There is a pressing need for health promotion programs focused on increasing healthy eating and active living among “unreached” rural-based men. The purpose of the current study was to describe rural-based working men’s views about health to distil acceptable workplace approaches to promoting men’s healthy lifestyles. Two focus group interviews included 21 men who worked and lived in northern British Columbia, Canada. Interviews were approximately 2 hours in duration; data were analyzed using thematic analysis. Themes inductively derived included (a) food as quick filling fuels, (b) work strength and recreational exercise, and (c) (re)working masculine health norms. Participants positioned foods as quick filling fuels both at work and home as reflecting time constraints and the need to bolster energy levels. In the theme work strength and recreational exercise, men highlighted the physical labor demands pointing to the need to be resilient in overcoming the subarctic climate and/or work fatigue in order to fit in exercise. In the context of workplace health promotion programs for men, participants advised how clear messaging and linkages between health and work performance and productivity and cultivating friendly competition among male employees were central to reworking, as well as working, with established masculine health norms. Overall, the study findings indicate that the workplace can be an important means to reaching men in rural communities and promoting healthy eating and active living. That said, the development of workplace programs should be guided by strength-based masculine virtues and values that proactively embrace work and family life. Engaging in healthy lifestyle behaviors including healthy eating and physical activity has been directly linked to reduced risk of developing chronic illnesses and cancer ; howeverIneffectual efforts to engage men in physical activity and healthy eating programs have been linked to failures to integrate gender into the design and implementation of health promotion initiatives . The infPrince George is located in the north of British Columbia, and with a population of 71,974 , it is, What constitutes “rural” is widely contested in geography and Prince George, as a conventionally defined city with a rural character, is illustrative of the instability of a binary distinction between urban and rural, or of any singular rural type . As suchM = 46; SD = 11.5) and worked in a variety of jobs and industries connected to Prince George’s resource sectors . The majority of participants (85%) were overweight to obese. Data regarding the men’s dietary options and opportunities to engage in physical activity at work were also collected along with self-reported body mass index details  who lived and worked in northern British Columbia were recruited using printed posters, online media , and targeted telephone calls to potential participants. The advertisements invited men to take part in focus group interviews to share their perspectives about healthy eating and active lifestyles in the context of workplace health promotion. A total of 41 men contacted the project coordinator, and further details about the study, including how the information shared would be used to inform the design of workplace health promotion programs for men, were provided to potential participants. Two focus group interviews were conducted with a total of 21 participants. The men ranged in age from 23 to 73 years  asking open-ended questions including “How does living and working in the north influence the way men take care of their health?” and “What kinds of things do northern men do or like to do that help them stay healthy?” One facilitator took a lead in easing the conversations, while two others asked probing questions and assisted with the small breakout group discussions. The interviews were digitally recorded and a fourth team member (KM) kept a speakers log to connect participant’s quotes in the transcribed record of the interviews. The small group breakout sessions were also facilitated, digitally recorded, and transcribed with researcher observations added into the transcripts. The breakout groups were included to ensure participants were active in the process, and to discuss the use of the pedometers given to the men at the beginning of the session, which they later checked to look at how many steps they had accumulated as a means to discussing the potential for pedometers to motivate men’s physical activity. Men’s health promotion sample materials were posted on the focus group meeting room walls, and in pairs or groups of three, men circulated stopping at each poster to discuss the key messages and evaluate the appeal from their perspective. In addition, participants provided advice to guide the design and implementation of men’s workplace health promotion programs in male-dominated worksites. Observing the focus group and small group breakout sessions revealed the men as quick to engage one another in voicing their opinions, and the permission of participants to discuss health-related issues and potential remedies was central to promoting the men’s dialogue. All participants provided written informed consent and received a $50 honorarium to acknowledge their contribution to the study and offset travel costs.The focus group sessions were transcribed verbatim and checked for accuracy. Potentially identifying information  was removed to aid anonymity. Participants were also assigned an identification number in the speaker’s log which in turn was linked to participant’s quotes in the transcribed record. The interview data were read independently by the team members and through discussion a coding schedule was developed. Codes included masculinity, northern influences, and man messaging, to which data segments were allocated using NVivo 10 . Each of the codes and the corresponding data were subsequently reviewed by the authors to inductively derive understandings and preliminary themes, within and across the data. Three themes were developed: (a) food as quick filling fuels, (b) work strength and recreational exercise, and (c) (re)working masculine health norms. These themes are discussed and summarized in the results section, and the findings are theorized using masculinities  and placThe men positioned their ability to take up a healthy lifestyle in the context of living and working in northern British Columbian communities. As such, their commentaries were punctuated with references to the influence of the subarctic climate, the long distances between communities and work and home, and the uninhabited wilderness that could be isolating amid providing unique recreational opportunities. In addition, work, family life, and “breadwinner” responsibilities featured in the men’s conversations. Participants prided themselves on their ability to work in, and overcome harsh conditions, and awareness of healthy eating and active living were entwined with workplace and family responsibilities.You get into that lifestyle, the quick food, because you haven’t got the time when you’re knocking off 100 miles away from home. You’re looking to try and maximize as much time as you can with your family so a lot of times it’s the quickest thing you can do, and it’s not always the healthiest.For the most part, from the researcher’s perspectives, participants were aware of what might constitute a healthy diet. However, men’s appetite and challenges around time management converged with locale specific food supply and access issues to influence participants’ positioning of food as quick, filling fuels. Within this context, paid work was central and food was a means to an end in garnering the energy for “getting the job done.” For example, men working in transport and resource extraction industries detailed their demanding schedules, highlighting the isolation of working far from home for extended periods of time. Within these spaces, the food choices were limited to what was easily accessible. Participants emphasized how quick food enabled them to keep working and balance the demands of family life. A 47-year-old highway truck driver explained:Evident here was how the demands of working remotely could extend to involve a significant commute, which in turn reduced men’s time with family. In addition, many men explained that because of their work schedules, family time was rarely organized around cooking and/or sharing a home cooked family meal together. Instead, many participants also resorted to quick and easy food options at home. The work and domestic spheres merged somewhat in this respect, wherein many men were chronically time poor, juggling the priority and demands of work with family life in ways that routinely resulted in taking up quick food options. Embedded in these quick food practices were northern norms, as a 43-year-old truck driver said, “The way my friends eat is kind of the way we eat.”You can eat healthy, the fruit and vegetables, but in 2 hours you’re hungry. You can’t just stop work and eat whenever right? And that’s the problem. You have 15 minutes to eat. A guy wants to eat, he wants food. You want to eat something that’s gonna work, right? A couple carrots and some lemons and stuff like that—in 15 minutes, in a half hour you’re hungry again and that’s the thing. It’s healthier, but you gotta eat more consistently and more times during the day in order to actually benefit from it, right. And that’s a big hurdle. I think that’s a hurdle for more guys.Also, central to the use of quick foods was their filling capacity. In contrasting and rationalizing the need for bulk and energy sources, participants pointed to the shortcomings of healthy options for quelling their appetite in sustained ways. As a 45-year-old welder explained:The problem up north here is we’ve got such great distances between centers, small population, everybody’s after the quick dollar. Nobody, unfortunately, due to economics and circumstances, nobody keeps stock anymore. So, everything moves day to day. But, all that stuff moves usually at night. Well, nothing’s open. So again, the drivers, a lot of them don’t have options. There’s nothing there.This man’s quote revealed issues around the workday affording him limited time to eat, perceptions round the inability to feel sated when consuming fruits and vegetables and his need to fill up quickly and continue to work. Similar challenges around scheduling meal breaks were shared by a 46-year-old engineering technician who explained, “It was hard for me to eat steady because I was getting my hands dirty so I had to eat at certain times.” Though some participants, including the truck drivers, could carry food supplies with them and had the opportunity to “graze” the remoteness and transient nature of their work revealed how the lack of infrastructure could reduce their access to healthy meal and food options. As a 47-year-old truck driver stated:I don’t think the north is conducive to eating better. . . . People eat moose, pig, beef, and whatever, but there’s a lot of things on the other side that we’re maybe not getting enough of. . . . In the winter time, it’s mashed potatoes and meat, and vegetables are really not available.Countering a reliance on vendors, a few participants asserted that hunting and fishing in the north could adequately provide fresh and healthy food options. As a 52-year-old saw filer explained, “You go and you kill something and you eat it. That’s kind of the way we’re living [here].” While catching wild game and fish was espoused as promoting healthy eating, some participants recognized the limitations, including one 73-year-old sales and security associate who countered:Complicating matters, hunting and fishing require men having the resources, skill, and time to pursue these activities. Revealed here were diverse alignments to northern masculine ideals wherein participants could embrace or distance themselves from the benefits of northern foods and/or the utility of men’s resourcefulness in securing those types of food options.They don’t take into account a guy that works physically all day and he gains mass from it. If I was 120 pounds, there’s no way I could fling steel around.Participants, especially those working physically demanding jobs contrasted the strength required to labor, as well as the physical conditioning drawn from that work, with recreational and/or family-related exercise. A 47-year-old truck driver suggested that in his workday, “You’re going to get a workout whether you like it or not.” He explained that he regularly moved a “3000 or 4000 lb converter around by hand” in asserting that because he “worked hard” having to exercise “on top of that” was neither feasible nor necessary. Evident in this man’s interview, and other like-minded participants, was a recursive relationship wherein the strength to labor, and strength and conditioning derived from that physical work, diminished the need for recreational or incidental physical activity. The focus of most participants was also on physical strength rather than aerobic capacity and exercise fitness. A 45-year-old welder/mechanic countered the traditional conventions by which fitness was evaluated:Herein body mass and particular body types were understood as central to the physicality required to do specific work, and these embodied ideals were differentiated and distanced from lean bodies and/or aerobic capacity. The men’s work also resulted in some fatigue, as a 42-year-old firefighter suggested, “You get home, put your feet up and have a bag of chips.”I’m not big “on going to the gym guy.” I like to be outdoors. But when the [winter] weather is the shits for 2 to 3 weeks at a time, I just kind of huddle up indoors.Indeed, outside of the direct context of paid work a range of locale specific factors emerged as barriers and facilitators for participants engaging in meaningful physical activity. For example, while living in the north was synonymous with the outdoors, the cold harsh winters could deter efforts to be physically active. As a 44-year-old firefighter explained:Coupled with climate challenges, some men explained that they put their children’s physical activities and sports commitments ahead of their own exercise. The time and costs associated with supporting these family activities in turn was put forth as eroding the capacity for some participants to have their own recreational exercise regimen.Three winters ago as a family we came here because we were all energetic and like the recreational stuff outside. There are two seasons [in Prince George], summer life and winter life. I think it’s easy to fulfill, being active outside [in summer], but winter becomes a bit more of a challenge. So, we bought five sets of snowshoes three Christmas’ ago . . . and we have a recreational cabin. We take them up there, snowshoe up there when the conditions are right.Overshadowing the barriers were participant commentaries suggesting the climate challenges were exaggerated. Offered instead, were assertions that the region had unique opportunities to be active and taking advantage of that was reliant on people “being flexible” and having the “right attitude.” As a 46-year-old engineering technician explained, “I’m trying to make the most of it and I see there’s a lot more here than I give credit for.” Similarly, a 53-year-old technician affirmed the north as affording him and his family a wide range of exercise-related experiences:You need your family. You can be tired and they say, “Come on dad, let’s go.” Let’s go for a walk, let’s go to the gym. That kind of helps, that kind of motivates you.Contrasts between the north and urban centers were also made in pointing to the cheaper golfing and gym membership options in Prince George. These narratives collectively defended and focused on what Prince George and life in northern communities had to offer, amid pointing to the resilience and innovation to fully muster those opportunities. Similarly, counter claims were made by many men, about the centrality of family for being active. A 53-year-old technician explained that his wife valued regular physical activity and would “kick [him] off the couch and say ‘hey, let’s go’” if he had not been to the gym in several days, while a 47-year-old sheriff pointed to the positive influence of his children:Men also highlighted the value of being a good role model in being healthy and able to “keep up” with their children. A 47-year-old truck driver boasted, “I told my girls I want to be the 80-year-old that is ripped in the gym and jogging 10 kilometers.” Traded on here, were long-standing masculine norms where men do self-health for others—most often, family.Overall, most participants revealed their appreciation for all that the north had to offer in terms of physical activity options while conceding that it took some effort to consistently engage with recreational physical activity. The triage of work strength, above recreational physical activity was also ever present in the men’s accounts, wherein work demanded and got much of the participant’s energy.If they [men] don’t want to do it, they’re not going to do it. Doesn’t matter what you throw at them, if they can’t see it’s for their benefit and they can’t see that it is going to make their life better, they’re not going to want to do it. It’s not until you can get them to want to do it, you might as well bang your head on the wall.Most men understood that being healthy would aid their ability to secure and sustain paid work, and within this context healthy eating and physical activity were seen as key to being fit to work. Participants also agreed, at least in principle, that the workplace was a viable environment for advancing men’s health. However, the men were clear that the ways in which workplace health programs were presented were critically important to men’s willingness to engage such initiatives. First and foremost, the foundation for success resided in convincing men that there were benefits to participating, as a 43-year-old truck driver warned:different foods:You know I go to work with my lunch and the hardest part for me of trying to eat the way I think is healthy, it’s other guys’ attitudes. I get ridiculed. They say “what the hell are you eating?” that kind of thing.This assertion drew strong agreement from fellow focus group participants, and collectively expressed was the need for program designers to understand that men would critically judge the usefulness and relevance of workplace health initiatives in deciding their involvement. Embedded also was the participants’ familiarity with masculine cultures characterized by men’s autonomy and decisiveness. Related to this, participants explained that one of the biggest challenges involved changing specific masculine norms within male-dominated workplaces. For example, healthy eating within the workplace, where filling and fuel food choices were normed, risked significant ridicule from male peers. A 61-year-old pulp mill worker explained how straying outside the workplace cafeteria meat and potato option and eating salad and chicken drew the following from his male coworkers, “What the hell are you eating? That’s not good for you.” Similarly, a 52-year-old saw filer lamented the policing that occurred around him bringing his lunch and eating Herein dominant ideals about men eating “manly” foods were reaffirmed, and eating healthy was “othered” as unmanly or worse still, feminine . In this context, the risks associated with transgressing work cultures might outweigh the potential benefits of eating healthy, a tension also threatening the overall feasibility of men’s workplace health promotion programs.Jokingly, we start teasing each other about how much coffee we were drinking and okay let’s replace it with a bottle of water a night. Fruit, well how much fruit did you eat today? How many veggies did you eat today?In terms of breaking with such restrictive masculine norms, participants offered a range of important strategies. For example, the ridiculing cultures referred to in the aforementioned examples were also understood and explained by some participants as a form of camaraderie, and with the right “friendly competition” health promotion programs, these dynamics could be capitalized on to support men to make healthy choices. A 47-year-old truck driver related a story about healthy food choices in this regard:proof could shift norms, “If someone is eating healthy then you tend to eat what they’re eating.” Senior management were also understood as potent change agents, as a 46-year-old engineering technician explained:A couple of guys were talking, and . . . they said, “Well why don’t we get like sandwiches or veggies.” That’s what I’m actually going to mention to the boss next time because . . . that’s one of my jobs is to find out what the guys want and to mention it whether it’s a coffee maker or healthy food options. So it’s kind of interesting that guys are interested in healthy food.These friendly challenges imbued with humor provided opportunities for some men to compare their performance and outcomes, as a 41-year-old corrections officer suggested, “So-and-so does something, we all hear about it and then from there it’s all one-upmanship.” Similarly, the influence of the group’s actions was understood as strong drivers for changing and challenging norms around exercise. A 34-year-old warehouse and courier manager suggested, “When everyone else is going out you can’t be the only one that’s sitting.” These poignant examples revealed how some masculine norms were reworked to promote rather than restrict healthy eating and physical activity in the workplace. Indeed, an individual or small group of men within the workplace could champion such change. For example, observing weight loss in men eating healthy was cited as a strong motivator, and the 73-year-old sales and security associate explained how this It needs to be simple, so men will understand it. And they need to know quantitatively what is healthy. You know protein, so how much a day, what is a protein, what is a serving of protein. . . . Show what a serving size is [so] you don’t have to wonder, you don’t have to worry about calories. It’s just a fistful, one baseball. That’s geared to men.Participants warned that workplace program content and its marketing messages needed to be “simple” with “hard stats,” visual information  and provide “tangible” ways of monitoring progress. A 46-year-old engineering technician explained:You start eating this kind of food, this is what’s going to happen, you’re going to add this to your life. You’re going to add momentum and strength and you’re going to be able to work longer you’re going to be able to decrease your injuries and so on.This participant, along with many others confirmed the need to focus on what was eaten in enabling men to choose and monitor their intake, as distinct from a focus on dieting which was implicit to excluding some foods and counting calories. There was also strong support for positively framing messages to promote healthy eating. A 42-year-old firefighter argued that cause–effect relationships explicitly linking health to benefits round work performance and productivity drove men toward certain foodsI think the employers need to be educated that the healthier . . . [we are] at work, the more beneficial we are to them in the long run. Exercise and stuff . . . if they’re going to expand on helping guys with gym dues or whatever, you know, even partial, it will make a huge difference.In summary, working and reworking some masculine health norms were central to participants’ advice for engaging men in workplace health promotion programs. In terms of convincing employees, many participants argued that employers should incentivize men’s participation in and beyond workplace health promotion programs. As a 45-year-old welder/mechanic pointed out, supporting men to take up recreational exercise was also key to having healthy employees:The current study findings provide important contexts for thoughtfully considering and perhaps reconsidering some of what is claimed as predominant male health practices round diet and physical activity. Food and men’s health research, for example, has highlighted how dominant masculine discourses can direct men’s food choices , the infIn the context of physical activity, affirmed are place specific findings from The potential benefits of men’s workplace health promotion programs, especially in male dominated work environments are encouraging. For example, men’s mental health can improve with programs focused on physical health, and this is vitally important given the rise in workers compensation payouts related to mental illness . That saIn terms of limitations, the current study is reliant on a small participant cohort and the findings are contextually tied to specific locales and workplaces. In this regard, the narrow focus limits what might be claimed to likely prevail in other locations. The cross-sectional nature of the study design also limits what can be said about potential changes across time. These limitations however provide some direction for future research which might usefully include larger longitudinal and mixed methods studies to distil with greater certainty the similarities and differences for men’s health practices in rural locales.In conclusion, the findings from the current study confirm the need for gender sensitive men’s workplace health promotion programs that are attuned to place specific rural cultures and norms. This was especially evident in how men’s health practices responded to and reflected Prince George ideals as well as specific workplace and gender norms. In turn, the effectiveness of potential remedies is deeply reliant on knowing, engaging, and working with, as well as reworking some masculine ideals about how men engage in healthy lifestyles in specific locales. In this regard, the participant’s engagement, curiosity, and willingness to tackle questions and ideas within the focus groups provided important insights about useful strategies for engaging and supporting men.


A unique topographical representation of space is found in the concerted activity of grid cells in the rodent medial entorhinal cortex. Many among the principal cells in this region exhibit a hexagonal firing pattern, in which each cell expresses its own set of place fields  at the vertices of a triangular grid, the spacing and orientation of which are typically shared with neighboring cells. Grid spacing, in particular, has been found to increase along the dorso‐ventral axis of the entorhinal cortex but in discrete steps, that is, with a modular structure. In this study, we show that such a modular activity may result from the self‐organization of interacting units, which individually would not show discrete but rather continuously varying grid spacing. Within our “adaptation” network model, the effect of a continuously varying time constant, which determines grid spacing in the isolated cell model, is modulated by recurrent collateral connections, which tend to produce a few subnetworks, akin to magnetic domains, each with its own grid spacing. In agreement with experimental evidence, the modular structure is tightly defined by grid spacing, but also involves grid orientation and distortion, due to interactions across modules. Thus, our study sheds light onto a possible mechanism, other than simply assuming separate networks a priori, underlying the formation of modular grid representations. The spatial cognitive map theory outlines such a flexible representation Tolman, , in whicDo these parallel representations occur at any possible scale? By systematic analysis of multiple unit recordings in single animals, grid cell activity was found to be organized in discrete modules, with only four to five spatial scales observed in each animal . The parameter b1, which in the model sets the timescale of the adaptation process, controls the grid spacing developed by the units , individual fields are also larger and the drift effect lasts longer. To compensate this (assuming it makes sense for the different modules to reach stability at about the same time), as the grid spacing increases, the head‐directional modulation should be less tuned. This weaker modulation at large grid spacing has an impact on the variability observed in the geometrical properties of the pattern, which generally display a looser overall alignment. This variability, both in grid spacing and in alignment, is also observed in experimental studies  would imply the emergence of a specific value of grid spacing. Given a population of NmEC units, labeled by i , to avoid boundary effects, we find it convenient to take the index i to run along the axis twice from the ventral to the dorsal and back to the ventral end  should be linearly related to the distance Δ from the dorsal end of mEC . Since one can characterize the relationship between the grid spacing, λ, and the parameter b1 as, roughly,b1 for individual units in the heterogeneous population asc0 and c1 and B1  one recovers the desired linear relation between Δ and λ. In particular, we set B1 from Figure t−1] (in inverse arbitrary time units). Concomitantly, inspired by  = 1.0 (sharply tuned head direction selectivity) and ν  = 0.2 (slightly tuned), and e0 and e1 to obtain ρ  = 0.2 , and ρ  = 0.4 (stronger influence).Parameters i − j| = 1  … , Nlat), and are sparse, (3) To avoid boundary effects at dorsal/ventral ends, they are joined together, but via the ring network mentioned above; in practice, this creates a mirror image of the dorso‐ventral axis, with the properties defined above selected according to the dorso‐ventral position along either half of the ring, see Figure In addition to endowing units with these variable properties along the model ventro‐dorsal axis, other aspects of the model are: (1) To reduce confounding effects, inputs from all place cells are taken to reach each conjunctive unit, so any scale variation in place fields and topography in CA1‐to‐mEC connections is disregarded, 2) Collateral interactions are localized to the neighborhood of each unit , but with an increasing number of units in the conjunctive grid layer, NmEC, we tested different gradients. In particular, in an all‐to‐all (but sparse) connectivity pattern, we did not observe the emergence of modules, although a mild effect of aggregation between close units was observed, interleaved with the natural development of the intrinsic grid spacing, given by the individual values of b1 (not shown). As expected, this aggregation process was strengthened as NmEC increases. The first signs of clear modularity were observed for NmEC = 600, the results reported hereafter.“Gradient smoothness” is controlled by the ratio 3b1, from the ventral to the dorsal and back to the ventral end. When units are relabeled progressively according to their dorso‐ventral position, the same trend is conserved but a step‐like behavior is revealed, with a small number of steps (left bottom panel). This is clearly shown by the multi‐peaked distribution of grid distances (right panel), which is different from the gradual distribution designed before adding interactions. We can also observe that between the steps (left panel), there are gaps along the horizontal dimension. These results from units that do not pass the criteria for further analysis and are therefore not shown, because they do not express a clear spacing. This effect is reduced by lowering the threshold on grid score. Overall, this means that units relax grid quality between clearly delimited modules . As the procedure does not produce a unique deterministic outcome, we run the analysis 300 times and evaluated the performance of each repetition by means of the population‐based mean of the so‐called silhouette coefficient Cs, see  than a simple linear one. This is reminiscent of the progression of values, geometric on average, observed experimentally, with mean coefficient just above 1.4 (Stensola et al., As to the logarithmic form of the variation of the time constant, it is at odds with the early observation of characteristic resonance timescales (Giocomo, Zilli, Fransén, & Hasselmo, Pilly and Grossberg  have proFinally, one may wonder about the origin of the total number of modules observed in each animal. In this respect, it seems premature to attempt to establish firm relationships with observations in rodents, for at least two reasons. First, both modularity and gridness appear to be elusive and increasingly ill‐defined notions as one approaches the ventral end of entorhinal cortex, suggesting caution in extending there an idealized conceptual model that only really applies to the units with shorter spacing at the other end. Second, observations and considerations arising particularly in the case of bats (Geva‐Sagiv, Las, Yovel, & Ulanovsky, Alessandro Treveshttp://orcid.org/0000-0001-7246-5673


Food marketing environments of Black American consumers are heavily affected by ethnically-targeted marketing of sugar sweetened beverages, fast foods, and other products that may contribute to caloric overconsumption. This qualitative study assessed Black consumers’ responses to targeted marketing. Black adults  and youth  from two U.S. communities participated before and after a sensitization procedure—a critical practice used to understand social justice concerns. Pre-sensitization focus groups elicited responses to scenarios about various targeted marketing tactics. Participants were then given an informational booklet about targeted marketing to Black Americans, and all returned for the second (post-sensitization) focus group one week later. Conventional qualitative content analysis of transcripts identified several salient themes: seeing the marketer’s perspective , respect for community , and food environments as a social justice issue . Effects of sensitization were reflected in participants’ stated reactions to the information in the booklet, and also in the relative occurrence of marketer-oriented themes and social justice-oriented themes, respectively, less and more after sensitization. The most recent dietary recommendations report from public health experts in the United States focused on influences arising from food environments, including marketing influences, such as promotion, pricing, and placement of products . This isFood marketing environments of Black American consumers are heavily affected by ethnically-targeted marketing of sugar sweetened beverages, fast foods and other products that may contribute to caloric overconsumption ,8. MarkeHow to counter targeted marketing of unhealthy foods to Black communities or other ethnic minority populations is far from straightforward . EffectiA study conducted by the Rudd Center indicated that this approach might be effective when parents are made aware of targeted marketing to their children . HoweverBlack adults and youth were recruited in Durham, North Carolina, and Prince George’s (PG) County, Maryland, in partnership with a local community-based organization at each location. These areas were chosen because of their involvement in a larger multi-site research project of the African American Collaborative Obesity Research Network (AACORN), and to take advantage of infrastructure developed during prior collaborations. The multi-site nature of the project was intended to allow for more demographic diversity among participants than would have occurred if focus groups were only conducted in one area. PG and Durham Counties are located in the mid-Atlantic and Southeastern United States, respectively, and have different sociodemographic profiles . Durham Staff at the collaborating community centers, where the focus groups were to be held, advertised the focus groups to their clients, and in the surrounding communities through flyers and word of mouth. Eligible participants were invited to discuss food and beverage marketing in their communities, and were told participation required attendance at one 60–75 min and one 30–45 min focus group, separated by about one week. Youth (ages 16–18) and adults (ages 19 and older) were recruited for separate groups, to allow for the possibility that youth and adults might have different marketing exposures, view food marketing issues differently, or respond differently in the presence of adults. Descriptive data were collected with anonymous questionnaires.Each site conducted four sets of focus groups . Focus groups are designed to elicit responses and thoughts on a topic, while allowing for deeper discussion and interaction among respondents , which fDuring the “pre-sensitization” focus group, participants were presented with scenarios focused on examples of marketing tactics that target Black Americans with high-calorie, low-nutrition foods through pricing, place (availability), products, and promotion . The general technique of posing scenarios that allow presentation and manipulation of various issues is common in marketing research. The concept for the scenarios was based on a study by Smith and Cooper-Martin , in whicResults of pilot focus groups with adults and youth in Philadelphia indicated that a “consciousness raising” approach could be informative . In the The post-sensitization focus group occurred about one week after receiving the booklet. The goal was to understand participants’ reactions to the information in the booklet, re-assess their perceptions about food and beverage marketing tactics discussed in the initial focus group, and determine whether sensitization had changed their perceptions relative to their initial reactions. Polling technology was not used during this less structured, follow-up focus group. Moderators first reminded participants of the information presented in the sensitization booklet, and then distributed slides (printed one slide per page) that presented the food and beverage marketing scenarios discussed in the pre-sensitization group. Participants were asked to review the scenarios and those in the booklet (copies were provided during the group), and were asked, “Is there any scenario there that stood out in your mind?” Additional questions were designed to allow participants to describe how their reactions to the scenarios might have evolved since the pre-sensitization focus group, for example: “Has your opinion about any of the scenarios we showed previously changed after reading the booklet?”, and “What did you learn from the booklet that informs your opinion now?”. The final question of post-sensitization focus groups aimed to understand what food and beverage marketing participants would want in their community: “In relation to foods and beverages what types of products would you like to see advertised in your communities?”.Written transcripts for each site were reviewed by the respective field site investigators and their team, as well as by researchers at the AACORN national office. Conventional content analysis was used to identify views of participants overall, including those that reflected or disagreed with perceptions that targeted marketing practices were unfair, and constituted a social justice issue. Conventional content analysis involves “open-coding” of text transcribed from focus groups to identify segments of text that reflect convergent and divergent ideas within and across transcripts. These codes then led to themes, which emerge from the data in an inductive manner . Two teaThe NVivo software  was used to facilitate the process of grouping data into categories and subcategories. During this phase, thematic development was assessed for salience in pre- and/or post-sensitization groups. The codebook and emerging themes were reviewed and discussed with the respective field site investigative teams and the AACORN Research, Evaluation, and Dissemination Core research team. These discussions led to both confirmation and further refinement of the final codebook and themes. The initial qualitative impressions of changes post-sensitization were further explored by tabulating the use of selected codes pre- and post-sensitization.Durham participants included 15 adults and 13 youth , and PG County included 15 adults and 22 youth . All youth participants were aged 16–18 years. Six themes were identified, and are described in detail below with illustrative quotes. We organized themes broadly as related to: seeing the marketer’s perspective , respect for community , and food environments as a social justice issue . Results revealed much similarity in youth and adult perspectives; themes identified were not age group-specific. Themes which were solely present in either the pre- or post-sensitization group were allowed, but they did not emerge from the data. Thus, any differences identified between pre- and post-sensitization findings are described within theme descriptions. For context, citations of quotes from transcripts are identified as from adult or youth focus groups, and also by gender for youth. Gender of speakers in the mixed-gender adult focus groups could not be identified from transcripts.“they (food companies) are not going to target people who do not want it (food product)”, and also, downplayed worries about high availability of unhealthy items and/or high-priced items in certain communities by saying, “if they don’t like it, they could drive somewhere else.” In regard to pricing, participants stated that businesses charge the highest amount they think they can get, and that is a good business practice and not an issue of “fairness”. Many also commented on the principles of supply and demand, pointing out that some scenarios presented, such as high food prices in small neighborhood stores and lack of supermarkets in some neighborhoods, were of less political or social justice relevance and more related to open markets, which cause food prices to be high when availability is low.During pre-sensitization groups, many participants pointed to the issue of consumer demand as an explanation for greater availability of unhealthy foods in certain communities. These participants often asserted that some business practices described in the presented scenarios were “good business practices”, and were mainly responses to consumer demand. One youth participant  raised this point, “It’s not a Black thing” when describing how different groups might have affinity to different products.Some participants also discussed positive aspects of marketing that targeted a racial/ethnic group. This perspective was found in both adults and youth, although was more pronounced in youth. These participants said that this might result in a product more in line with cultural values and preferences; therefore, targeted marketing could result in more satisfaction with the product. They also described how culture draws you to certain products, with one youth  stating, “it’s an individual thing before it’s a community thing” and another adult following up with, “some people just don’t care. Some people are willing to die for that last pork chop”. But in most cases, the context around these sentiments seemed to change, where participants expressed more tension between “good business strategies” and the potential impact on the community. For example, one youth participant  said in the post-sensitization group, “it’s a good (business) strategy but at the same time it’s not good for our society”.In the post-sensitization focus groups, some sentiments of demand side issues being in the consumer’s control were still asserted, with one adult participant, stating that “If you want a soda, you want a soda” (adult participant during pre-sensitization). Others even described unintended consequences of SSB taxes, with one participant describing that those taxes on SSBs or “junk food” would result in people spending a greater percentage of their food budget on those items, leaving them less money to spend on healthy foods. There were also some references to community members being “addicted” to certain “unhealthy foods” such as fast foods and SSBs. They also described some motives of consumers, including wanting quick and convenient options that are either “on-the-go” or do not require cooking. Desires like these were connected to less healthy food purchases. For example, one adult participant said, “I think people going to still go fast foods sometimes because you just don’t want to cook it”.Some participants emphasized the individual choices which often lead to negative, food-related health issues. These participants expressed the power of individual choice, stating that interventions such as sugar sweetened beverage (SSB) taxation would not change behaviors because, “But if you don’t have a supermarket in your neighborhood, then you’re more likely to go to those fast food places because it’s quick. And then a lot of times parents, they work late. So it’s—it’s really easy to just stop by somewhere, pick up a whole meal, come home, feed the kids, and do everything that you’ve got to do even though we should all eat more fresh fruits and vegetables”. And some reiterated that businesses are focused on profits, and that individuals need to recognize their “choice”: “but you can’t stop a person from making a living, that’s what they’re doing, this is your choice to go there” (adult participant in post-sensitization group). Participants talked more positively about taxation approaches particularly when discussing how the money could be used to “fight back” against marketing and to help stop the obesity crisis.During the post-sensitization, focus on consumer responsibility was less pervasive. Participants began to mention environmental challenges faced by consumers, such as lower pricing of unhealthy items, time pressures on families, and low availability/promotion of healthier options, to acknowledge the difficulty of making the “healthy” choice. This statement by a youth participant  illustrates this tension between individual responsibility and the environmental features of a community that promotes unhealthy choices: “wrong”. One youth participant  acknowledged this as a business strategy, while questioning the justice of the approach during the post-sensitization group: “It’s smart, but wrong”. As scenarios portrayed approaches of targeted marketing, participants would comment that the scenario got them “thinking”. This was particularly observed in the post-sensitization focus groups where participants expressed they had been taking notice of marketing tactics in their environment in the time since the pre-sensitization group. They expressed frustration with some marketing tactics during both the pre- and post-sensitization groups, saying: “They are setting us up for failure”, “They do not look at us as actual human beings, just as a profit” and “why it got to be a Black neighborhood so it makes me angry but… I know we still got a choice”.While adult and youth participants appreciated the profit-driven motives and business strategy of targeted marketing, many expressed the perception that targeting a racial/ethnic group was “false advertisements”, as it portrayed slim celebrities promoting calorie dense foods. And one adult wondered during the post-sensitization group whether marketers could use celebrities to promote healthier options: “if they’re going to advertise using these celebrities, advertise them eating a carrot”. Regarding specialized products, many participants felt like a product targeted to a racial/ethnic group was equivalent to “altering” a product, and this was met with negative views regarding the food/beverage company. One adult participant stated, while reflecting on this issue, “if they are going to do that to our drinks… how far will they go?”. And others expressed a need to know what was in a product, and to not mislead consumers on the ingredients or nutrient make-up of a food or beverage. This led some participants to discuss a need for more government oversight in the marketing of products in order to have consumers understand what exactly is in the product they are purchasing.Two scenarios were met with substantial criticism when first introduced in the pre-sensitization focus group: celebrity endorsement of products and product development targeted at certain racial/ethnic groups. On celebrities in advertisements, some participants stated these were often “trying to kill us” (“us” is referring to the Black community). They commented that food marketing approaches highlighted in the focus group and in the sensitization booklet might result in worse health and early death, citing health conditions such as hypertension and diabetes.Some adult participants connected targeted marketing to a broader social justice issue during both the pre- and post-sensitization groups. Numerous adults stated that targeted marketing is an example of outside entities “It matters to me because I don’t want to be stereotyped because like okay he is Black so he is going to go to Church’s  every Friday for fish specials”. Regarding assumptions about whether Black consumers want healthier options, some participants noted that individual choice is involved, but that it seemed marketers are focused on making less healthy options enticing for Black consumers.Participants discussed thinking that marketers are making false assumptions about preferences of Black consumers, which was observed during both the pre- and post-sensitization groups. They felt that Black consumers are assumed not to want healthier or fresher options. In these conversations, participants also expressed being insulted by the assumptions behind the marketing strategies presented. One youth participant  expressed his concerns, “going for that younger generation with using a young celebrity to bring in to make it popular with the younger kids”. And another adult said, when describing a popular professional athlete endorsing a flavored sugar-sweetened sports water, “because you can hear, “Mommy, I want this because (Athlete’s name) had it and I want to be a basketball player just like him” so I think marketing has a huge effect”.Adult participants expressed concern about strategies that target youth, as they felt youth were being manipulated. One adult described the tactic: “a trap for our people”. Many participants also raised the importance of food store availability in response to scenarios depicting neighborhoods without supermarkets. Particular concern was raised for community members who did not have cars or other means of efficient transportation, stating that this was “unfair” or making it hard for these individuals to access healthier options.Participants also raised concerns that certain marketing strategies might target particularly vulnerable sub-populations of the Black community. An example given was “value” menu platforms, which offer select items at low prices . An adult participant described how such pricing strategies “prey” on the circumstance of lower income and/or single-parent families, where low cost, quick and easy options are needed, but that these options are all unhealthy. When describing the placement of fast food restaurants and their use of value priced menus, she said it is like “nobody’s watching the door, in terms of what’s being put out into the community”, and that unhealthy options were prevalent in the community. In these cases, participants spoke with some frustration that government officials and/or other leaders were not “minding” (in the sense of monitoring) the actions of businesses with the intent to protect community health. Other non-food-related threats to the Black community were also discussed in this context, including a lack of response or slowed responses by officials to problems in Black communities relative to non-Black communities. Others pointed out the need for community members and individual consumers to take a stand against the marketing of unhealthy foods, particularly during the post-sensitization groups. One adult stated that people need to speak up because individuals have more influence than they currently utilize. A youth participant  spoke with frustration, saying “Don’t wait until there is a problem then you can’t solve it. Have half of the world population be dead by the time you cure it”. And another youth participant  pointed out that it is difficult to activate community members: “I know some activities and stuff you involve yourself in that make you more susceptible to it but like he said until people actually—until it actually affects them personally I think for the most part a large part of the population won’t actually take it seriously”. Others raised concerns about government involvement in obesity prevention efforts, citing either lack of oversight or suggesting ways to alter current government strategies to make them more effective. For example, one youth participant  said during the post-sensitization group: “Why wouldn’t they just lower the taxes and stuff for that healthy food”. Another adult reflected during the post-sensitization group, “it’s bringing to my attention is just how shabbily the U.S. government regulation people are, in terms of what they allow people to feed us”. Participants suggested numerous approaches where the emphasis would be on increasing promotion of and availability of healthier options, while reducing prices of these foods.This theme ran contrary to the theme “Consumers Choose”, and was most pervasive in the post-sensitization group. Some participants connected the marketing of unhealthy foods to larger social justice issues. One adult participant spoke in frustration during the post-sensitization group about the marketing tactics, saying I’m shocked and appalled. I think they’re setting us up”, while another similarly expressed surprise, saying it “slapped me in the face”. A few participants stated that reading the booklet encouraged them to do further research to better understand targeted marketing. Overall, post-sensitization discussions focused on the new awareness that business strategies of the food industry can impact health, and that the Black community might be experiencing this effect in a more detrimental way. When asked by the Moderator, “what would make you/others want to get involved in changing the way foods and beverages are marketed to us in our community?”, participants often cited need for raising awareness of health impacts of certain foods and the use of targeted marketing to promote less healthy options, through educational activities. For instance, one adult participant said, “I think maybe educating people on you know, how do you take the first steps in something like this”. And another adult talked about reaching children: “You’ve got to teach nutrition. It should be part of the education system to the extent that kids are taught to count calories just like they do green, yellow, and red”. Others talked about specific approaches to impact the food environment, as mentioned by this adult participant: “they (community members) can make a difference if they can find space in communities that’s willing to give them space to put their larger groceries in there”. Other potential approaches to increase healthy eating were drawn from observing other communities, including gardening programs, information exchanges, and calorie labeling on menus.In post-sensitization sessions, many participants found the booklet informative because it had details on food marketing strategies. Participants said they felt the booklet provided them data (often referring to “statistics”) which made them more aware of marketing strategies and their potential impact on health. A youth participant expressed concern, saying “Participants indicated, in response to direct questions, that the sensitization booklet increased their awareness of and interest in previously unrecognized issues associated with food marketing .Food environments as a Social Justice Issue theme, noting that one of these was directly related to a question about sensitization, and so could not have occurred in the pre-sensitization groups; and (c) with one exception (“people do what they have to do to sell/good business tactic”), the codes associated with Seeing the marketer’s perspective were applied more in the pre- vs. post-sensitization groups. A more mixed pattern of pre–post changes was seen for codes associated with Respect for Community. This analysis also permitted assessment of where, i.e., in which groups, changes occurred, based on examination of the tabulations within each theme for each focus group as it applies to the codes in Seeing the marketer’s perspective was similar from pre- to post- in Durham; whereas it was used less after sensitization in all four of the Maryland groups. For Respect for Community, the code use was greater post-sensitization for male youth in both Durham and PG County and less post sensitization for adults in Maryland. For Food environments as a Social Justice Issue, use of all codes increased post-sensitization within all eight groups.As described in Methods, the initial impressions of changes in participant views and reactions also were evaluated by tabulating the pattern of code use pre- and post-sensitization. The initial step involved identifying codes that met two eligibility criteria: (a) they were used only for pre- or only for post- within a given focus group; and (b) they were used in more than one of the eight focus groups. The summary results of this analysis are shown in When presented with depictions of targeted marketing approaches, including promotions, placement, pricing strategies, and tailored products, both Black youth and adults responded with varied lenses. In themes identified, some participants viewed marketing practices as being expected and understandable, because they aligned with good business practices that aim at getting the most profits possible. Profitable business strategies were not universally viewed as negative, as it was felt that profitable businesses could be good for the local community and/or offer access to products which might be desired by the community. Participants also endorsed the role of individual responsibility in determining how detrimental or influential marketing tactics were, where beliefs that consumers needed to choose better were asserted. Conversely, some themes evoked expressions of frustration and concern for the Black community at large, and particularly for children, older adults or those with additional constraints, such as lower income or being short on time . These concerns came through even more after the participants were given the booklet to sensitize them to common food and beverage marketing practices. They led to discussions of a need for more government oversight, more education on nutritional issues in the community, and more community advocacy to circumvent the marketing strategies they identified as leading to poor dietary quality and related negative health effects.The themes identified, for the most part, were seen across both pre- and post-sensitization. Themes oriented to seeing social injustice in food and beverage marketing strategies were present before and after sensitization, although were more salient in post-sensitization. Conversely, themes sympathetic towards the need for companies to make money were more evident in pre-sensitization focus groups, although not absent from post-sensitization groups. Thus, the sensitization process appears to have increased negative views towards marketing approaches for some participants. These findings align with a small marketing study that assessed effects of participation in an educational workshop on media literacy on parental media literacy and perceptions/attitudes about unhealthy and healthy foods among children . The autConsidering the objective of this study, the identified themes provide insight on potential approaches for mobilizing community action to increase demand for a healthier mix of products in the Black community. Participants’ comments supported efforts that would potentially tax less healthy foods if the revenue went to educate the community on nutrition. They also stated that the government could play a larger role in reducing the extent of some targeted marketing to which the community is exposed. Last, they described the need for community members to begin to advocate to reduce marketing approaches that increase access to less healthy options and to promote approaches which lead to greater access to healthy foods.Lobstein and colleagues identified the roles of corporate and governmental entities in developing policies to reduce obesity, and described the role of advocates in identifying policies that support, rather than obstruct, healthy eating . AdvocatThis study on the issue of targeted marketing has several strengths, particularly, its relevance to Black Americans, a population group at high-risk for obesity and related chronic diseases. Black American ethnicity has been, and continues to be, a major focal point for targeting of unhealthy products to adults, youth, or both—not only high-calorie, nutrient-poor foods and beverages, but also alcohol and tobacco ,25,26. OWith respect to the analytic approach, the conventional content analysis performed by two researchers offered a reliable and valid method of identifying emergent themes from the data. The coding approach allowed for codes to occur across pre- and post-sensitization groups, so that analysis would lead to an assessment of how sensitization influenced the emergent themes. The computer assisted coding process facilitated various ways of examining the findings, including the tabulation of codes which confirmed the initial impressions of changes in salience of themes, pre- and post-sensitization. Last, the sensitization process was novel for this food marketing topic.The qualitative approach allowed for depth of findings on this topic for which there is limited empirical data in the public health literature. However, the findings should be considered in light of limitations of this study, which include the predominantly female sample among the adults , the potential for selection bias favoring an interest in food marketing issues, and possible lower applicability of relying on a booklet approach to people with limited literacy. With respect to selection bias, this does not necessarily detract from the utility of these results, given that people interested in the topic would be those most likely to become engaged in related advocacy efforts. The samples were small, although engaging with both adult and youth participants in two different geographic areas provided for diverse views. The method of sensitization and a post-sensitization focus group allowed for participants to have more time to think about questions posed and discuss with others between sessions, although there is no way to determine the occurrence or influence of such interactions outside of the focus group setting. The paper booklet offered a good method to engage with adults and youth of varying economic/age levels who might have varying access to technology  but would be less effective in the context of lower literacy. Access to mobile phones with “smart” applications has opened the door to utilizing technology for both polling and to deliver a sensitization, which increases feasibility, potentially allows for more dynamic and tailored presentations of sensitization data, and facilitates tracking of participant engagement/interaction with the sensitization material.In light of these issues, the current findings can be used to encourage the use of sensitization procedures to heighten awareness of marketing tactics which may negatively influence food choices of Black adults and youth. Such approaches could be introduced in research interventions and into policy approaches. Others have suggested that policy approaches to reducing obesity should be tailored to the community in terms of food preferences, social factors, and economic constraints . Thus, p


In sub-Saharan Africa, there is growing interest in the use of cash transfer (CT) programs for HIV treatment and prevention. However, there is limited evidence of the consequences related to CT provision to adolescents in low-resourced urban settings. We explored the experiences of adolescents receiving CTs to assess the acceptability and unintended consequences of CT strategies in urban Johannesburg, South Africa.We collected qualitative data during a pilot randomized controlled trial of three CT strategies  involving 120 adolescents aged 16–18 years old in the inner city of Johannesburg. Interviews were conducted in isiZulu, Sesotho or English with a sub-sample of 49 participants who adhered to study conditions, 6 months after receiving CT (280 ZAR/ 20 USD) and up to 12 months after the program had ended. Interviews were transcribed and translated by three fieldworkers. Codes were generated using an inductive approach; transcripts were initially coded based on emerging issues and subsequently coded deductively using Atlas.ti 7.4.CTs promoted a sense of independence and an adult social identity amongst recipients. CTs were used to purchase personal and household items; however, there were gender differences in spending and saving behaviours. Male participants’ spending reflected their preoccupation with maintaining a public social status through which they asserted an image of the responsible adult. In contrast, female participants’ expenditure reflected assumption of domestic responsibilities and independence from older men, with the latter highlighting CTs’ potential to reduce transactional sexual partnerships. Cash benefits were short-lived, as adolescents reverted to previous behavior after the program’s cessation.CT programs offer adolescent males and females in low-income urban settings a sense of agency, which is vital for their transition to adulthood. However, gender differences in the expenditure of CTs and the effects of ending CT programs must be noted, as these may present potential unintended risks. Cash transfer (CT) programs are largely used in low- and middle-income countries as a mechanism to alleviate poverty. In the past two decades, they have been used to improve health outcomes and promote healthy behavior. Studies show that conditional and unconditional CTs have significantly improved health-seeking behaviors and the uptake of healthcare services , 2. FollStudies in developing countries show promising findings in relation to the potential role of CTs in reducing HIV infection by changing risky sexual behaviors . StudiesCT programs have historically targeted adult women  and therDespite the inconsistent findings, agencies such as UNAIDS and the World Bank are willing to support governments to scale up CT programs . The UniWhile AGYW are a priority target group for these sorts of structural interventions to address HIV; Gibbs et al. (2012) highlight the need to include men in structural interventions for HIV prevention , as evidCurrently, it is not known how adolescents in a low-resourced African urban setting perceive CTs, how they spend CTs, or what receipt of transfers means to them. In addition, there is limited data and understanding regarding the impact of cash transfers on adolescent male behaviours. This limits the understanding of the impact of CT programs designed for HIV prevention and treatment in various contexts, indicating the need for further research in this regard. We present findings from a qualitative study conducted among adolescent boys and girls who participated in a CT intervention study where we explored participants’ experiences of the CT intervention and the meaning that they attach to the intervention.The research was conducted in inner city of Johannesburg, South Africa, specifically in the Hillbrow, Berea, and Yeoville areas. This location was selected because of evidence that HIV prevalence in South Africa is highest in informal urban areas , 25. TheCHANGE study, a pilot RCT assessing the feasibility and acceptability of CTs in a low-resourced urban setting. The aim of the intervention was to compare three different CT interventions strategies.This study was nested within the n = 120) for participation in the intervention through distribution of pamphlets at three schools and by word of mouth. The inclusion criteria were being aged 16–18 years, self-identifying as sexually active, and enrolled in school. Potential participants were contacted and invited to our research offices .We recruited male and female adolescents  Unconditional monthly payments of 280 ZAR (USD 20) for 6 months; 2) monthly payments of 280 ZAR for 6 months, conditional on 80% school attendance; 3) and a single payment of 280 ZAR conditional on a once-off clinic visit involving sexual reproductive health education, services related to family planning and contraception, HIV counselling and testing, HIV risk assessment, and HIV risk reduction counselling. Payments were made through a cardless service that allowed cash withdrawals from an automated teller machine (ATM) using a pin code, which was sent to participants’ mobile phones via a short message system (SMS). Those who either did not have a mobile phone or had a shared phone were paid using ATM cards with a linked pin; these were provided to participants at enrollment. Participants completed surveys at 6 and 12 months after receiving CTs; the survey results are reported elsewhere .n = 30) and girls (n = 19) to participate in-depth interviews. We selected participants who adhered to study conditions such as attending school and visiting the clinic across the three study arms .From the 120 participants enrolled in the intervention, we purposively selected a sub-sample of 49 adolescent boys  and up to 12 months after the intervention had ended (March 2015). Different sets of participants were interviewed at the two time points. The purpose of the second interviews was to gain insights into the effects after the cessation of a CT programme. We contacted participants telephonically and invited them to take part in the interviews.Participants were interviewed in a private room at our research offices in Hillbrow. The interviews were conducted by one male and two female interviewers, who were fluent in isiZulu and Sesotho. Each interview took approximately 1 h, and participants were compensated 100 ZAR (approximately USD 7) for transport costs and their time. The interview guide consisted of the following topics: (1) descriptions of adolescents’ households ; (2) experiences of the CT program; (3) participants’ sources of income before, during, and after the CT intervention; (4) and spending patterns and perceived impact of CTs. All interviews were audio-recorded and transcribed. Interviews in isiZulu and Sesotho were transcribed and translated (one-step) into English by trained transcribers. Personal identifiers were substituted with pseudonyms during transcription.An interpretative phenomenological approach was employed to explore how adolescents make sense of their experiences of CT programs. The phenomenological approach focuses on how people perceive and talk about objects or events . This meAs an initial step, two of the authors of this paper (JS and NK) reviewed the transcripts to identify preliminary themes and sub-themes, using an interpretivist approach to analyze the data . Atlas.tWe had intended to include 30 participants at each follow up, making up an envisaged total of 60 participants. However, obtaining a balanced representation according to gender was challenging, especially at the 12-month visit. Some of the contact information was invalid and some participants had completed school, while others had relocated. Our final sample of 49 participants, therefore, had more male participants and more participants in the unconditional arm than was initially planned. Table n = 21) of participants were recipients of unconditional CTs, followed by 15 participants who formed part of the school arm, and 13 participants in the clinic arm. At 6 months follow-up, the age range was 16–18 years. Participants were in grades 10–12. At 12 months follow-up, the majority (67%) of participants had completed the 12th grade; a few (13%) participants were enrolled in tertiary education, some (30%) worked temporary jobs , and others (23%) were seeking employment. Most participants’ households were headed by single parents, who were in unskilled employment or ran informal businesses. The majority of participants lived in one-bedroomed apartments. On average, there were four occupants per household, with parents sleeping in the bedroom and siblings sharing a bed in the living room. In some instances, two or three families shared a living space.The majority  stated: “…at least there is a project out there that is willing to help young girls and guys and show them that they don’t have to do bad things that are out of their comfort zone to get money.” .Overall, the unconditional and conditional CTs were acceptable to both boys and girls, who indicated that the program encouraged them to be responsible and attend school, and prevented girls from engaging in sex with older men, and boys from committing crime to get money. As one participant noted: “For me, being in the program was all about learning about HIV and how to protect ourselves from contracting such diseases by practicing safe sex.” Similar to other participants, P8 reported that he gained knowledge about HIV and testing by completing a mobile phone-based survey in the main trial.While the study did not offer formal lessons on sexual reproductive health (SRH), several participants mentioned that they liked the information on HIV/AIDS and sexually transmitted infections, which they received through their participation in the study. In relation to this, P8  illustrated: “I was going to school every day. It is something that I was doing since grade 1; so, it was not like I was working for it, because it was something that I was already doing. So, I was just getting paid for something that I was doing, but I was now pushing even harder because I was getting paid for it.” Several adolescents in the school arm reported that CTs had minimal to no impact on their school attendance. Some indicated that the program encouraged them not to miss school. They put in extra effort into their attendance, as they did not want to miss their cash payments; for example, they attended school even when they were sick. However, this was contradictory to the main trial’s findings, which showed that participants who received school-conditioned payments were more likely to report missing school relative to participants in the other study arms  Kentucky [fried chicken]; so, I would go and buy vegetables or a tray of chicken, and go home, cook, and eat with my mom.”Generally there were similarities in patterns of expenditure across intervention arms. Similar to girls who had received monthly payments for 6 months, those who had received a single payment also spent CTs on their personal needs and to support family members.“I gave half of the money to my mom to buy groceries in the house, and then I used some of the money for entertainment. I went to the movies with my friends, and I used some of it for toiletries like perfume, make-up and other things that I needed.” Only two male participants reported spending CTs on alcohol, to entertain themselves. However, adolescents highlighted that expenditure of CTs on alcohol was common among their friends and acquaintances. They spoke of peers who used CTs on “alcohol and drugs” and “gambling,” and “falling prey to money lenders,” which reflected some form of moral judgment. “Most of the young people that I know used their money for drugs and alcohol.” .We noted gender differences in the adolescents’ decision making regarding the use of CTs and some differences in their spending and saving patterns. Most girls sought advice from their parents or other family members on how to use the money. Some girls believed that they had to discuss this with their parents first, even though they made the ultimate decision. The most common advice that they received from parents was to spend the money wisely, and some were encouraged to save it. In some instances, mothers used and controlled the CT, but even then, this had been the participants’ decision.“To me, it was just free money. (Laughs) So, it didn't matter ... like, it was just free money.” Some participants who had received a once-off payment viewed it as “luck money”; one participant in the clinic arm described it as money that you pick up on the street. The notion of “free money” or “luck money” yielded two possibilities among participants. For most, free money was supposed to be saved or spent wisely on necessary items, and for a few, it was to be spent randomly and not carefully planned for.We also noted that the meanings attached to CTs could influence how adolescents spent the money. Some participants in the unconditional arm considered CTs “free money” because they “did not work for it” and there were no conditions for receiving the cash. This is how P44, a young man, perceived unconditional CTs: “I felt great because it made me more independent.” Likewise, P34  stated: “… it taught us how to be independent, and not to rely on boys.” Adolescents described CTs as helpful, convenient, and providing access to resources that they needed. “We need clothes; some of us use make-up, and we may need money to party with our friends; so, sometimes our parents can’t afford to give us money.” . Therefore, the cash provided them with resources that they would not otherwise have accessed.One of the most prominent themes cited by the adolescent boys and girls in this study was the sense of economic independence that they experienced upon receiving CTs. P43  remarked: “There are no [conflicts], because I don’t ask her [sister] for money. Sometimes ... you see, sometimes it’s bad when you start asking for money from people. If you don’t [ask] it’s okay.”Before the intervention, adolescents depended on their parents and family members, and some girls relied on their sexual partners for financial support. For most participants, this was stressful and caused conflicts, particularly in instances where funds were insufficient. When asked to describe her family relationships while receiving the CT, P38 , who lived with her sister responded: “It was one less stress for her. She was not worried about the matric dance anymore … She wasn’t going to be paying for it anymore. Because she was already worried about buying the books.” Feeling independent and responsible enhanced participants’ self-esteem and decision making, as P4 noted: “It [CT] boosted many young peoples’ confidence by showing them that they can do things on their own without asking for help or working hard.” CTs seemingly offered adolescents choices, including choices about their behavior. Some of the girls spoke about how receipt of CTs changed their behavior. P35, a young woman who received school-conditional payments, reported that, before the intervention, she counted on her boyfriend for financial support, since her mother was unemployed. As a way of showing appreciation to her boyfriend, she felt pressured to have sex with him. When she received CTs, she did not ask her boyfriend for money because she could support herself. She decided not to have sex with her boyfriend. She said:“It helped me because I didn’t have to sleep with my boyfriend when I asked him for money … No, he never forced me to have sex with him, but I know that it makes him happy, you know … he said that if I want him to make me happy, then I must also make him happy.”P35 continued to do things for herself, even after the intervention; she found part-time employment. Similarly, P1 stopped having multiple relationships and dating older men for financial support, and remained with one partner.“The first one was the cash I received because it helped me stop doing many things that I used to do to get cash … Like dating older men, who usually gave me money to buy myself things.” Participants recognized the financial constraints faced by their parents, who were mostly single parents and held informal jobs or ran small businesses. Hence, they were mindful of putting extra financial pressure on their parents. Receipt of CTs lessened financial demands on participants’ parents. Moreover, to some extent, CTs provided resources that parents would have had to pay for; this meant that they could focus on other competing domestic needs, as the extract below indicates:“It taught me things ... like, I can now budget for my money appropriately and know when to spend on the right things ...” . Some participants reported saving their transfers over a short-term period for essential purchases or for an event that they wanted to attend. Participants felt in “control” and “responsible.” Some reported that had become open-minded, could help others, and had gained self-confidence.Adolescents spoke about the gains that they had made from their involvement in the program. The majority mentioned that day-to-day administration of CTs equipped them with financial management skills. These skills included drawing up a budget, saving, and making independent financial decisions. Nothing [changed]… I knew that I was going to get it once. It was like picking up money; you never know you are going to be lucky enough to pick it up again…” . Adolescents of both genders in the school and unconditional arm felt that a valuable resource had been taken away and that they are back to where they had started, relying on other people. This was stressful, as they had grown accustomed to having their own money and doing things for themselves, as the quotation below illustrates:“Right now, everything that I come across that has to do with finances, I have to ask my parents, and sometimes this is difficult because they have their own things to pay for. So, I can say that my life has now changed, since I don’t have that money. Yeah, I can say that it went back to where I started. I’m used to having money I made myself.” Receipt of CTs appears to have somewhat compelled adolescent boys to earn an income. Two male participants reported that after the intervention, they saw a need to find employment, so as to meet their personal and families’ needs.“I have to hustle to get money … When in the study, there was no need. But when the money stopped, there was a need because I still had those needs; so, I had to get more money to patch up that empty space.” The end of the CT program made a few of the boys think of easy ways of making money, such as engaging in criminal activities. However, only one criminal incident was reported.“Money is an addiction for some people; so, the less they had, the more they wanted. Some had to try and steal other peoples’ goods to get the money for whatever they had to buy. I remember there was an incident by one person that stopped receiving the money; he mugged someone, took the person’s phone, and sold it to get money.”One male participant  reported that he was used to getting easy cash, money that he did not work for; so, after the program ended, he considered engaging in criminal activities to get quick cash without putting in much effort. It also appears that such thoughts and frustrations were experienced mostly by those who were neither in school nor employed after the program.Most adolescents, particularly those who had received a once-off single payment, reported that everything remained the same as it was prior to the program, stating that they knew that receipt of CTs was temporary. “This qualitative study of CTs in a low-resourced, inner-city neighborhood explored adolescent recipients’ experiences and meanings of CTs. It also provides insight into adolescents’ spending patterns and outcomes after cessation of the CT program. This is important, as often long term outcomes after cessation of research studies are not known.In our study context, CTs mostly generated positive experiences and meanings when transfers were offered directly to adolescents of both genders. Specific benefits included a sense of independence, financial freedom, and social growth; these attributes form a crucial component of adolescents’ development, as related to the transition from childhood to adulthood . In low-Most studies have shown that CTs offered to parents/guardians improved children’s outcomes . HoweverWhile the adolescents in our study mostly reported positive expenditure; it is important to consider the implications of their expenditures in the local context. Research has shown high levels of alcohol consumption among young South African men ; thus, eThe sustainability of the CT program’s effects after the program’s cessation remains questionable. In our study, the benefits to adolescents’ appeared to be short–lived, as they reverted to old behaviors and relying on their parents; this was probably because of the short intervention period. In a few instances, the intervention introduced pressure to earn money, particularly among boys. Pressure to make money may be either a positive or an adverse outcome; positive in the sense that, after the program had ended, some adolescents had also completed schooling, so they had found employment to sustain themselves. However, for others, the program created a need to make easy money, and could lead to committing crime as reported by two participants.The experience of the program and its processes, conditionalities, cash delivery strategies, and the grant size were acceptable to the majority of boys and girls. Our findings show that conditionalities based on routine activities such as school attendance was not felt, since they do not require additional effort, unlike if unusual or dreaded activities had been set as conditions. However, if conditions include activities that adolescents consider necessary , then CTs are more likely to encourage uptake of the dreaded service. Contradictory to other studies that reported jealousy and tension between recipients of CTs and participants in the control group , no adveThis study was not without limitations. We acknowledge that interviewing a different set of individuals at 12 months follow-up limited the depth of understanding of individual experiences. Participants provided self-reports on how the transfers were used; thus, there is potential for bias in their reports of their spending patterns, with the possibility that responses perceived as desirable were provided. For example, although the majority of participants in the school condition reported positive outcomes we cannot rule out the potential social desirability bias particularly because the findings from the main trial indicate that participants in the school conditioned study arm were more likely to miss school.Our findings demonstrate that from the perspective of young men and women, adolescent-directed CT programs are acceptable and benefit individuals as well as households in low-resourced urban environments. They instill a sense of agency and responsibility in adolescents, facilitating transition to adulthood. The gender differences in adolescents’ spending decisions and expenditure regarding CTs are worth noting. Spending on domestic domains in girls and public domain in boys show that CTs could potentially reaffirm traditional gender norms in this population. Program implementers need to take this into consideration, and think strategically about targeting adolescent girls with the provision of CTs. However, we also recommend that boys be considered for CT programs. Despite no data being available on the effects of CTs on HIV prevalence or incidences among males, access to transfers contributes towards their psychosocial development, although this needs to be balanced against the risks of expenditure on alcohol and alternative money-making strategies that could lead to consideration of criminal activities when the CT program ends. These, however, require further exploration. These findings provide additional insights to studies that highlight the importance of adding more supplemental funds to the already existing social grants for vulnerable children in South Africa.