Leaders influence followers’ meaning and play a key role in shaping their employees’ experience of work meaningfulness. While the dominant perspective in theory and in empirical work focuses on the positive influence of leaders on followers’ work meaningfulness, our conceptual model explores conditions in which leaders may harm followers’ sense of meaning. We introduce six types of conditions: leaders’ personality traits, leaders’ behaviors, the relationship between leader and follower, followers’ attributions, followers’ characteristics, and job design under which leaders’ meaning making efforts might harm or ‘kill’ followers’ sense of work meaningfulness. Accordingly, we explore how these conditions may interact with leaders’ meaning making efforts to lower levels of followers’ sense of meaning, and in turn, lead to negative personal outcomes , as well as negative organizational outcomes . By doing so, our research extends the current literature, enabling a more comprehensive understanding of leaders’ influence on followers’ work meaningfulness, while considering the dark side of meaning making. The dominant perspective on leaders’ meaning making role, in both the leadership and the meaningfulness literature, focuses on leaders’ positive influence on followers’ work meaningfulness. This line of research has shown that transformational leadership, empowering leadership, and high-quality leader-member relationships are positively related to followers’ perceptions of work meaningfulness e.g., . HoweverOur conceptual model introduces six types of conditions under which leaders’ meaning making efforts might harm followers’ meaningfulness at work: leaders’ personality traits, leader behaviors, the relationship between leaders and followers, followers’ attributions toward their leaders, followers’ characteristics, and job design. This model makes important contributions to the literature on meaning making, work meaningfulness, and leadership in the following ways. First, our research provides a conceptualization, grounded in theory and empirical findings, of several conditions under which leaders’ meaning making may have detrimental effects on followers’ work meaningfulness. In such, we provide a novel perspective on the influence of leadership on meaningfulness e.g., . The concoherence, which refers to employees’ understanding and ability to make sense of what is happening at work; purpose, which refers to directionality of employees’ work and the ability to connect their work to a higher-order goal; and significance, which refers to employees’ evaluation of their work worth . Second, a reduction of followers’ purpose means that the experience, belief, or hope of followers that their work makes a positive difference in the world is reduced, and that they do not see a clear direction and contribution of their work. They might feel that their work is going nowhere or that their work does not serve a higher-order goal (lack of purpose). Third, regarding significance, the reduction of feelings of one’s work significance refers to the worth, value, and importance of one’s work. Followers might experience that their work is useless and not worthwhile. They might struggle to explain the worth of their work, be unable to justify the worth of their work, or consider the worth of their work and tasks as ambiguous. Furthermore, they may lack solid accounts for the worth of their work, or their established accounts, based on personal values and what matters for them, might have been impaired . In terms of esources . In addiesources . This sopurpose, empirical studies of corporate psychopaths have shown that they create a toxic work environment, characterized by conflict, bullying, increased workload, low levels of job satisfaction, and unnecessary organizational constraints  will moderate the effect leaders’ meaning making has on followers’ work meaningfulness, such that this relationship is reduced if the leader scores high on any of the dark triad traits.low cognitive flexibility and low communication flexibility – accumulating in rigid behaviors of leaders – can hurt followers’ sense of work meaningfulness, through leaders’ inability and unwillingness to adjust to and incorporate new situations .There are multiple leadership behaviors that can reduce followers’ sense of meaning. Here, as a central example, we focus on behaviors that highlight leaders’ rigid and inflexible behaviors. Several facets of inflexibility and rigidity that pertain to leadership are introduced in the organizational literature . In our Cognitive flexibility is defined as the ability to shift attention in order to respond to the environment in a new way . LeadersAnother aspect of flexibility that can affect followers’ sense of meaning is communication flexibility, which has been defined as the ability to generate and select communicative options according to the needs of the situation . This foTaken together, if leaders are low on cognitive flexibility—thus, unable to shift the work goals and tasks according to the situational demands— and low on communication flexibility —thus, unable to communicate clear expectations, goals, and tasks— they may weaken followers’ sense of coherence, purpose, and significance in the following ways. Regarding followers’ coherence, if employees do not understand what the leader is trying to convey due to leaders’ very limited range of words and phrases, overly abstract or overly detailed speech (low communication flexibility), followers’ ability to understand and make sense of their work will be compromised. In addition, if the leader has low cognitive flexibility, the leader may not be able to change the meaning they provide for work according to their audience. In these situations, the leader is more likely to distort followers’ ways of realizing their selves at work and their ways of justifying the worth of their work rather than facilitate these. Followers are likely to be left with an unstructured, chaotic picture of their work and might struggle to make sense of their work based on leaders’ thoughts and words.Even worse, regarding followers’ work significance, cognitively inflexible leaders might be so rigid in their opinions and evaluations that they squelch followers’ sense of meaningfulness of and at their work as they provide too little space for followers to self-realize and to express themselves. Metaphorically speaking, ‘his/her personal song is so loud,’ pervasive, and insistent that followers’ ‘song’ is not heard or that followers stop singing. In addition, lack of cognitive flexibility implies an inability to engage in perspective taking. Lacking the ability to see things from the other’s point of view and to integrate another’s perspective, makes it difficult for a leader to tap into the values of their followers. In addition, as such leaders overlook what is important to their followers and only emphasize their own view and values, followers’ feelings about their self-worth and the worth of their work are likely to be reduced.Taking these characteristics one step further and considering the dimension of purpose, cognitive and behavioral rigidity is a characteristic of the ideological or dogmatic leader who holds strong personal convictions and values that mostly refer to the past: “The ideological leader, moreover, will justify actions based on a limited number of relatively inflexible core beliefs and values. Appeal to others will be based, not on the leader per se, but rather the truth embedded in these beliefs and values” , p. 133.Overall, the inflexible and rigid thinking and behaviors of leaders is likely to hurt followers’ potential for self-realization at work. Followers may be provided with too little space to discover and express their true selves at work, be intimidated and miniaturized when leaders are so small-minded, fixated, and focused on their personal truth and convictions. Besides hurting their self-realization, followers’ justification base might be diminished if only leaders’ thoughts and words are allowed to be used to justify the worth of their own work. The narrow-mindedness of leaders might also limit followers’ ability to think more openly and flexibly in the long-term hurting the likelihood of them finding salient accounts for the worth of their work on their own in the long-term.Proposition 2: Leaders’ behavior will moderate the effect of leaders’ meaning making on followers’ sense of meaning such that followers’ sense of meaning will be lowest, if leaders behave in rigid ways .ability refers to their capabilities, competence, experience, skills, and qualifications and to their professional behavior related to their role as leaders .Above, we focused on the characteristics of leaders, their behaviors, and their relationships with followers. While these actual characteristics interact with leaders’ ability to foster or harm a sense of meaning among followers, another key aspect, which needs to be taken into consideration, is what followers ascribe and attribute to their leaders. A major stream in the leadership literature highlights the crucial role of followers’ attributions toward their leaders in shaping how leaders’ behaviors and intentions are understood and evaluated by followers, as well as how they affect the leader-follower interaction e.g., . For exaIf followers attribute leaders’ meaning making to leaders’ self-serving motives, their sense of meaningfulness might be distorted. Leaders, who are perceived as aiming to influence followers for their own self-interests, such as solely increasing their own power, prestige, or advancing their own career, might reduce followers’ ability and willingness to relate their own work activities to a higher-order purpose. Feelings of ‘I am being used’  might arAnother possible attribution of followers toward leader behaviors refers to unethical motives, that is, to intentions that are morally unacceptable to the larger community  and thatProposition 4: Followers’ attributions toward leaders’ meaning making attempts will affect the way they interpret and internalize a sense of work meaningfulness, such that when followers perceive leaders a) as manipulative and self-serving, or b) unethical, leaders’ conveyed sense of meaningfulness will lead to lower levels of followers’ work meaningfulness.We also consider the characteristics of followers as conditions that might influence the effects of leaders’ meaning making attempts on followers’ sense of meaning. In particular, we focus on followers’ personal values and their extent of misfit with leaders’ values as well as on followers’ emotional state. We argue that the combination of leaders’ meaning making and the misfit between leaders’ and followers’ values will reduce followers’ level of meaningfulness because the values prescribed by leaders as important might not matter or might be less meaningful to followers and hence, will reduce the level of their work significance. Researchers studying incidents in which followers lost their sense of meaningfulness discovered that employees related to events of leaders’ behavior that were disconnecting them from their own set of values . If follBesides the threat to one’s self-realization, the justification of meaning might also suffer in case of a value misfit because followers need anchors, such as values, to competently justify the worth of their work . If the While the misfit with leaders’ values is deeply rooted in followers’ more stable personal characteristics, there may also be emotional components of followers, which are likely to interact with leaders’ meaning making processes. For example, if followers are emotionally exhausted by their work due to overwhelming intense situations  will moderate the effect of leaders’ meaning making attempts on followers’ sense of work meaningfulness, such that (a) followers’ experience of a misfit between their own and leaders’ values, or (b) followers’ emotional exhaustion, will reduce this relationship.Another way through which leaders influence followers’ meaning is through structuring the work of their followers and hence, through job design . This moThe aforementioned negative effects might even be exacerbated when leaders try to inspire followers with some higher-order goal, while simultaneously giving them ever changing, non-achievable tasks. Consider a leader who paints a picture of an idealized future and of how the organization will make a difference in the world, but at the same time randomly re-assigns tasks or gives irrelevant tasks . FolloweDisconnecting followers from products and results is not the only form of disconnection a leader can bring about to impair followers’ sense of meaningfulness. Sometimes leaders create interpersonal isolation or distance among their followers or between themselves and their followers. Both create disconnection from supportive relationships, which might harm followers’ work meaningfulness . ResearcProposition 6: Job design aspects will moderate the effect of leaders’ meaning making on followers’ sense of meaning, such that followers’ sense of meaning will be reduced, when the job is designed as irrelevant and disconnected from others.We argue that the decrease of followers’ work meaningfulness will have negative consequences for followers’ cognitions, well-being, and behaviors. In particular, we expect that followers, whose sense of meaningfulness has been reduced, will show a heightened level of cynicism. Cynicism has been defined as both a general and specific attitude, characterized by frustration, hopelessness, and disillusionment, as well as contempt toward and distrust of a person, group, ideology, social convention, or institution . In the We also expect that a lower level of work meaningfulness will lead to a lower level of well-being, including heightened levels of negative affect, distress, exhaustion and depression among followers and reduced levels of vitality and thriving . While pMoreover, we expect that followers’ reduced work meaningfulness influences followers’ behaviors; in particular, we expect a higher level of disengagement. Disengagement is defined as the uncoupling of selves from their work roles, which means that followers are physically uninvolved in tasks, and that role demands guide their task behavior . When foProposition 7: Followers’ reduced sense of meaningfulness will (a) enhance followers’ cynicism, (b) reduce followers’ well-being, and (c) enhance followers’ disengagement.Furthermore, we suggest that followers’ decreased levels of work meaningfulness will have organizational-level consequences. First, we argue that the level of corrosive organizational energy increases when followers’ work meaningfulness decreases. Corrosive organizational energy describes the level of shared destructive energy within the organization characterized by aggression and destructive behavior . ImportaAdditionally, based on previous insights, we expect that reduced levels of work meaningfulness leads to higher turnover rates in organizations. For example, Moreover, we expect that a decrease in followers’ work meaningfulness leads to lower organizational productivity. If followers do not fully engage in their tasks, they are less productive, which is likely to yield an overall lower level of organizational productivity . In addiProposition 8: Followers’ reduced sense of meaningfulness will (a) increase corrosive organizational energy, (b) increase turnover rates, and (c) decrease organizational productivity.According to The theory of positive organizational psychology highlights the role of positive upward emotional spirals in organizations  as a pownegativity bias (asymmetry effect (Harming one’s sense of meaningfulness may be easier and more common than enhancing followers’ sense of meaningfulness. This is due to a negativity bias that is evident in numerous psychological phenomena . These wity bias  and the y effect . With rey effect . This hay effect . For exay effect , p. 77. With regards to work meaningfulness, this implies that the model we suggest, which aims to understand how contextual characteristics in the leader–follower process may harm followers’ meaningfulness, may have significant effects on the ability of managers to maintain followers’ meaningfulness without harming it. Furthermore, we contribute to the leadership and followership literature that considers the ‘dark side of leadership’ by showing under which conditions leaders might have a negative influence on followers’ motivating forces, namely meaningfulness.By incorporating the recent advancements of research on work meaningfulness , we devenot to dismantle followers’ work meaningfulness.Moreover, our research extends prior writings on the critical perspective on the management of meaning  by reveaOur conceptual model offers a wide terrain for future research. It suggests that there are multiple contextual conditions that interact with the process of meaning making to effect its outcomes. We offer various dimensions for underrating the process of work meaningfulness hindrance as a multi-focal process. In order to study this complex phenomenon, qualitative studies would be helpful at a first stage. In-depth interviews and ethnographies that explore the complex processes of meaningfulness hindrance over time will enable a more nuanced and deeper understanding of the mechanisms of this process. At a later stage, quantitative studies are warranted. Following and extending the work of Future research might also develop further conditions, which might harm followers’ work meaningfulness. While we focused on leaders, followers, their relationship and job design, considering these the major building blocks of the factors harming followers’ work meaningfulness, future studies might add factors to each of our categories or even suggest new categories. For example, the phenomenon of multiple team memberships  and the Although the current model offers a wide variety of contextual conditions that are likely to harm followers’ sense of work meaningfulness, we could not come up with an exhaustive list of conditions that harm followers’ work meaningfulness. Future studies may want to consider additional aspects of the leader-follower relationship, such as gender bias or followers’ attachment orientation, leaders’ abusive supervision, the financial climate, time pressure of the leaders and other aspects that may harm the meaningfulness making process. Importantly, while our model mainly considered particularly negative factors, such as leaders’ dark triad traits, also seemingly positive characteristics and circumstances might undermine followers’ sense of work meaningfulness. Furthermore, in our conceptual model each contextual condition is offered as a stand-alone variable. However, in the organizational life, these different aspects interact. For example, leaders who are perceived as Machiavelli may also be seen as unethical and may build a relationship with employees that is characterized by a low level of trust. Thus, future work needs to further develop the interaction among different contextual aspects, or conditions in which more than one of these contextual characteristics is evident, in order to obtain a more complex theoretical perspective. Moreover, our model is focused on the individual level. However, employees in organizations work in teams and in workgroups and their sense of meaningfulness is likely to be shaped and effected by other team members, the team environment and the heterogeneous specific relationships that different team members construct with the leader. Last, our model explores one direction of influence in which leaders shape and harm followers’ sense of meaningfulness. However, followers are also active agents and they may also harm leaders’ sense of work meaningfulness. Thus, future studies should also explore the opposite direction of influence or multiple and reciprocal directions of influence on reducing meaningfulness.It is worthy to note that in most circumstances managers may be attuned to fostering work meaningfulness and may be conscious of their behaviors aimed to elicit and affect the sense of meaningfulness. However, the behaviors and conditions that reduce the sense of meaning may be more hidden and managers may act upon them without full awareness. This dynamic should be explored in future studies.Our research makes a major step forward in better understanding the erosion of meaningful work through leaders. While an answer to the quest for meaningful work could be to increase the meaning making of leaders, our research shows that such behavior could decrease followers’ work meaningfulness. Thus, our conceptual work suggests that leaders should be trained and taught in the ways they should refrain from harming employees’ sense of meaningfulness. Under certain conditions of personality characteristics such as the dark triad, organizations should be attuned to better select managers that are low on such behaviors and personality structure, in order to reduce the possible negative effects of such leaders on employees’ sense of meaningfulness. Furthermore, if there is a negativity bias, and an asymmetrical effect of fostering versus hindering a sense of meaningfulness, leaders should be aware of their ability to harm more than to construct a sense of meaning. This implies that managers, practitioners and HR personnel should be mindful of followers’ sensitivity to this negative dynamic, and attempt to refrain from giving rise to such a dynamic that can result in the loss of followers inner meaningful ‘songs.’This project was a joint effort. Both authors developed the theory and ideas and contributed to writing the manuscript. The manuscript was written by both PK and RK, however, PK took the leading role in the writing process.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The last decade has seen improved public awareness of disability in sub-Saharan Africa. However, negative and stereotypical views of disability still persist in many communities. We conducted a study to promote awareness of disability in rural Kenya, using a process of reflection and education. This paper reports on the second aspect – education. The research question was: How can personal narratives of living with disability affect community attitudes and responses to disability?A qualitative phenomenological approach was adopted. Twenty community-based groups involving 249 participants took part. Each group participated in one focus group discussion at baseline, to explore the members’ personal experiences and views of disability. The intervention involved three adults with disabilities sharing their personal narratives with each group. After the intervention, repeat focus group discussions were conducted with each group. Thematic analysis was carried out according to the framework method.The emergent framework consisted of four main themes, organised as opposing constructs: ‘burden’ and ‘agency’, ‘sub-human’ and ‘human’. ‘Burden’ focused on the perceived hopelessness of the situation. Post-intervention revealed greater support for the ‘agency’ of persons with disabilities, evidenced by what the person could do, rather than their inability, and the relevance of support. The ‘sub-human’ to ‘human’ construct captured dehumanising and discriminating practice towards persons with disabilities on one side, and recognition of the person and inclusion in the community on the other. Whilst support and empathy were evident at the pre-intervention stage, post-intervention revealed greater recognition of people with disabilities as fellow human beings.This study provides a proof of concept regarding the deployment of persons with disabilities as agents for change. Exposure to experts-by-experience provided community groups with opportunities to reflect on, examine and adjust their views on disability in this rural part of Kenya. The sharing of personal narratives appeared to resonate with group members, to encourage recognition of the person and not just the disability, and to move their resolve toward ideas for collective action. Further research is needed to assess the effects of such interventions.The online version of this article (10.1186/s12914-018-0158-2) contains supplementary material, which is available to authorized users. How a community views, understands and responds to disability is important to the everyday life of people who have disabilities. Cognitive maturity –3, cultuCultural learning is also important. Traditional beliefs have tended to associate disability with negative images and experiences , althougThe question of how such stigma spreads across a community remains. Dipple et al. considered the relevance of ‘stigmergy’, a term originating from the French language, to the human world . Thus stAs a counter point, purposeful encounters with people who have disabilities appear to be critical to the formation of positive attitudes. Allport’s early ‘contact hypothesis’ proposed that increased interactions by one social group with another would promote more positive attitudes and decrease prejudice . This haDisability awareness training often involves interacting with people who have disabilities, combined with activities that have a more cognitive focus, e.g. engaging with new information and participating in discussions that challenge stereotypes. By increasing exposure to the people who are the very objects of devaluation in a positive and informed way, previous evaluations may be challenged –37. KrahDisability awareness training features in the ‘empowerment’ component of the Community-Based Rehabilitation (CBR)/Inclusive Development guidelines, which cuts across the other four components of health, education, livelihood and social . HoweverBased on the evidence that personal encounters with people living with disability have positive influence, and in harmony with the recommendations of the CBR guidelines, a project was set up to engage neighbourhood communities in a process of reflection and education. The first aspect - reflection, focused on community beliefs about disability causation and the attendant challenges . The curWith reference to Creswell et al.’s description, a phenomenological approach was adopted . ThematiThe setting was Kilifi County, one of the poorest areas in Kenya, with a poverty level of 71% . SituateBe formally constituted as a CHW or WG;Be active, having regular meetings, at least once a month;Have a consistent membership as evidenced by attendance of meetings;Have contact with people with disabilities.The study was conducted across five constituencies of Kilifi County, Kenya. They included Magarini, Malindi, Kilifi North, Kilifi South and Ganze. The focus was on two types of established community groups, namely community health worker groups (CHW), who are volunteers brought together to support the work of health dispensaries and health centres , and womRecruitment of the groups was facilitated by Pambazuko Disability Initiative, a community-based organization involved in providing support for children with disabilities in Takaungu, a sub-location in Kilifi County. Building on their existing links with WGs and CHWs, they identified 20 groups (10 CHW and 10 WG) who met the criteria in ten sub-locations. Each community group had around 15 members making an estimated total of 300 participants. The representative from Pambazuko approached each community group and arranged for the Project Researcher to attend a meeting for purposes of providing information about the project and soliciting their consent to participate. Each member gave their consent separately, recorded by signature, personal mark of thumb print on a consent form designed for the purpose. Fig. V, male, aged 45 years with cerebral palsy;W, female, aged 36 years with hearing impairment;X, male, aged 20 years with intellectual disability and traits of autism spectrum condition (ASC);Y, female, aged 20 years with hearing impairment;Z, male, aged 25 years with intellectual disabilityThe intervention aimed to promote disability awareness in the community. Based on Allport’s contact hypothesis , the ratEach member of the expert group was first given an opportunity to narrate his or her life story.Then JKG and the special needs teacher assisted in putting their stories in organised sequences.Each member was given a topic to talk about to minimise repetition: V was to talk about social life experiences, W about challenges of doing business, being independent, X to talk about challenges of being in school and living in a homestead. A homestead in this context means a structured cluster of houses belonging to relatives of the same grandparents.The group met for three hours every day over a six-week period to develop their personal narratives of living with a disability for sharing with the community groups. The first author (JKG) facilitated the training in partnership with the special needs education teacher. JKG organised for the training facility, and made sure the expert group reached the training venue on time. The special needs teacher rehearsed with the group and did sign language translation.After the six weeks, two members of the expert group, Y and Z, opted to pull out of the study. Y did not have basic knowledge of Kenyan Sign Language and Z relocated to another place with his parents. The special needs teacher interpreted the sign language to members of the community groups who participated in this study.The experts-by-experience were invited to share their stories with the community groups. Meetings started with prayers. Then the persons with disabilities proceeded to relate their stories one at a time. V was first to give his story about when he was in school, after school and his struggle in trying to get a wife. W was next in giving her story. She had a hearing impairment so the special needs teacher translated her sign language to the participants in the community groups. She based her presentation on personal experiences of starting a business within a community and being discriminated against within a family setup. X talked about experiences in school, and the challenges experienced at home. After the narratives, the community group members were given the opportunity to discuss issues and pose questions to the experts-by experience. The expert group was given financial compensation for their time, both for the training and the visits to the community groups during the intervention period.Focus group discussions (FGD) were conducted with each of the twenty community groups, pre-and post-intervention. The meetings were arranged by the Pambazuko representative in communication with group’s chairperson. The meetings took place in usual meeting place for each group, and refreshments were provided. The Chairperson opened the meeting and led the group in a prayer. The discussion was then introduced by the first author (JKG) who followed an interview schedule consisting of topics and a questioning route. At baseline, the groups were also asked to reflect on the causes and challenges of: (a) having a disability; and (b) caregiving for someone who has a disability. This is reported in a separate paper . They wePost-intervention visits were conducted approximately 2 months after the group had been exposed to the personal narratives of the experts. The groups were asked to consider the narratives shared by the experts by experience and what they had learned. The schedule of questions is provided in Additional file n = 134; post = 145) compared to that of the CHW  with a higher median attendance .Table The WG were comprised of all women and the CHWs had female to male ratio of 6:9. Discussions were carried out in the preferred language of the group and recorded on a digital audio device. With reference to the questioning route, questions were posed to the whole group initially to invite spontaneous responses. In order to establish a fair distribution of turns, this was followed by encouraging others to add to or comment on the views previously expressed. The duration of the FGDs was about two hours.The recorded data were uploaded to a computer and transcribed in the language used by the group, before translation into English; imported to the data management programme NVivo 10 for storage and analysis. To ensure accurate representation of meanings in the translated copies, checks were carried out during the analysis period. This involved the first author  and the last author -based visitor to Kenya) reviewing the transcripts, querying emergent concepts and their meanings, and using back translation as appropriate.‘Framework’ was the method of analysis used to evaluate impacts associated with the intervention . The entThe emergent framework consisted of four organising themes: Burden; Agency; Sub-human; Human. They were arranged as pairs of opposing constructs along a continuum (A. to B.), i.e. burden vs agency; sub-human vs human as shown in Fig. With reference to the framework in Fig. Inability-ability;Hopelessness-opportunity.The ‘burden vs agency’ construct was composed of two pairs of opposing themes, referred to as sub-constructs:‘Burden’ was defined as a problem that affected other people around the individual with a disability, with particular mention of the mothers as the primary caregivers. In the context of limited resources, both economic and psychological, there was the expressed view that having a person with a disability in the family, and in the wider community, was a source of difficulty. Reference was made to negative images of disability and disturbance to the well-being of others, both caregivers and members of the community. It was the case that disability was associated with ‘burden’ defined by ‘hopelessness’ and ‘inability’, almost exclusively at the pre-intervention stage, with 81 references made pre-intervention and only 3 references post-intervention. However, there was also recognition of the ‘agency’ of people with disabilities, defined as the capacity of an individual or group of individuals to act in the world. At post-intervention, ‘agency’, defined by ‘ability’ and ‘opportunities, emerged more emphatically with 193 references pre-intervention and 230 references post-intervention.inability, which captured a lack of capacity or what the person could not do, and what was perceived to be missing in the person. This was associated with dependence on others for care and support needs. The other side of the construct was ability, which referred to the individual having skills. It focused on the things the person could do, e.g. walking, learning, drawing water, earning money.On one side of this sub-construct was totally disabled”, and qualifiers as in “…cannot even eat”. Negative structures, such as “not”, were used in the pre-intervention references to people with disabilities. There was a shared perception of them being incomplete. Post-intervention, disability and ability were not mutually exclusive. That is, the respondents cited examples from the experts-by-experience, concluding that disability was not inability. Table ‘Ability’ was recognised both pre- and post-intervention. Pre-intervention discussions tended to focus on persons with disabilities who were known to the respondents. For example, references were made to individuals who used manual signing for communication, whose work involved digging the land and carrying water. Post-intervention the discussions focused more on the abilities of the experts who had presented their personal narratives. However, the opposing construct of ‘inability’ was expressed almost exclusively in the pre-intervention groups, with the exception of just 1 reference made post-intervention:“ …having limitations and there are things they cannot do.” CHW10–2]. However, the use of ‘things’ implies a more measured response that is different from the more exacting responses in the pre-intervention discussions. Here the emphasis was on what the person could not do – their lack of capacity, as exemplified by the use of intensifiers as in “. HoweverHopelessness captured the sense of giving up and the desire to have the individual with a disability gone. Associated with this was a lack of ideas or momentum to act in a different way. The antithesis of this was opportunity, which encapsulated the idea of supporting the person with a disability to take part in activities, e.g. attend school, regardless of their particular challenges. This implied putting help in place, and helping to circumvent some of the observed difficulties.hopelessness. A sense of despondency was conveyed in the stories shared, and even of individuals with disabilities being rejected. There was some notion of supporting the child with a disability to be “in the world” at the pre-intervention stage, but this was augmented considerably in the post-intervention discussions. Opportunity was defined as support and calls to action by the community. Greater awareness of opportunities was shown post-intervention, with consideration of health, education and employment, which underpinned the groups’ growing sense of the ‘agency’ of people with disabilities. Calls to action included having a community meeting as “…one voice...” and getting others to listen to the stories of people with disabilities. Table Pre-intervention, the focus group discussions told of situations that implied Dehumanisation-recognition;Discrimination-inclusion.The theme of ‘Sub-human’ denotes a focus on the disability before the person, which dominated group discussions before the intervention .. In contrast, the theme ‘Human’ refers to recognizing the person before the disability. This included attributing positive value to the individual and viewing him/her as a member of the community . The ‘sub-human’ vs ‘human’ construct was composed of two pairs of sub-constructs:ehumanisation included references to people with disabilities that rendered them as negatively valued. The words used for people with disabilities referred to the type of disability as a collective noun, with neglect of the person. Practices were described that were devoid of humanitarian effort, e.g. chained up, tied, food passed with stick. The individual was rendered as an object, without human feelings or potential. The antithesis of this was recognition, which acknowledged the person in his or her own right. There was notice of the person’s struggles and difficulties, with expressions of empathy for their experiences.Dsub-human, viewed as an ‘object’ or “grown like that of an animal”. However, there was also ‘recognition’ of the ‘person’ as stories of familiar individuals were told, e.g. “…raise my hand to greet him…”, ‘“the first person to get the news”. Post-intervention, the terms used previously in relation to people with disabilities were revised towards greater ‘recognition’ of the person, before the disability, e.g. “we are all human beings…” Realisation of the sameness of persons with and without disabilities was expressed in relation to their religious convictions, e.g. “created by the same God” also.The terms used in the groups before the intervention, depicted persons with disabilities as ‘things’ belonging to the ki-vi class of nouns in the Kiswahili language. Individuals were referred to as “kiwete” (crippled), “kiziwi” (deaf) and “bubu” (dumb), or “akili punguani” . This had the effect of classifying the person with a disability as The basic theme ‘shame’ referred to the indignities suffered by people with disabilities and some of terrible treatment meted out by others. The stories were told both at pre-and post-intervention; however, greater ‘empathy’ characterised the stories at post-intervention, although not exclusively, e.g. “…you will sympathise with him…” said one respondent describing someone in her local community before the intervention. However, after hearing the narratives of the experts-by-experience, the group members expressed affect as well as awareness of the person’s emotions, e.g. “…saddened by their stories…” and “…he also has emotional feelings”. Table Discrimination described the ways in which the person was treated differently to their peers, being ‘discounted’ or ‘abused’. Opportunities were constrained and exclusions were commonplace, rendering the person disempowered and disenfranchised. The opposite of discrimination was ‘inclusion’, which captured being ‘valued’ and establishing ‘acceptance’ in everyday life.The discussions pre-intervention revealed tales of ‘discounted’ individuals who were acknowledged to be “…valueless in the family” and discriminated against when earning a living, e.g. “…the (fried) fish will not be bought…” Other stories told of ‘abuse’ which included exploitation also. Post-intervention there was deliberate consideration of the actions needed to counter the ‘discounted’ ways of responding to persons with disabilities. Actions that valued the individual included “...showing them love…”, “…care(ing) for them…”, and “…know(ing) about their health, their wellbeing…” – all expressions of human need. Finally, there was ‘recognition’ of a need for ‘acceptance’ such that persons with disabilities should be treated in a similar way to those without disabilities, with a call to “…sensitise the community…” Table Occurring mainly in pre-intervention group discussions, dominance of negative images and the use of language that tended to focus on the physical or visible characteristics of disability were suggestive of the individual or medical model . The opeCultural beliefs and traditional practices have been commonly associated with negative images , 15–18 aMany of the stories of people with disabilities spoken about in the focus groups, particularly pre-intervention, yielded images that portrayed children and adults with disabilities as undesirable or associated with an unpleasant encounter, which affected the extent to which the person was accepted by the community –26. TherEncountering experts-by-experience who shared their personal narratives, appears to have triggered a reassessment of the meanings associated with disability –37. ConfThe sample was comprised of established groups of community health workers and women’s groups. Whilst the value of formally constituted memberships brought mutual familiarity and shared local knowledge to the focus group discussions, gender bias in the women’s groups may be a factor in their discussions, just as the more health focus of the CHWs may have influenced their particular views on disability. Future research could involve other community groups considered to be opinion leaders, such as heads of ten homesteads, village leaders and even traditional healers to give diversity of perceived views. The experts-by-experience originally recruited to deliver the intervention were representative of a range of the most common developmental disabilities . However, 2 individuals withdrew their services during the preparation period, which reduced the diversity of personal narratives presented to the groups. This may have affected opportunities to consider the broad spectrum of disability in the groups. Saturation checks on the data for possible follow up in terms of data collection were not made due to financial and time constraints. The questions and prompts used to guide the focus group discussions post-intervention, might have usefully included reflections on the pre-intervention discussions. By asking participants to comment on the views expressed prior to meeting the experts-by-experience, direct capture of any transformations in attitude may have been possible. Whilst the study was able to capture community group responses to disability, and to examine the potentially mediating effect of exposure to experts-by-experience, further research is needed to evaluate intervention potency and effect size.The research contributes to the evidence on CBR, demonstrating the potential of a low-cost, relatively brief intervention, which may be applicable in other low-income settings. The very act of employing people with disabilities assigns them a higher status as ‘experts-by-experience’, which is in opposition to the more familiar ‘discounted’ role seen in many communities. The participants wanted the experts to have the same opportunities as others, which extended to being married and having their own home.The sharing of life experiences through organized community engagement, appears to have facilitated community groups to reflect on, examine and adjust their attitudes towards people with disabilities. The personal narratives served to authenticate the process of learning by the community groups. Listening to and interacting with the experts-by-experience invited the participants to reflect on their own values, against a backdrop of deeply held cultural beliefs and practices. The personal stories guided the participants in viewing the ‘person’ before the ‘disability’. This appeared to be a catalyst for change, both in the attitudes espoused, and in the motivations expressed by the groups. For example, the groups articulated a shared quest to achieve better understanding of disability and to reach more people in their communities. Ultimately, the findings from the current study have implications for mobilizing DPOs, parent or caregiver groups and other rights-based organizations as agents for change in local communities. In this way, a new type of ‘stygmergy’  may be tAdditional file 1:Appendix 1. Pre-intervention guide and Post-intervention guide. (DOCX 14 kb)


Self-medication is described as the use of drugs without a physician’s prescription to treat self-recognized illness or symptoms, and an important health issue among the elderly. Despite the wide range of different definitions, recognizing all forms of self-medication among older adults, particularly, in developing countries, help healthcare professionals and providers to reduce harmful effects of self-medication. The purpose of this study is to describe the practice of self-medication and its related factors among elderly people in Iran based on the experiences of people who are involved in this phenomenon.This qualitative study was conducted using content analysis. Purposive sampling was used to select the participants and continued until saturation. The participants were the elderly, their care-givers, physicians, and pharmacists. Data was collected using semi-structured interviews, and analysis was done using an inductive approach. The theory of planned behavior was used as a framework to explain the role of the emerged factors in the occurrence of self-medication behavior.: “patient’s attitudes towards disease, treatment, and physicians”, “living with disease”, “unfriendly environments”, “enabling health system”, and “influential others”.Based on the expressed experiences of the participants, factors related to the practice of self- medication among the elderly in Iran fit in these 5 categoriesBased on the results of this study, self-medication of the elderly in Iran has commonalities with many countries in regard to over-the-counter medications and complementary and alternative medicine; however, self-medication is also seen with drugs that require a prescription but can easily be obtained from pharmacies. Contributing factors, apart from the elderly themselves, include their families, caregivers, and social circle, the physical environment where they live, and the health system from which they receive services. Self-medication is a health-related issue which is currently being discussed and addressed in most countries around the world. Multiple definitions have been presented in different studies, their common point being the use of unprescribed medications to treat symptoms and disease identified by the individual himself or herself. Different forms of self-medication can be found in the literature including use of unprescribed medications, medication refills, medications prescribed to friends and relatives, leftover medications from previous prescriptions, and changing the dosage of prescribed medications. Self-medication can also be in the form of using pharmaceutical medications, traditional and home remedies, and supplements –4.Studies have pointed out multiple problems related to self-medication which includes increased risk of adverse drug reactions, drug interactions, drug resistance, and even sudden death in certain cases. These eventualities are partly attributable to prescription drugs used on an individual’s own initiative and partly to misuse or abuse of OTC medicines –7. NonetOf note, the list of OTC medicines and their provision methods vary by country, and their access and consumption patterns depend on the nation’s health system and regulations. In some countries, such as the United States of America, OTC medicines are sold directly to the consumer in drugstores and general stores. In the United Kingdom and many other European countries, they are only available in drugstores where they are dispensed at the discretion of the pharmacist, and only small amounts of low doses may be available in general stores . These dSelf-medication may be practiced at any age, but when it comes to the issue of treatment and medications, special attention is given to the elderly as a special group, because various studies have found them to be the largest consumers of medicines in most countries, and Iran is no exception to this fact , 9. One Multiple studies have addressed self-medication around the world, and multiple causes have been identified. Causes include the high costs of treatment and insufficient insurance coverage, and therefore, many people who cannot afford physician’s fees will resort to self-medication. Other causes mentioned in the literature include avoiding loss of work-time, distrust in health personnel, long waiting times for seeing a physician, having previous experiences with the disease, and underrating disease , 11, 12.Available studies on self-medication in Iran are descriptive and focus on the prevalence and reasons for self-medication, diseases associated with self-medication, and common medicines used in this regard , 13–15, Unlike many other countries, in Iran, only pharmacies are allowed to sell prescription and non-prescription medicines , althougOverall, a variety of factors can be involved in the practice of self-medication and predisposing factors may vary by population and culture. Also, in-depth studies in this area are very limited in Iran. Therefore, in light of the unique circumstances of its health care system, this study aims to achieve a comprehensive understanding of self-medication practices by elderly people in Iran and its determinants based on the experiences of stakeholders including the elderly, their caregivers, physicians, and pharmacists.This is an inductive qualitative content analysis study of self-medication among elderly people in Iran. The researchers performed an in-depth direct analysis of stakeholders’ experiences. Any prejudgment and expression of personal opinions were avoided during data collection and analysis. In this regard, the applied strategies included memoing, member check, interviewer training and engaging experts in qualitative studies in the research team. The results are presented as codes, subcategories, and categories using an inductive approach , which wParticipants were selected through purposive sampling from stakeholders who were believed to be the most information rich regarding their experiences with self-medication. Selection of study groups was based on the objective of the study, and in light of the research question, study samples included groups of elderly people, their caregivers, physicians, and pharmacists.The inclusion criterion for elderly participants was having a history of self-medication. This was determined through review of their medical history by a physician and finding at least one non-OTC item which was consumed without a prescription. Enrolled caregivers were in charge the elderly who practiced self-medication, lived with them, and were fully aware of their life situations. The inclusion criterion for physicians and pharmacists was to have encountered elderly patients.All study participants were residents of Tehran, consented to participation, had favorable communication skills, and were interested in sharing their experiences. As agreed with the participants, interviews with the elderly and their caregiver’s were conducted at their home or the hospital where they were hospitalized, and interviews with physicians and pharmacists were done at their workplace.The endpoint for sample selection was reaching data saturation regarding self-medication . At thisThe data for this study was collected between July 2015 and May 2016 through in-depth semi-structured interviews with the participants. Interviews were conducted by the first author (SSM) who has experience in research on the elderly and trained for conducting qualitative interviews. In addition to interviews, we used available documents and evidence such as the list of OTC medicines and related regulations as well as prescription records, their medicine bags, and medicines they had stored at home. Elderly participants were approached at the residence where a researcher and a general practitioner examined the contents of their medicine bags and their prescription records, obtained a medication history, and determined their eligibility for study inclusion.Interviews with the elderly started with their experience about self-medication, and according to the interview guidelines, general open-ended questions were asked saying “Think of an instance when you were feeling unwell or in pain. What did you do to alleviate this feeling?” or “Describe an instance when you were using medicine without consulting a physician.” Then, depending on the context of the responses, the interviewer continued with exploratory questions such as “Can you please give an example?” or “Could you explain more?” to clarify concepts for the researcher and participants. The duration of the interview ranged between 45 and 90 minutes depending on the willingness and situation of the respondent. Since certain issues could be beyond the scope of the interview, respondents were given the opportunity for an informal conversation at the end of the interview by asking them “Would you like to add anything else?” Each respondent had 1–3 interviews, as needed. Additional interviews were scheduled when participants still had more to say or the preliminary analysis (transcription and coding) indicated a need for obtaining further information. In the latter case, interviews were kept short and limited to specific questions. Other participants were enrolled based on data direction.After each interview, audio files were listened to several times and verbatim transcriptions were prepared. Each entire interview was considered as an analysis unit. The transcribed script was read several times to become familiar with the context, after which, the meaning units were identified. The meaning units were then condensed according to their content and context. Then, the condensed meaning units were abstracted and labeled with a code Table . Which wIn the process of this study, we adhered to the recommended criteria for the assessment of qualitative data , 23, 24.This study was approved by the Ethics Committee of the Iran University of Medical Sciences. The study purpose and procedures were fully explained to target individuals before each interview, and only those providing informed consent were enrolled in the study. Participants were assured of confidentiality and anonymity of the information provided, and they were free to withdraw from the study at any point. Participating elderly who had presented for treatment were assured that their non-participation or withdrawal would not affect their treatment or care.The participants of the study were 21 people, 12 women and 9 men, who took part in a total of 25 interviews. Participants included 10 elderly people 60 years of age and older, 3 caregivers, 3 pharmacists, and 5 physicians. The mean age of the participants was 57.78 ± 14.1 years, and the mean age of the elderly was 69.6 ± 8.4 years. Among participants, 16 were married, 3 were widowed, 1 was single, and 1 was divorced. Two of the participating elderly were illiterate, 3 had elementary education, 3 had completed middle school, 1 had a high school diploma, and 1 had a bachelor’s degree.OTC medicationsComplementary or alternative medicinesNon-prescribed prescription medications recommended by the selling pharmacistPrescription medications purchased using expired and non-refillable prescriptionsLeftover drugs from old prescriptionsPrescription medications offered by family and friends.In this study, respondents mentioned the following forms of self-medication:For example, elderly participant No. 3 stated: “I get it from the pharmacy myself. Some doctor prescribed to me some time ago, and now I just take the packaging and tell them that’s what I want. Sometimes I ask them at the pharmacy. I tell them my problem and they tell me which medicine is good and they give it to me.”Caregiver No. 2: “Her friend told her that she was taking chlordiazepoxide, it’s good, and she was so calm. Now she’s started taking it too.”Elderly participant No. 2: “I had some myself. A doctor had prescribed it to me once. I still had some at home. So I started taking it. ”Self-medication is sometimes the first line of treatment, and the patients seeks medical advice only after self-medication fails, while in other cases, self-medication is practiced as the substitute treatment.Our study participant’s experiences about self-medication and its determinants were grouped in 5 categories: “patient’s attitudes towards disease, treatment, and physicians”, “living with disease”, “unfriendly environments”, “enabling health system” and “influential others”; each had their own subcategories. These results are summarized in Table In some cases, elderly participants turn to self-medicate because they believed that their diseases were self-limiting, did not take their disease seriously, or they found an intervenable and simple justification for their problem with the logic that the disease was unvarying. Some of them indicated that age-related complaints are common among their peers and most of their symptoms are caused by the aging process, therefore visiting a doctor is useless.For instance elderly person No. 2 said: “Ten years ago my doctor said I had high blood sugar, prescribed a pill and said take one in the morning and one at night. I didn’t take it seriously and took one instead of two pills. I told myself I’d work and burn the extra sugar by working. Then my disease got severe.”Elderly participant No. 8: “Some diseases, like the heart, are no joke. You have to see a doctor right away. You have to take them seriously. You can’t just do something about it yourself. But things like joint pains, headaches, and colds don’t need a doctor. I can somehow handle it myself.”Caregiver No. 2: “She resists going to the doctor and thinks that’s how it is, won’t get better, it’s because of her age and has to bear it. She says what’s going to come of going to the doctor?”On the other hand, elderly’s perception of drugs and their belief that certain medicines such as pain killers, vitamins, home and herbal remedies, and even certain antibiotics are harmless and effective leads them to use them groundlessly. In this regard, pharmacist No. 1 said: “A lot of times, they think they’d get better if they keep taking the same drug. We keep telling them that it has a certain course of treatment, and they may have side effects if used more than prescribed. If I refuse to sell it, they’ll go get it from the next pharmacy.”Physician No. 3 said: “Usually, patients have already used home and herbal remedies and any medications that they perceive as effective when they come see us, especially with colds and digestive problems. They take herbal teas and extracts. They don’t count them as medicine, they think they’re safe, and they use them.”Elderly No. 2: “I believe in herbals because they’ve worked for me. If they didn’t work, I wouldn’t. For example, I didn’t know yellow goatsbeard is good for the heart. My brother told me, I tried it, and it was good. It’s best that we old people medicate with these herbs. They’re harmless and all.”Our data showed that negative attitudes toward visiting a physician leads to self-medication. For elderly participants, these negative attitudes ranged from psychosocial issues such as mistrust, fear of hospitalization and surgery, fear and anxiety of being diagnosed with medical conditions  or adding more to their medications, fear of medical interventions due to previous problems and complications and also logistical issues. The logistical concerns for visiting a doctor include: lengthy waiting times at the doctors’, long interval between identifying a need for specific tests and treatments and actually receiving those services, and lack of support from their caregivers or families.Elderly participant No. 1 expressed: “I don’t go to the doctor’s if I can help it, and pain doesn’t bother me, because doctors are like construction workers. It’s the same with doctors. They keep sending you for a checkup here and a checkup there. They’re bound to find something eventually. Now the doctor tells me to get an angio, but my mom got a bruise in her leg when she did hers. It was hard for my sister too. She couldn’t walk at all. I’m too scared to do it.”According to our data, self-medication among older adults is influenced by high pain intensity, severity of other symptoms, and urgent need for treatment of sudden symptoms. In addition, prolonged and persistent symptoms after receiving (ineffective) care from providers also leads to all types of self-medication. For instance, elderly participant No. 8 recounted: “I had a kidney stone and the pain was getting too much. Excruciating! I even went to the doctor’s but the drugs didn’t work. I did anything to ease the pain. I took any painkiller.”Caregiver No. 1: “When she has unbearable symptoms or severe nausea and vomiting that are too disturbing for her, she will do anything anyone recommends because she can’t bear it. Some neighbor might suggest it’s something she ate, and that she should take some herbal or other, and she listens.”The experiences of the participating elderly indicated that environmental factors can prevent seeing a doctor and set the grounds for self-medication among the elderly.In this regard, caregiver No. 2 stated: “If you want to take her to the doctor, you have to get a cab, and it costs too much. If you want to walk, just look at the sidewalks. Do you think they’re suitable for the elderly? It’s all troughs and bumps. If you want to take public transportation, she can’t get on. That’s why it’s totally difficult and you can’t go to the doctor’s too frequently. Not going to the doctor has effects too. For example, her friends told her they were taking chlordiazepoxide, it’s good, and they’re calm. And now she has started taking it too.”Caregiver No. 1: “We can’t move mom. It’s really hard. She had a hand skin problem. I had to get a photo and take it to the doctor. I couldn’t take mom because there was a staircase to the office and no elevator. Besides, the office is crowded and my mom can’t wait a turn on account of her condition. She can’t sit long, and if the waiting time is too long she needs to use the restroom and most offices don’t have a suitable one for the elderly.”Certain factors relate to the health care provision system in Iran. Medicines are available to patients with no limitation. All participants had the experience of simply going to the pharmacy and purchasing any medicine they needed with or without a prescription. This method is easier and more cost-effective for them than going to a physician’s office and spending extra time and money. Moreover, the low price of medicines in Iran compared to many other countries makes it easier to access drugs. Also, patients have to pay a high share of the costs of office visits and treatment, and all these issues set the grounds for self-medication.In this regard, elderly person No. 3 stated: “I go to the pharmacy myself and name what I want or I take the packaging. Even if I don’t know the name, I ask the pharmacists. They give me any medicine I want. I get to save the physician fee, and I can get my apprentice to go get it for me if I’m busy.”Pharmacist No. 2 indicated that: “A packet of cold medicine or even antibiotics is cheaper than bread. This means medicine is cheaper than basic needs. Patients see if they go see a doctor, they have to pay the fee, it’ll cost them more. So they’ll go get it from the pharmacy. And there is a very bitter joke between pharmacists that we have close to 3000 OTC medicines in Iran, and the list practically includes all drugs.”Hanging in the balance in the health system is another contributing factor to self-medication. When individuals feel unwell, they do not know who to consult, and they are faced with a long list of specialists; eventually the choice is up to them. Almost all participants recalled having seen several physicians for the treatment of the same disease. This is while most specialists they chose were irrelevant to their problem, and seeing them was a waste of time and expenses. Eventually, many cases resorted to self-medication to alleviate their disturbing symptoms.In this regard, caregiver No. 3 stated: “The problem is that we didn’t know who to see for mom’s problem. And there was no one to advise us. We kept going to different doctors others’ recommended; it was no use. During this time, she tried everything anyone suggested.”The lack of any record regarding patients’ medical history and medications is another issue in the health care system. Physicians and pharmacists have no knowledge of the drugs used by patients and provide them with any kind of medicine. In this regard, pharmacist No. 1 stated: “As a pharmacist, I don’t have their medication history. Since I don’t have any access to the other drugs they’re using, there’s not much I can do. So I give patients the drugs they want. If I don’t, they’ll get it at the next store.”Receiving insufficient information at the time of visiting a doctor is another predisposing factor. In many cases, the physician does not provide enough information about the course of the disease, instruction about prescribed medications and their possible side effects, and thus, the patient feels confused even after seeing a physician. Since they are undecided about whether they should return or get a refill, they resort to self-medication.In this regard, elderly participant No. 5 stated: “The doctor prescribed me a bag of drugs without saying a word. So, what am I supposed to do with these? What am I supposed to do when I finish these? I get confused.”People around the elderly patient play an important role in self-medication. Elderly people’s families and caregivers can have a strong influence on how they deal with therapy and use of medications because the elderly often rely on them for seeing a physician and managing their medications. On the other hand, friends and neighbors exert their influence by sharing their experiences. In many cases, people who have experienced the same illness recount their experiences and influence the elderly directly or indirectly with their suggestions. For instance, caregiver No. 2 said: “The lady I care for started using a drug after a friend of hers recommended it, because she said it worked for her. That’s how she got started. Or her son brings her medications from abroad. She goes to the park and someone tells her what their doctor gave them for their pains, and she goes to the pharmacy and gets the same thing.”As presented in Fig. Based on the results of this study, self-medication among elderly Iranians occurs under circumstances where the individual is not the only person who has a role in it. While certain factors are related to the elderly themselves, the environment they live in, the health care platform, and even the families, caregivers, and other people around them play an important role in their treatment process and their decision to self-treat. A common problem in Iran is using non-prescribed prescription medications. Our data showed that the unauthorized use of prescription medications in Iran is not a rare or isolated self-medication approach. Almost all participants pointed to the easy access of Iranian adults to such medications that are obtained from local pharmacies. Use of old/expired prescription medications, unauthorized refills and receiving them from friends, and family are also common.Although the present study had an inductive approach and the presented concepts emerge from the data, results can be explained within the frameworks of certain theories and models in health behavior studies. Compared to available theories, the extracted categories in this study seem to be consistent with the TPB, which is well-known among health behavior theories and has three constructs: attitude toward behavior (ATB), subjective norms (SN) and perceived behavioral control (PBC) , 25, 26.Our study results indicated that patients’ attitudes, beliefs, and perceptions about disease and different ways of dealing with it are a major determinant of patients’ behaviors. When patients believe there is no need to see a doctor, they definitely turn to self-medication. This is while sometimes a symptom such as fever is considered ordinary and simple by patients, but can be a serious sign of disease for the elderly . In addiThe emerged concepts from this section are consistent with the PBC construct in TPB which refers to people’s perceptions of their ability to perform a given behavior . This coFacilitators of self-medication in the elderly include situations when they have mild or tolerable symptoms or conditions that can be attributable to older age. In these cases, individuals believe themselves to be self-efficient and capable of handling the situation on their own. Therefore, by taking into factor the effect of patients’ attitudes about disease on the intention to self-treat, and the subsequent behavior, this construct can be used to design behavior change interventions to prevent self-medication when there is need to refer to a physician.Based on the results Patients believe many medications such as sedatives, supplements and herbal medicines are safe, and thus, they consume these products carelessly. Self-medication with medicinal herbs and herbal medicines is common practice. The belief is that these medications are useful or at least there is no harm in using them. A positive attitude of the elderly toward the effects of self-medication with these groups of medications on their health and diseases is one of the important factors leading to self-medication behavior which is known as ATB in TBP. ATB is defined as positive or negative reactions or evaluative affects about a behavior which display as feelings, beliefs, and even behaviors. In other words, when people believe a given behavior will lead to valuable outcomes, they will develop a positive attitude toward that behavior, and vice versa. As a result of this positive attitude, such medications are consumed without any consideration to precautions, especially that they are often combined with pharmaceutical products. Designing interventions that aim at correcting this false belief can reduce the risks associated with the improper use of sedatives, supplements and herbal medicines.Non-prescription medications used for self-medication often come with patient information sheets, but the main challenge in Iran is that, unlike many other countries, reading them is not common practice . TherefoBased on the participants experiences distrust in physicians is another factor that arises from having a history of failed treatment, misdiagnosis and the belief that diagnostic procedures are unnecessary and prescribed by physicians mainly for their own financial gain. Distrust in medical services has been mentioned by Sawalha and Shaghaghi et al. , 30. In Most of the elderly resisted going to a physician as far as they could. The refusal is sometimes due to fear of being diagnosed with a dangerous illness or the possibility of a serious new problem. Although studies suggest that fear of death decreases in old age compared to other age groups , they wiOther factors expressed in this study concerned situations when the patient struggled. Practicing self-medication in acute situations that are unbearable for the elderly is another good example of the function of the PBC construct in the TPB model. Even those who closely follow their physicians’ orders might do anything they can when they have acute and agonizing symptoms, and they may turn to self-medication while they wait for the chance to see their physician, or even afterwards when their symptoms do not resolve. Under these circumstances, the elderly resort to a solution to alleviate their symptoms until the physician arrives or the situation becomes bearable. From another point of view, the circumstances facilitate performing self-medication. Presence of severe symptoms and failure to resolve them were the most common reasons for self-medication. In the study by Pineles and Parente as well .In Iran, an additional problem is lack of urgent care services. There are cases with non-life-threatening conditions who do not feel the need to present to the emergency room, but arranging an early office visit is not possible either, and urgent care seems the right services for them . There iAnother expressed issue in our study, which fits as a PBC construct, concerns complicated situations due to chronic disease comorbidity. Self-adjusting the dosage, discontinuing their use, forgetting certain medications, and self-medication, are among other issues that arise from multimorbidity and multiple drug consumption. This result is consistent with previous studies . In mostIn many cases, the physical environment is unsuitable for the elderly and prevents them from seeing a doctor on their own when they feel the need. This factor deprived them from available health services and they resorted to self-medication at home. While special assistance is available for the handicapped and the elderly in developed countries, public transportation in Iran has not considered the special needs of incapacitated individuals. In addition, sidewalks and pedestrian passageways are not proper or safe, and clinics lack disabled facilities. Concepts within the category of “unfriendly environments”, as described here, facilitate performing self-medication among elderly through a mechanism consistent with the PBC construct.New theories of disability also suggest that unsuitable environments can hinder the utilization of health care services, and thus, the individual resorts to self-managing the disease and its symptoms; this problem could be avoided if the given individual was in a well prepared and supportive environment . Should The setting of the health care services can play a facilitating role in self-medication as well. Factors such as easy access to low-priced drugs, high physician fees, and other issues in this category make the health system and its components consistent with the PBC construct in the TPB model. When treatment does not follow a specific process and patient information is not recorded in a unified system, the patients are free to go to any physician and pharmacy and ask for the medications they need. Patients referring to pharmacies are unaware whether the medicine they are asking for is an OTC drug or requires a prescription. The lack of awareness in our country is probably because, unlike other countries, OTC drugs in Iran are not sold off the shelf and they are treated similar to other drugs. In any case, the provision manner of OTC medications along with unawareness about the list of such medications complicates the problem. In this regard, the role of pharmacies which sell off-list items despite their knowledge of the list of OTC drugs should not be overlooked. In this process, most medications are practically available as simply as OTC drugs are. This issue has been discussed in the study by Sahebi et al. as well .An additional issue expressed by our participants is the low price of drugs in Iran. Studies suggest that this is because 95% of them are manufactured domestically  and unliAnother concern within the health setting in Iran is that, although most people have health insurance, out-of-pocket percentages are high, and health expenses can impose a heavy financial burden. As a result, people may settle for obtaining medication without a prescription rather than seeing a doctor. Mehrdad has discussed this matter in his description of the health system in Iran . In the When a patient consults a physician but does not receive sufficient information about the treatment process, they are less likely to follow the physician’s instructions, and in many cases, they make decisions themselves. In this regard, physicians’ work load and busy clinics, especially in public settings, should not be overlooked. Physicians participating in this study stated that their busy clinics did not leave enough time for them to discuss matters with each patient.  In addition to the mentioned issues, the people who influence the elderly can have a substantial effect in the treatment process. It appears that this influence is even stronger when herbal and traditional medicines are concerned, which is due to the misconception about their safety. Family and caregiver support for receiving medical care is mentioned in other countries as well, especially for elderly who are incapable of living independently . This fiIn Iran, however, the elderly have low levels of literacy , and conIn conclusion, as presented in Fig. According to this model, determinants of health behavior can be fit into interacting categories that form a given behavior. Each one of these factors may belong to the intrapersonal, interpersonal, organizational, community, and public policy categories. Therefore, if self-medication is considered an elderly patient’s health-related behavior, the behavior is formed by patient’s attitudes and living in pain in the intrapersonal level, influential others in the interpersonal level, service providers in the organizational level, improper physical environment in the community level, and enabling health setting in the public policy level.This study had certain limitations. Since data was collected using participants’ previous experiences, similar to other studies of this kind, there is the probability of recall bias. Since recall bias is more likely among older participants, focus was placed on their more recent experiences to reduce this bias, and where necessary, data was completed and verified through family members. Another limitation is that people may not be willing to admit having behaviors that may appear to be improper by others. This tendency can increase the social desirability bias, and the most important measure to reduce this bias was to gain their trust. Other approached used to reduce this type of bias included asking indirect questions so that the behavior would not seem unjustifiable or unacceptable.The elderly in Iran practice different forms of self-medication that involve prescription, non-prescription and herbal/complementary medicines. Determinants of performing self-medication behavior, as identified in this study, include a variety of factors that are consistent with the constructs forming behavioral intention and behavior in the TPB model. These include patient’s attitudes, living with disease, unfriendly environments, enabling health system, and influential others.


In this article physical activity, screen time, and academic work are studied as mediators between socio-economic status and sleep duration among school children in India. Participants were 268 school children aged 10–15 from Pune, India. They were sampled from private schools and impoverished public schools. We found that the highest socio-economic status children reported almost an hour and a half less sleep than their lowest socio-economic status counterparts. The lower socio-economic status children reported more physical activity and screen time, and the higher socio-economic status children reported spending more time on academic work. Although screen time was negatively related to sleep duration, academic work was the strongest mediator between socio-economic status and sleep duration. Physical activity was not a significant mediator. In India, academic work is a strong predictor of a lower sleep duration among children and adolescents. Several studies have revealed a link between socio-economic status (SES), here defined as family wealth and material resources  viewing, the use of computers and/or internet use, electronic gaming, and mobile telephones increasingly dominate the leisure time of children and adolescents  and four private (seven classes) schools were included in the study. One public and one private school were segregated by gender and the remaining schools had mixed-sex classes. All classes from public schools were semi-English  and all private schools had English as their primary medium of instruction. We obtained parental and children’s consent for 442 children. We excluded 16 children from the sample due to learning disabilities or psychopathology. In the higher SES, 42 children withdrew during the course of the study. The reason that was mostly cited was that the study was seen as too time-consuming or bothersome. Furthermore, we tried to collect data on 3 days for time spending patterns, and we chose to only include those students who provided data on SES, and time spending on at least one weekday and a weekend day, because children’s sleeping patterns may be different between weekend and weekdays . The analyses include152 boys (56.7 %) and 116 girls (43.3 %). For descriptive purposes SES categories were created using the Family Affluence Scale , the middle SES category  and the lowest SES category   = 187.47, p = .001 was seen; The vast majority of the lowest SES students  attended public schools, of the middle SES group, the vast majority attended private schools , and in the highest SES group, all children attended private schools.The adolescents ranged in age from 11 to 17 years  and ten randomly selected children from public school  were double coded. The intra-class correlation coefficients were .91 for sleep, .86 for time spent in physically active pursuits, .90 for screen time and .93 for time spent in academic activities.SES was measured using the “Family Affluence Scale” (FAS), which consists of four items  and secondary activities (were you doing anything else at that time?) for each 10-min epoch of the day, again increasing variance and reducing dependency on other time spending variables.p < .05  = 12.282, p = .001, η2 = .085], that there are no significant differences between the SES groups in terms of physical activity , but there are significant differences on screen time , and academic work , with the lowest SES group reporting the most screen time and the least time spent on academic work. The correlations between the variables are reported in Table The means and standard deviations for the variables in this study are included in Table F, 265 = 1The outcomes of the analyses of the role of mediators are reported in Table Using the procedure described by Preacher and Hayes  we testeThe current manuscript focused on the relation between SES and sleep, and potential mediators in this relation. Though past studies suggest that children with a lower SES sleep less (El-Sheikh et al. In line with our first hypothesis, we found that children from a higher SES in India sleep less than children from a lower SES, which is similar to results earlier found in Turkey (Arman et al. Screen time was found to be a significant mediator in the relation between SES and sleep time, with lower SES children reporting more screen time, and screen time negatively related to time spent sleeping. Paradoxically, even though higher SES reported less screen time, they also reported less sleep than the lower SES children. Consistent with our hypothesis, academic work was found to be a significant mediator between SES and sleep duration. To an extent, these results are comparable to what has been previously suggested by Arman et al.  for chilMuch of the waking time of higher SES youth was spent in academic work, which was, on an average including a weekend day, just below 6 h a day. A previous study comparing Western and Asian cultural contexts of sleep (Liu et al. Some limitations of the current study must be noted. Screen time was treated as a compound variable in our study, consisting of television viewing, electronic games, and computer-use. We made this choice because most of the children’s screen time consisted of television viewing, with electronic games and computer-use being reported far less; coding each category of screen time separately would likely have resulted in too little variation in the data, and we believe that our choice to create a compound variable is justified, given that all separate forms of screen time have been found related to overall screen time, and similar explanations have been offered for all these relations (Cain and Gradisar The current study adds to a growing body of literature that suggests that in Asia study related stress and activities might be so large that they intervene with children’s sleep (Corno and Xu