most densely urbanized regions in the world and one of the main hubs of China’s economic growth, and it comprises 21 districts . The data were aggregated to weekly counts. In China, all cases of dengue were diagnosed according to the unified diagnostic criteria issued by the Chinese Ministry of Health. Population data for every district in Guangdong in 2014 were retrieved from the Guangdong Statistical YearbookYi,t denote the number of cases of a specific disease in region i = 1, …, I at time t = 1, …, T. The counts are assumed to be negatively binomially distributed with conditional meanThe multivariate time series model established by Held and Paul20Ψ is an overdispersion parameter such that the conditional variance of Yi,t is uit(1 + Ψuit). eivit is the endemic component and parametrically models seasonal variation and trends. The other two components are observation-driven epidemic components: An autoregressive component λiYi,t−1 on the number of cases at the previous time point, and a spatiotemporal component vit, ϕi is a log-linear predictor of the formwhere v), biϕ) assumes that an epidemic can only arrive from directly adjacent districts The first-order neighborhood model (ϕ by ei is the population fraction and Fo + pop.)To reflect commuter-driven spread in our model, we scale the district’s susceptibility according to its population fraction by multiplying PL) is suggested, which assumes the form wji = ojid−, for j ≠ i and wjj = 0, where oji is the order of neighborhood, the decay parameter d is to be estimatedTo account for long-range case transmission, a power law model (ϕ by ei is the population fraction and βpop is to be estimated (PL + pop.).Based on the power law model used to measure neighborhood weights, we scale the district’s susceptibility according to its population fraction by multiplying The weights The estimation of parameters involves integration of the likelihood with respect to the random effects which cannot be obtained analytically. Paul and Heldendi,t, ari,t and nei,t denote endemic, autoregressive and spatiotemporal components accounting for the proportion of number of cases in district i = 1, …, I at time t = 1, …, T respectively, i.e. endi,t = eivit/Yi,t, ari,t = λiYi,t−1/Yi,t and i from t = s to t = e can be denoted as Based on the multivariate time series model, for each district, endemic, autoregressive and spatiotemporal components are different over time. For each district, the relative contributions of endemic, autoregressive and spatiotemporal factors in driving the dengue prevalence with time are called the “pattern driving dengue transmission”. Let First, we define the distance between two patterns driving dengue transmission by using the Euclidean distanceet al.ρi of data point i is defined asThen, we revise the Fdp clustering method proposed by Alex Rodriguez d represents the distance between data point i and j, and Nej(i) represents the jth-nearest neighbor of data point i. In this paper, let k = 3.where δi of data point i is measured by computing the minimum distance between the data point i and any other data point with higher densityThe distance δi is much larger than the typical nearest neighbor distance only for points that are local or global maxima in the density. Thus, cluster centers are recognized as points for which the value of δi is anomalously large. After the cluster centers have been found, each remaining point is assigned to the same cluster as its nearest neighbor of higher density. Some points have a relatively high δ and a low ρ because they are isolated; they can be considered clusters composed of a single point, namely noise.If the data point is with the highest density, we conventionally take How to cite this article: Cheng, Q. et al. Analysis of heterogeneous dengue transmission in Guangdong in 2014 with multivariate time series model. Sci. Rep.6, 33755; doi: 10.1038/srep33755 (2016).