Highly educated immigrants are part of the growing population of immigrants who are impacted by the increasingly hostile migration policies in the U.S. This qualitative study used a phenomenological approach and inductive reasoning to explore the possible impacts of migration integration policies as social determinants of health among this group. Data was collected through 31 semi-structured interviewees with highly educated immigrants who had an intention and interest to stay in the U.S. at the time of the interview. Data were analyzed using reflexive thematic analysis and four main themes emerged: (1) a life overshadowed by silent worries, (2) living through uncertainties and forced decisions as the result of migration integration policies, (3) complexities and challenges of living on a work visa, and (4) shared recommendations by interviewees. Documented narratives as part of this study suggest high rates of stress and anxiety as well as negative mental and physical health outcomes among the participants. Results also suggest high levels of internalized vulnerabilities. Participants shared that migration policies can be enhanced in the U.S. to support highly educated immigrants’ growth by creating a better and more transparent communication system, replacing random review processes for applications with systematic procedures, creating expedited pathways to citizenship based on merit, and granting access to work as a basic human right. Highly educated immigrants (HEIs), or immigrants with graduate degrees, are part of the growing population of immigrants who are fostering innovation, economic growth, and knowledge sharing in the U.S. . HoweveFrequently the professional, academic, and social capital that an immigrant had in their country of origin does not receive equivalent recognition in the U.S.; this undervaluation of human capital can create additional barriers to finding a job or maintaining a previously established social position and cause additional stress for HEIs  provided HEIs with avenues for temporary stay and work in the U.S., while pathways to citizenship were offered through Employment-Based (EB-1 and EB-2) or Family-Based applications. The H-1B and EB-2 visa , necessitate a sponsor, whereas OPT and EB-1 applications can be self-petitioned. The EB-1 visa category is for individuals with extraordinary ability in the sciences, arts, education, business, or athletics and OPT is designed for graduating students. Applications for H-1B visas sponsored by private sector industries are subject to a lottery system. These applications are accepted once per year during a designated window. All these visa categories come with application fees and intricate application processes. Furthermore, a considerable backlog exists for HEIs from certain countries due to country-based quotas, leading to extended waiting periods.The U.S. migration integration policy is complex and undergoing continuous changes, largely influenced by administrative priorities. The systemic and individual-level issues addressed here demonstrate a possible connection between migration policies and the health of HEIs. Our study is focused on migration integration policies and rules and regulations facilitating or hindering HEIs’ access to a path to citizenship. In this study, we explored the role of migration integration policies as social determinants of health among HEIs who had the intention to stay in the U.S. and were planning, were in the process of applying, or recently (less than six months) applied for permanent residency at the time of the interview.This qualitative study used a phenomenological approach and inductive reasoning  to docuAfter receiving approval from the first author’s university institutional review board, the study was advertised in two online immigration forums in March 2021. Seventy-one HEIs  filled out the online demographic survey of the study and filled out an informed consent form agreeing to be contacted for an interview shortly after the advertisement of the study. Fifteen additional participants were recruited during the study (between April 2021 and March 2022) and through referrals from interviewees. Participants who filled out the survey were adult (18 or older) HEIs in the U.S. with valid visas or permanent residencies issued less than six months before their participation in the study. Among the participants who filled out the online demographic survey of the study, 60 electronically consented to have an audio-recorded Zoom interview with our research team. Interviews were conducted by two interviewers in English between April 2021 and April 2022. In the course of conducting 60 interviews, we observed that while immigrants with and without an intention to stay in the U.S. might face similar stressors, these stressors impact HEIs in distinct ways. For this study, we specifically included interviews that clearly expressed an intention or desire to remain in the U.S., resulting in a sample size of 31 participants. We intentionally excluded HEIs without interest or intention to stay in the U.S., enabling us to focus on the effects of migration integration policies, as well as the rules and regulations that either facilitate or hinder HEIs’ pathway to citizenship.The online demographic survey of the study collected information on age, gender, country of origin, years in the U.S., education, marital status, annual income, and visa status of the participants. Semi-structured interviews of the study were conducted based on an interview protocol and collected information about the experiences of participants as immigrants, potential stressors in their life, their support system, migration policies, and their recommendations to enhance migration policies to foster the well-being of HEIs in the U.S. Interviews were audio-recorded and transcribed using Zoom. The Zoom-generated transcripts were edited by the research team to ensure accuracy. In the process of editing the transcripts, any identifiable information was redacted. Interviews lasted between 25 and 75 min.Edited transcripts were analyzed using the reflexive thematic analysis method . This pThe age range of the study participants was between 22 and 40 . Around half of the sample self-identified as female , and the other half as male (n = 15). The majority  of the participants in this study lived in the U.S. between two to five years. Less than one-third of the sample was married , and the rest chose the category “single” for their marital status. Participants were from 17 countries including Brazil, Canada, China, Colombia, Ghana, India, Indonesia, Iran, Japan, Netherlands, Nigeria, Pakistan, Russia, Rwanda, South Korea, Sudan, and Venezuela. We had five participants with a Ph.D. degree, and the rest of the sample had a master’s degree at the time of the interview. The reported average annual income by the interviewees varied; around 39% of the sample (n = 12) had an annual income between $100,000 and $200,000, 23% (n = 7) selected the $50,000 and $100,000 range, around 16% (n = 5) had an annual income between $25,000 and $50,000, around 16% (n = 5) had an annual income below $25,000, and 4% (n = 1) had an annual income above $200,000. At the time of the interview, around 77% of the participants (n = 24) were on a student visa (F1) or Optional Practical Training  after graduation). Around 10% (n = 3) of the sample had work visas (H-1B), around 10% (n = 3) were in the process of getting their permanent residency, and one participant was on a dependent work visa (H-4) at the time of the interviews.Four main themes emerged from the analysis of the narratives shared by the interviewees in our sample: (1) a life overshadowed by silent worries, (2) living through uncertainties and forced decisions as the result of migration integration policies, (3) complexities and challenges of living on a work visa, and (4) shared recommendations by interviewees. The study was conducted during the COVID-19 pandemic which introduced additional challenges as reported by some interviewees (n = 8). Participants referred to their heightened stress due to prolonged visa processing times, feelings of isolation, job loss, and the implementation of hiring freezes as a result of the pandemic.I’m feeling very powerless in front of this monstrous immigration system which makes no sense to me… I speak the language, I respect the laws, I pay my taxes. … I don’t have any ties back to Russia…. I consider United States my home... for the last few years I’ve been in a horrible depression. I’ve been taking antidepressants, I wasn’t able to work, it there were nights where I couldn’t fall asleep for hours- thinking that sometime from now they just going to deport me out of the country.... This whole immigration system is just, it just complete- complete nightmare.Worries about visa status and migration policies were present in the narratives of almost all participants in our study. An immigrant from India explained that many aspects of her life depend on her visa status. She said, “There are nights I can’t sleep, and I know it’s just not the visa, it’s a lot of things, because it’s all, like, half of my things, or anybody else’s, people like me, that depends on your visa.” She added that “There is no time to enjoy [life]. I feel like you’re always just thinking about the immigration… It’s, like- every, like- eventually builds up to a place where you feel everything in your life just revolves around your visa.” Similarly, an immigrant from Nigeria stated that her immigration status has been a “major theme” in her life. This interview added that she was so worried about changing her status after graduation that she thought of postponing it; she said, “I was talking with my mentor, I’m like, I’m really concerned, like, I don’t even think I want to graduate yet, … I know once I’m out of school it’s like, okay I’m illegal now.” An immigrant from Russia stated that she feels “powerless” in navigating the immigration system in the U.S. She explained that she is having a hard time understanding why staying in a country that she contributes to and considers home should be this difficult:As part of the interviews, we prompted participants to quantify their stress level while navigating the U.S. immigration system on a scale of zero to ten, with ten as the highest level of stress. All interviewees, except one participant, scored their stress level higher than five. The average self-reported stress score was 7.5 (SD = 1.4). While talking about the stress caused by migration policies, many interviewees referred to negative mental health outcomes they have experienced. For example, a 38-year-old immigrant from India told us that “when I was going through this up and down [related to getting a work visa], I suffered depression…I started relying on Alpax [medication for moderate or severe anxiety] and all those things to get some sleep.” Similarly, a 27-year-old Chinese immigrant told us that she and her husband relied on sleep medication as a result of the anti-Asian sentiment in the country and the stressful process of getting approval for Optional Practical Training (OPT). She said, “There [is] a lot going on outside in the Asian [population], etc., and also the OPT process, I just feel a little bit insecure so it kind of affects myself and my husband’s sleep a little bit, cause he just, had a hard time to sleep, we are relying on melatonin.”I’ve definitely also experienced panic attacks.... You send it [application for permanent residency] into the big government and the big government decides whether you can stay or not, and whether you can have your life the way that you wish.Participants also referred to other health issues such as panic attacks or weight gain as the result of the stressors caused by migration policies. An HEI woman from India said, “Now I am depressed. I’m gaining weight. But my depression doesn’t allow me to go out and take care of myself.” Similarly, a participant from Iran stated, “I’m in [a] medical field, so I know that when I eat emotionally it comes from this kind of stress, so I’d eat; put on a lot of weight during this specific event for the Green Card.” In this context, a participant from the Netherlands referred to her panic attacks during the process of her permanent residency application and said:Several participants told us that after applying for any change in their immigration status, their life became consumed by constant worries and stress about the processing time of their application and the decision of the United States Citizenship and Immigration Services (USCIS). A Chinese immigrant waiting for her OPT application to be approved told us that “when I’m working in the daytime, I just keep refreshing that, update, [USCIS] website.” A participant from the Netherlands waiting for her permanent residency application to be processed said, “just like you’re constantly checking your email and your bank account, has the check cashed out yet that I sent to USCIS? Like all this, the constant checking is what gets you, and it is distracting to from my day-to-day work.”While stress and worry were apparent throughout the recorded interviews, many interviewees stated that they felt they could not share their concerns with others, even their close family members. They told us that most people would not fully understand the nuances of being a HEIs in the U.S. A graduate student from India said that her parents do not understand a lot of her concerns. She said, “sometimes I’ll tell them, ‘oh this bill didn’t get passed and that’s going to make it harder for me to get a Green Card,’ and then they just don’t understand it.” Another participant stated, “my parents are in Brazil and I don’t talk about it [visa issues],” and another HEI from Rwanda shared that “My classmates, right, they are mostly American, so they don’t really understand … I think that the people who understand, who can understand what I’m going through, are just friends that are also immigrants.”When I left my country, I knew, like, that would be my life, you know, and I picked my life, no one forced me to pick my stressful life and I picked me, and I am responsible, whatever I am going through, you know...like, I am not even a tree in this country, you know, am I just an immigrant, you know, I don’t have any root, you know… I am a great walker, so I walk every evening, so when I go to the park I see- you know, I see, maybe, you know, what is called, squirrel, or cat, or dog, I just feel like, you know, they are luckier than me because they are not immigrant, you know, they- that’s their country, they don’t have to think about what will happen in tomorrow, you know, they know they are safe, but that’s not me.Recorded interviews also illuminated internalized vulnerability in response to reported stress and worries. Some participants blamed themselves or their choices for their worries, and some considered themselves lucky for not experiencing the worst-case scenarios. An architect with a master’s degree told us:When discussing their coping mechanisms in response to their worries, participants mainly referred to the support of their close family members and their immigrant friends with similar experiences.Most participants spoke about uncertainties in their lives and their inability to plan for the future. Constant and random changes in migration policies, long and unclear application processes, and unclear communication with USCIS were among the most cited factors creating uncertainty for the participants.I was a top-rated student in Iran, and I could go wherever I want but my dream was high, … I wanted to experience the, the, the educational life in USA. ... So, before 2017, it was, like, for an educated individual like myself…you send your application for NIW, the national interest waiver, that’s the program, and you get your Green Card in mail in six, four to six months. You don’t do anything else. The way he [Trump administration] exactly changed it, when I started this, it took me almost two years and a lot of efforts and unnecessary documentation.Regarding changes in migration policies, a student from India said, “[immigration policies] change based on the government, so [when] there’s a new government the policies will change… you can’t like think really long term about staying in the U.S.” An immigrant from Russia referred to a proposed policy by the Trump administration to send international students back if they are not taking in-person classes during the COVID-19 pandemic and told us that she was afraid to be deported. She added that the policy was never implemented, but at the time, she started to think about where to go. Relevant to this topic, an immigrant from Iran shared his frustration about the changes in the national interest waiver  application process during the Trump administration and said:I got, um, I got an [job] offer letter in January itself at the end of the month. I can’t join, I’m waiting for the EAD [Employment Authorization Document] card to be received so I can join my employer; they’ve been nice, they’ve been waiting for me for a month. Last time I contacted them by the beginning of March. And they are still waiting for my application, for my, uh, application to be done and I receive the OPT so I can join them… then like waiting for like four months is going to hurt the finances as well. ... this uncertainty from the, from the, processing [time] and as well as the employer himself, I mean they’re patient, but, yeah, definitely, they won’t be waiting for, forever, right?Participants discussed the long and random review process of specific visas and requests, including OPT. They explained that USCIS reviews OPT applications randomly within a period of time deemed as “normal processing time,” a timeframe that can change and be long as eight months based on the backlog of the applications. Participants added that during the normal processing time, USCIS does not answer follow-up requests and this timeframe can change at any moment. An immigrant from Nigeria called this process “a waiting game,” and that “you have to play the waiting game with the immigration office, you know, because no one is really telling me anything. You’re just waiting for your status to change from whatever it is.” She added that waiting a long period of time for approval of an OPT application is hard, as applicants do not have a right to work during that period. She said, “you have to wait from three to six months [for OPT approval], and what are you going to do for those three to six months, you know? Because you can’t work, because illegal, you know, so it’s very challenging.” Similarly, an immigrant from Sudan said:Participants also discussed challenges in applying for work visas (H-1B). They explained that the lottery system of the work visa in the industry has made their lives full of uncertainties. An immigrant on OPT at the time of the interview told us that his company has applied for his work visa this year and the last year, but his application was not selected for review by the USCIS lottery system. He said, “I did have a lot of plans which had to change.” He added that despite all uncertainties in his life, he had to make sure that his work is not impacted so he can keep his job; he told us “We can’t plan ahead, like, we can’t buy any house, or can’t get any loans… It’s kind of a little bit impactful, but we have to make sure that it doesn’t impact our work.” Another participant explained the process of getting a work visa (H-1B) in the industry as part of his interview and said “They’ll [applicants] have to apply for an H-1B and they have three tries, no they have six tries in total, but for students, it’s three [years] while they’re in the U.S… it’s based on a lottery system, it’s not based on a merit system.”So, right now, there are certain caps that are imposed on the number of Green Cards given out to each applicant. And I think it’s seven percent per country right now and, at the moment, there are a lot of Indians who are waiting in queue to receive their card and because of these caps there’s only a certain amount of people from each country who get the residency every year, so the queue just keeps growing and then it just takes a lot of time for people born in India or in China to receive their Green Cards and oftentimes I also hear from my friends that our best bet at getting a Green Card is just by having like having kids here and then applying through them once they turn 18 which is this really morbid, but yeah, it just, it takes a long time.Participants commonly expressed concern about the long process and wait time for residency applications, but this issue was more dramatic for immigrants from certain countries, including India and China, who told us that their wait time could be over a decade. An immigrant from China referred to this process as unfair and explained that “You cannot do anything, basically. You wait for whatever comes to you, like- so you feel, like, powerless. It’s not fair process.” Another participant from India stated that “I feel like I kind of keep putting most of my life on hold based on this [wait time for residency application].” One of the participants said that for some Indians, it is more feasible to wait for their U.S.-born children to turn 18 and apply for their citizenship as the wait time for their own application could be longer than that. She said:[In my] three years of OPT, they [my employers] applied for my H-1B [work visa] every year and I did not get it. My lottery was not lucky enough. And, you know, the Green Card is pretty messed up for Indians .... So, I basically had to go and get another Master’s degree from [name of the university is redacted] to be able to stay back in the U.S. The first degree was in electrical engineering and I had my second Master’s in engineering and technology management. And, now, on my fourth attempt I got my H-1B and this was in the midst of the pandemic.... morning I was at work, evening I would attend classes twice a week, and then the weekend could go- would be spent in solving assignments, and sometimes work would be busy that I needed to do some work tasks on the weekend. So, I needed to be at it, I didn’t have the luxury of falling sick, had I had COVID.Uncertainties and restrictive migration policies were linked to an array of forced decisions in the narratives of the interviewees. For instance, a participant talked about getting an additional degree for a second chance in the U.S. work visa lottery. An immigrant from India told us:I tried to get a job on H-4 [visa for dependents of a noncitizen worker] … starting from square one. But then it didn’t work out. I did not have the H-4 EAD [Employee Authorization Document] at that time because my husband did not have the I-140 petition [petition for a noncitizen worker to become a permanent resident in the U.S.] approved … I was, like I need to do something… I went back to the college ... I was able to do that. Then, the problem was, I needed to do an internship. Now, I cannot do an internship on H-4 [without a right to work]. They don’t allow you to do an internship on H-4. So, my university suggested me to move to an F1[student visa]… so I stayed here; waited, I think, almost a year, nine to 10 months it was, and then when I got my …F1 approval … I was so happy, but it was summer break, so it was almost a year before I could get into that position and get the internship… I had to, you know, extend my studies for at least one semester.Another interviewee from India shared her complex journey and series of forced choices to be able to work as an HEI immigrant in the U.S.:My husband just recently took a job in a city 10 hours from here so he’s going to be up north, where I’m going to be in [name of the state was redacted] and we had to make the decision for me to stay, just because I can’t count on USCIS giving me a new EAD [Employment Authorization Document] by the time that we’d have to move… so my best bet is to stay where I am and hope that my current employer will re-hire me.Participants also told us about years of family separations due to restrictions of their single-entry visas or perceived risks associated with re-entering the country with multiple-entry visas. One of the participants who had a single-entry visa said, “My mother-in-law passed away last year… my husband has two brothers, but due to all these visa issues, none of them could go.” She added, “So, it’s not only us who has to bear the brunt of … these visa issues, it’s also our families back home and here.” An interviewee from the Netherlands explained that she cannot leave her current job and join her husband in another city out of fear of delays in getting work authorization for the new job. She said:The last year was traumatic because, you know, it was kind of a lottery-based visa system… so I did not know my visa will be picked up or not. So, the whole year… it was kind of every night I had to take sleeping pills… because I can’t control my chaos.Interviewees on a work visa, those on work visas in the past, and participants in the process of applying for a work visa talked about the complexities and challenges associated with this specific type of visa. Regarding the H-1B work visa, most of the interviewees indicated feelings of powerlessness and anxiety in going through the random and lottery-based application process. An interviewee from India shared her experience applying for an H-1B visa and said:Yeah, it kind of takes a miracle, you know, because I only have, like, one year OPT and then I don’t know …, you know, it will be thrown in a lottery anyway, but, yeah, that’s the hope and- Yeah, if that doesn’t work, well maybe I would get a- Yeah, I don’t know, I might go to Canada.An interviewee from Indonesia on a student visa indicated that she might go to Canada if her application would not be selected in the work visa lottery system because she only had one year of OPT as her legal status to stay in the U.S. The U.S. immigration authorities grant three years of OPT to STEM graduates, but only one year of OPT to non-STEM major students. H-1B applications are often accepted once a year during a certain period marked as the application window. For non-STEM students, this would be their only chance to apply. The interviewee from Indonesia said:I saw somebody on the internet who sent in twelve applications, and seven of those got picked under the same name, and it’s just ridiculous, you know, because he only needs one to go forward, and then there’s six other slots that have been filled up which could have been taken up by people who weren’t picked, and some people, unfortunately, this was their last time to try for the work visa, and now they are left in the dark as to what happens to them next. So, it’s kind of ironic that a country like the US still hasn’t figured out how to work around that gaping loophole, but that’s something that definitely needs a lot of attention.Some participants told us that what makes the lottery system of the H-1B visa worse are the loopholes in the system. They explained that applicants can ask multiple employers to submit applications for them to maximize their chances, but this can hinder the chances of other applicants. An interviewee from Nigeria explained:People working in certain organizations, such as in universities and non-governmental organizations, do not need to go through the lottery system to get an H-1B visa, but delays in processing requests can still cause great anxiety for them. An interviewee from Ghana said, “I believe there was technically one day that I had no status. I think my OPT had, like, had just expired before the H-1B notification was given.”I think because my employer’s processing my visa, I have to be with them for two more years. So, even though I want to move my job I have to stay with this job with unfair wage and- Like, if they don’t give me any raise. So yeah, that’s- so- that’s part, I think... it’s also related to my job, but I want to do other, like, job, but I can’t do it because my visa restriction.Work visas in the U.S. are often sponsored by employers, meaning that immigrants on these visas can legally stay in the U.S. as long as their employers are willing to keep their visas valid. This system creates more room for abuse of power by employers. In this context, a Korean interviewee said:When you’re applying you have- there’s the option oh, are you going to require sponsorship in the future? And the more you click yes, the more they’re not gonna call you back so it’s definitely stressful … if you don’t know and also applying knowing that you might get rejected just because you have- you require sponsorship in the future.Because HEIs’ ability to obtain work visas largely depends on employers’ willingness to sponsor them, many immigrants encounter subjective and objective discrimination in the labor market. An interviewee from Rwanda shared her job search journey and explained:I also felt a lot of problems applying for jobs. A lot of them put that right away that we do not sponsor work visas, neither now, nor in the future. So that automatically disqualifies me from a lot of jobs. I honestly do see a lot of those notes that, if you’re an international person, do not even apply to us- neither now, nor in the future, we cannot sponsor your visa. So, I don’t know where to find that unicorn position that can actually satisfy my level of knowledge, pay normal money, and actually sponsor me.Interviewees told us that many employers covertly reject immigrants, and some publicly announce that they do not hire immigrants to avoid challenges associated with work visa sponsorship. An interviewee from Russia referred to work visa sponsorship as a structural barrier and explained:As part of the interviews, participants told us about ways to improve the migration system and proposed policies that would foster growth and mental health among this group. Recommendations discussed by interviewees were grouped into four main categories: (1) better and more transparent communication, (2) systematic review processes for applications, (3) access to work as a basic human right, and (4) expedited pathways to citizenship based on merit.An immigrant from Sudan said that he avoids contacting USCIS since a machine will respond and will “copy and paste what’s in the website.” He added “for us, being able to talk with a human agent from the USCIS would relieve a lot of stress. So we can know what’s actually happening, you know, with our application.” In regards to the lack of communication, an immigrant from the Netherlands said, “not having a person to reply, or anything; that specifically was challenging in the process.” Many interviewees said that in the absence of clear information and communication by USCIS, they have used unofficial platforms to get information about their application status. An immigrant from Venezuela said:Reddit forums, online trackers, kind of like, give you a really good overview about the process ... I feel like these are amazing resources that people have put together and they should be better for like all the other applications…. And I think that they [USCIS] could do so much better, but I feel like they don’t want to. Like, they want to keep the process completely isolated from… the applicants and… it’s frustrating… The system that immigrants created themselves; a[n] OPT tracker, USCIS tracker, OPT timeline, all these things, you know, the public forums - I think those are the ones that actually help you out. I even myself, you know, create my own, you know, tracking script to, like, just pull information from UCIS and kind of… have a more holistic view of what’s going on.Interviewees referred to the lottery system in the USCIS review process and the wide and constantly changing “normal processing time” and recommended more transparent and systematic review processes. An immigrant from Sudan said that having a structured process for the application review by USCIS can help him with “managing finances, managing time, and having, planning ahead.” A participant from China referred to the lottery system in the review process of work visa applications and called it “ridiculous;” he asked, “why can’t they just do first come first serve thing?” Similarly, a participant from Venezuela who was in the process of applying for OPT said, “I don’t really [think] that needs to be a lottery, it should be first come, first serve. If you apply early, you get a spot … it makes no sense; why it is not simply just first come, first serve and that’s it?” He further talked about the wide USCIS processing timeframes and said:I just feel like they put that timeline because they are just trying to cover their bases. And … every time that you ask, hey, how’s my case? It’s still a normal processing time, and it’s like, okay, I mean, that’s true but, like what is this? A normal processing time? I think it’s just biased, so you can never complain about it.Many interviewees referred to their restricted access to work and asked for more supportive policies that would provide a right to work for HEIs. An immigrant from India who was on a work visa said, “we’re just asking for basic human rights to work.” He added that “I’ve paid $200,000 in U.S. taxes, I’ve contributed to the economy,” and said the U.S. needs a “more permanent work authorization” for immigrants on work visas. A participant on an H-4, a visa with no right to work for dependents of immigrants on a work visa, told us:Well, there are many western countries like UK and Canada, who allow dependents to work. There is no restriction which separates the prime visa holder and the dependent in terms of working. And it starts from day one; they get the visa. I would say first thing I would want to change is take that curse away from H-4 EAD or L-2 or any other dependent visa.Among the other recommendations by interviewees to make more supportive migration policies was the creation of a merit-based point system to prioritize HEIs. A participant from India said, “I’m all for a merit-based immigration system, at least for highly educated immigrants.” Another shared recommendation by interviewees was improving procedures in reviewing permanent residency applications of Chinese and Indians. A participant from India recommended “having a point-based system” and several other interviewees from India recommended removing the “country-based quota” for permanent residency applications.Jasso’s (2011) work on “visa stress” and “visa depression,” and Torres and Young’s (2016) discussion about the relationships between legal status and health disparities.Findings suggest that migration policies can be conceptualized as social determinants of health for immigrants and restrictive migration policies are associated with negative health outcomes among HEIs. Interviewees repeatedly reported stress, anxiety, uncertainties, and forced decisions in their interactions with migration policies in the U.S. Some reported sleep disturbance, depression, and weight gain as health outcomes associated with restrictive migration policies. Interviewees also discussed the impacts of restrictive migration policies on the other aspects of their lives, including their careers and ability to plan for the future. These findings are in line with The findings of our study call for the rethinking of vulnerabilities among HEIs, a group that is often considered a privileged group in terms of income or educational background. Vulnerability in the general term refers to susceptibility or exposure to harm. In our study, the susceptibility to harm among HEIs was mainly concerning psychological distress and was caused by migration integration policies. Restrictive migration policies can impact HEIs’ mental health and overall well-being despite their relatively high socioeconomic status (SES). Exploring vulnerabilities only through the lens of SES  can mislabel HEIs and similar groups impacted by different structural barriers, including restrictive migration policies.Restrictive migration policies can put HEIs at risk of experiencing deprivations and hardship in different aspects of life. For instance, international students on a student visa (F1) in the U.S. should be enrolled as full-time students to keep their visas valid. Meanwhile, these international students with F1 visas do not have a right to work, except part-time on campus . Most iIn the era of globalization, human rights should guide migration policies for global citizens. Through analyzing these interviews, we presented multiple cases in which migration policies have neglected human rights and subjected HEIs to institutional, social, and cultural discrimination and exclusion in the U.S. Besides being restrictive, many of the existing migration policies in the U.S. are targeting specific groups of immigrants or have different implications for them. For example, international students from Iran often receive single-entry student visas that can cause years of family separation, the same visa is often multiple-entry for international students from other countries. Or, the permanent residency application process can take over a decade for HEIs from India or China, while this process is often between a year or two for other groups of HEIs. Previous studies have shown associations between visa processing time and negative health outcomes such as depression . The roThe results of the study are not generalizable based on the qualitative nature of the study. Qualitative studies are inherently subjective and based on the conclusion of the research team . MoreovOur study is unique as it focuses on an under-studied population of HEIs and explores the intersection of migration policies and health. Moreover, our paper challenges the conventional assumptions about HEIs as a group facing fewer challenges in life by highlighting how restrictive migration policies can significantly impact their mental health and overall well-being.This study aimed to explore the impact of migration integration policies as social determinants of health among HEIs. Based on semi-structured interviews with 31 HEIs, we concluded that restrictive migration policies are associated with negative health outcomes among HEIs. Interviewed HEIs told us that their lives are overshadowed by silent worries. They disclosed that they are living through uncertainties and forced decisions as a result of migration integration policies and shared the complexities and challenges of living on a work visa. Interviewees of this study provided concrete recommendations about improvements needed in the migration policies and asked for (1) enhanced and transparent communication during the visa application process, (2) the establishment of systematic review procedures for applications as opposed to random reviews and lottery-based methodologies, granting all HEIs the fundamental human right work, and expedited pathways to citizenship based on individual merit.Many interviewees believed that providing HEIs intending to stay in the U.S. with the option to secure employment or a path to citizenship based on their skills rather than chance, visa type, and major can improve their quality of life. We had participants from India who strongly believed that removing country-based quotas would make the migration integration journey more just and unbiased in the U.S. Given the substantial intellectual and financial contributions of HEIs to the community, it is crucial for them to feel truly welcomed in the U.S.As discussed by the participants and reported in the previous studies, U.S. migration integration policies are showing limitations in several ways and are associated with negative health outcomes . While


Arts engagement programs (AEPs) are non-clinical, structured programs led by artists and educators to support mental health and wellbeing. While evidence demonstrates positive mental health outcomes in adult AEPs, studies of childhood AEPs remain sparse. We created a gallery-based AEP (Culture Dose for Kids) for children with anxiety based on a successful arts engagement pilot for adults with depression. We questioned whether our tailored-for-children adult program would effectively and feasibly support children’s mental health. Through parents’ perspectives and feedback, this study tested the program’s acceptability, feasibility, and effectiveness with children with anxiety. Quantitative and qualitative measures were used to determine whether the program was an effective and acceptable mental health support for children with anxiety. Our findings revealed that the program positively and significantly impacted parental perceptions of their child’s anxiety. Our findings illustrate depictions of improved mood, confidence, and sense of empowerment in the child, qualities associated with resilience and mental wellbeing. Open-ended activities provided opportunities for connection, creativity, and experimentation—sources of strength for improving mental health. This study adds to the small but growing evidence base supporting the role of arts-based community care in youth mental health and wellbeing. Late childhood and early adolescence (about ages 9–12) are times of heightened emotional turbulence. Transitioning from childhood to adolescence presents many physical, intellectual, social developmental, and personality changes. This period can also see the onset of mental health issues, and one of the most common issues for young people is anxiety disorder  is an age where it’s actually kind of hard to find a conversation point with your child that everybody’s comfortable with. And [CDK] is a great starting point. You’ve got a topic you can move on from it and it can lead to other things as well.The connectedness theme highlights the importance of a program that safely creates a space and time to share activities, experiences, and conversations to increase parent–child bonds.The gallery setting has been established as a safe place to facilitate personal and community wellbeing . The parIn addition, CDK took place in a metropolitan city. With this in mind, a parent (P9) spoke of how “coming to an appointment in the city has always been a lot of questions and anxiety around what we’re doing, where we’re going, holding my hand tightly” but that while her daughter “still doesn’t enjoy the city crowds and the pressure, [CDK] is a very safe space and she’s more than happy to come”.This third theme, empowering children to make mistakes through open-ended creative activities is reflected in the following comments:I think is really important that she loves art, but she stopped painting because she was overthinking things, she didn’t think it was good enough, so this is brought back her creative side I really happy for it.Art is a medium that has no right and wrong. You can’t do mistakes and that’s something kids with anxiety need.He wants to excel and if he doesn’t excel, he’ll just take a step back and this [CDK] has encouraged him so much…this is also taught him the fact that you don’t have to excel in everything you do.CDK art activities were intentionally open-ended, not prescriptive, to encourage self-expression and creativity. Artworks could be finished in the time allotted or taken home. Some group art activities took place over weeks, to be added to as and when participants felt like it on the day.This last theme describes how parents reported a change in their child as a result of participating in CDK over the eight weeks. Parent P2 remarked that their child “always seems to come out in a good mood, always comes out of here happy, they get into a happy creative space, and that seems to last the day”. Similarly, parent P4 found “it’s a positive activity and it sets the mood for the whole day”. Parent P5 referenced that “there’s been a big jump in just him being happier and more confident, I think that’s the biggest takeaway [from CDK]”. Another parent said,So far, [CDK] really helped his confidence most of all. Yeah, I have noticed a change. It might be because of this program—I couldn’t correlate it with anything else other than this program. Yeah, it has definitely helped.It’s too early to tell if it’s made a difference to my child’s unique issues, being alone, being in the dark, but I can see a little bit of difference. I can now drop him on the corner to run that last bit on his own that before he wouldn’t do.Comments from the parents signify that the time spent in the eight-week program created a change in their child that endured beyond the program, including positive changes to their child’s happiness and self-confidence.This study aims to understand CDK’s effectiveness, acceptability, and feasibility  with children with anxiety through their parents’ perspectives and feedback. Our inclusion of quantitative and qualitative analysis increases the robustness of determining whether CDK is a practical, viable, effective, and acceptable mental health support for children with anxiety.The quantitative parental RCADS results indicate an improvement in their child’s anxiety levels as a direct outcome of the project, signalling its effectiveness. In addition, when examining the evaluation form results, all parents view CDK as a resource they would recommend to another parent to support a child who experiences anxiety. These two findings, taken together, indicate a high level of CDK’s effectiveness, acceptability, and feasibility by parents.Notwithstanding these quantitative results, a more nuanced understanding of CDK’s impact on the child and parent can be understood through qualitative enquiry. This approach embraces the complexity of human health and social behaviours to enhance research findings ,27. Our The program facilitates a safe place and time for parents and children to be reflective and creative together to broaden and deepen parent–child bonds. CDK creates extended moments of calm to connect parent and child, providing parents with opportunities to explore their children and themselves in new ways to foster understanding, echoing Stock et al.’s  findingsOur findings illustrate depictions of improved mood, confidence, and sense of empowerment in the child, qualities associated with resilience and mental wellbeing ,20. OpenEarly interventions can improve young people’s lifelong mental health and wellbeing . By engaAs this study was a pilot program, our findings were limited to a small group of urban children and families. Participation in CDK was established by parental belief that their child experienced anxiety (RCADS were not used to diagnose). Three-month RCADS follow-up had a low response rate, which, in future studies, we will incentivise with art gift packs. Furthermore, given the focus on supporting child anxiety, the authentic voice of children is absent in the paper. Instead, this paper’s findings are derived chiefly from mothers’ perspectives. In addition, while many parents responded that CDK was a great “reset” for them and their children, a quantitative measure of parental wellbeing before and after the program is missing.In future CDK programs, we plan to tap into children’s experiences in more creative ways, befitting the ethos of this study. We will also quantitatively measure parents’ wellbeing levels to understand the impact of CDK on them. We acknowledge the limitations of the current research, thereby warranting further studies with a control group and improved longer-term follow-up to establish reliable causality and longitudinal findings.This study reveals that CDK positively and significantly impacted the parents’ reported anxiety level of their child, indicating its acceptability as a mental health support. Our qualitative and quantitative findings illustrate the role CDK can offer as a practical, viable, effective, and acceptable mental health support for children with anxiety. The program fosters increased parent–child connections as a significant outcome, facilitated by the interplay of extended time, reflexive activities, and space. In addition, over eight weeks, children are empowered through open-ended creative activities to connect to their feelings, thoughts, and imagination to build self-confidence and resilience while challenging the need for perfectionism. Comments from the parents signify that CDK creates positive mental health outcomes that last beyond the immediacy of the program.This study adds to the small but growing evidence base supporting the role of community and cultural care in youth mental health and wellbeing. Health professionals, decision-makers and policymakers can look outside traditional care systems to improve community health and mental wellbeing. Specifically, they can look to community programs, like CDK, that emphasise self-expression, creativity, and enjoyment to nurture positivity and wellbeing. Moreover, public galleries and cultural organisations can use the findings from this study to further develop mental health and wellbeing programs as a strategic and integral part of their work. Our results support the limited positive evidence about arts engagement programs, children, and mental health, contributing to yet highlighting the need for further research in this age group.


Intimate relationships are not always easy to keep. Accordingly, the current research has attempted to identify the strategies that people employ in order to improve their relationships with their partners. In particular, by using open-ended questionnaires in a sample of 219 Greek-speaking participants, we have identified 81 acts that people were likely to perform toward this end. Subsequently, using quantitative research methods in a sample of 511 Greek-speaking participants, we classified these acts into 14 broader relationship enhancement strategies. Trying to understand partners' needs, discussing problems with partners and showing more interest in a partner, were among the most likely to be used strategies. Moreover, we asked a sample of 367 Greek-speaking participants to rate how effective these strategies would be on them, and we found that, trying to understand partners' needs, discussing problems with partners, and showing one's love to a partner, were rated as the most effective strategies. Men and women, and people of different ages, were generally in agreement over what strategies they were willing to use, and how effective these strategies would be on improving their relationship with their partners. Keeping an intimate relationship is not an easy task. For instance, it has been estimated that about one in two marriages is likely to fail . In a rePartner defection leads to the loss of a valuable reproductive resource, as well as forfeiting all the investment diverted in attracting and retaining the intimate partner. It follows that partner defection would lead to a considerable decrease in one's reproductive success or fitness. This fitness loss would result in the evolution of strategies that would decrease the probability of losing their partners to others . Mate reMost human evolution took place in a pre-industrial context, where our ancestors lived as hunters and gatherers or agropastoralists . In suchIn this argument, people form intimate relationships in order to have around them individuals who could provide reliable and long-term support to them and to their current or prospective children. It follows that relationship strain would arise when partners behave in a way that indicates lack of commitment to the relationship; for instance, they neglect their mates, do not devote time to them, flirt with others, and so on. Similarly, relationship strain would arise from partners demonstrating lack of qualities such as a good resource provision capacity or a good character . Subsequently, the authors asked a sample of 1,099 Greek-speaking participants how likely each difficulty was to cause them strain in an intimate relationship. By applying factor analysis, they classified these difficulties into 12 broader factors, the most important one being “Fading away enthusiasm,” followed by “Long work hours” and “Lack of personal time and space.” One issue with this study was that it asked participants to rate hypothetically how much strain each factor would cause them, and not how each one actually caused them. To address this limitation, a subsequent study asked 1,403 participants from China and Greece who were in an intimate relationship to indicate their agreement on how each of the 78 items caused them strain in their relationship . Using principal components analysis, they classified these difficulties into 13 broader factors. Participants rated “Clinginess” as the most important source of relationship strain, followed by “Long work hours,” “Lack of personal time and space,” and “Not making compromises.” In the middle of the hierarchy were “Character issues,” “Lack of effort,” “Violence and addictions,” “Fading away enthusiasm,” and “Bad sex.” At the bottom of the hierarchy were “Infidelity,” “Children,” “Social circle issues,” and “Not monogamous.”In our theoretical framework, relationship strain arises predominantly from lack of commitment and support, exhibiting undesirable traits, and constraining a partner. Accordingly, we hypothesize that, in order to improve their intimate relationships, people would employ strategies that aim specifically to address these issues. That is, these strategies would, to some degree, aim to address the sources of strain identified by previous research. In particular, we hypothesize that they would include, giving partners more space, and demonstrating to them that one is committed to the relationship, is supporting, and has desirable traits. The current literature provides support for these hypotheses.There have been several other studies on the strategies that people use in order to maintain their intimate relationships , and the mean age of men was 36.96 years (SD = 12.75). In addition, 38.1% of the participants indicated that they were in a relationship, 29.3% married, 25% single, and 7.6% indicated their marital status as other.The research project was designed at a university located in the Republic of Cyprus, and run online. The study received ethics approval from the university's ethics review board. Participants were recruited by forwarding the link of the study to students in various departments, asking them to forward it further, and by promoting it on Facebook and Instagram to participants living in Greece and in the Republic of Cyprus. The initial sample consisted of 281 participants. However, in order to increase validity, we excluded participants’ answers who had no relationship experience; that is, they indicated that they were currently single and they had never been in a relationship before. Accordingly, we employed a sample of 219 Greek-speaking participants  who had relationship experience. The mean age of women was 32.38 years , and the mean age of men was 36.23 years (SD = 13.38). Moreover, 36% of the participants indicated that they were in a relationship, 30.1% married, 29% single, and 4.9% indicated their marital status as other.In order to recruit participants, we employed the same procedure as in Study 1. The initial sample included 663 participants; however, similar to Study 1, in order to increase validity, we excluded participants who indicated that they were currently single, and that they never had an intimate relationship before. Accordingly, the analysis was performed on a sample of 511 Greek-speaking participants  who indicated that they had relationship experience. The mean age of women was 33.75 years , 5 (very likely to do it). The order of presentation of each act was randomized across participants. In the second part, participants were asked about their demographic information, including their sex, age, marital status, and whether they had been in an intimate relationship before.The survey consisted of two parts. In the first part, participants were given the following scenario: “Suppose you are in a romantic relationship. Indicate to what extent you would perform each of the following acts in order to improve your relationship with your partner,” and subsequently, they were given the 81 acts identified in Study 1 to rate in the following scale: 1 , we extracted 14 distinct strategies, which are presented in The first strategy to emerge was the “Try to understand her/his needs,” where people would attempt to improve their intimate relationships by trying to better understand their partners' needs. One way they could achieve this goal was to listen more to their partners and to their problems. The second factor to emerge was the “Improve looks,” where participants would improve their appearance, by renewing their wardrobe and losing weight. Such changes in looks would also aim to make partners jealous. People would also attempt to “Create experiences together” with their partners, by organizing trips and excursions, and going out on romantic dates. Moreover, in order to improve their relationships, participants would make attempts for “Self-improvement” by attending seminars, getting help from specialists, and reading relevant books. In the “Give my partner more space” strategy, people would attempt to improve their relationship by giving their partners more freedom, more time to be with their friends, and by trying to be less pushy. They would also try to “Be less withdrawn and grumpy.” In the “Show more interest in my partner” strategy, people would put their partners in higher priority and would show them more interest and trust.Moving on, in the “Discuss our problems together” strategy, people would attempt to improve their relationship by discussing any problems that arise with their partners. In the “Show her/him my love” strategy, people would try to demonstrate their love to their partners by telling them more frequently that they loved them, improving their sexual life, and claiming them more. In addition, in the “Look after myself” strategy, people would attempt to be better-off with themselves as a way to be better-off with their partners. In the “Open to her/his criticism” strategy, people would be more open to their partners' criticism as a way to figure out what was wrong with the relationship. People would also “Make concessions and compromises,” and they would further try to be more patient and accepting of their partners' idiosyncrasies. They would also try to “Build trust” with their partners, by being honest with them, and by keeping the agreements they have made with them. Moreover, people would attempt to “Exercise self-control,” reacting calmly when their partners would do or say something that bothered them.In order to identify which strategies people were more likely to use in order to improve their intimate relationships, we estimated the means and the standard deviations for each one. As we can see from M = 3.95, SD = 0.61) than women . A significant main effect of age was found for the “Try to understand her/his needs” and the “Show her/him my love” strategies. In both cases, the regression coefficient was negative, indicating that older participants gave lower scores than younger participants. In addition, marital status was not significant for any of the identified strategies.We performed 14 MANCOVA tests, one for each identified strategy. In order to avoid the problem of alpha inflation arising from multiple comparisons, Bonferroni correction could be applied, setting the alpha level to .004 (.05/14). A significant main effect of sex was found only for the “Make concessions and compromises” strategy, where men gave higher scores , we extracted two domains. As we can see from SD = 7.58), and the mean age of men was 29.04 years (SD = 5.73). Moreover, 48.9% of the participants indicated that they were in a relationship, 29.5% single, 17.2% married, and 4.4% indicated their marital status as other.In order to recruit participants, we employed the same method as in Study 1. The initial sample consisted of 426 participants; however, similar to Studies 1 and 2, we excluded participants who indicated that they were currently single and they had never been in a relationship before. Accordingly, the analysis was performed on a sample of 367 Greek-speaking participants . The mean age of women was 28.89 years , 5 (very effective). The order of presentation of the different acts was randomized across participants. In the second part, participants indicated their demographic information, including their sex, age, marital status, and whether they had been in an intimate relationship in the past.The survey had two parts. In the first part, participants were given the following scenario: “Suppose you are in a romantic relationship. Below you will find a series of acts that your partner is likely to perform. Please indicate how effective you think each one would be in improving your relationship with her/him”: Subsequently, participants were given the 81 acts identified in Study 1 to rate on the following scale: 1  = .916, p < .001 (two-tailed), indicating that the hierarchy of strategies people was willing to use matched well the hierarchy of how effective these strategies were judged to be.In order to examine which strategy was considered to be more effective, we estimated the means and the standard deviations for each one, and we placed them in a hierarchical order in M = 4.24, SD = 0.61) than men , and for the “Be less withdrawn and grumpy,” where women gave also higher scores  than men . Moreover, there was a significant main effect of age on the “Self-improvement” and the “Improve looks” strategies, both with a positive regression coefficient, indicating that older participants rated these strategies as more effective than younger participants. In addition, no significant main effects of marital status were detected.Turning to MANCOVA results, Bonferroni correction could be used as in Study 2, setting alpha to .004. A significant main effect of sex was found for the “Show more interest in my partner” strategy, where women gave higher scores . We hypothesized that, in order to improve their intimate relationships, people would employ strategies that would convey to their partners the message that they are committed to the relationship. Consistent with this hypothesis, we have identified a number of strategies, including “Show more interest in my partner,” “Create experiences together,” “Build trust,” “Discuss our problems together,” “Show her/him my love,” and “Make concessions and compromises,” which enable people to indicate to their partners that they are committed to the relationship. The “Discuss our problems together,” the “Show more interest in my partner,” and the “Create experiences together” were among the most likely to be used strategies, while the “Discuss our problems together,” the “Show more interest in my partner,” and the “Show her/him my love” were rated to be the most effective strategies.We have argued further that, another source of relationship strain, was the partner being controlling. In particular, research in the area has identified “Clinginess” and “Lack of personal time and space” to be among the most frequent sources of relationship strain . Accordingly, in order to improve their intimate relationships, people employ the “Give my partner more space,” reducing in effect the control they exercise over their partners. Nevertheless, participants indicated that this strategy was among the least likely to be used, one reason being that it was not particularly effective. Another reason can be that, by giving more space to their partners, people expose themselves to the risk of infidelity.We hypothesized further that lacking desirable qualities was another source of relationship strain. Previous research has identified “Character issues” and “Lack of effort” to be frequently reported sources of relationship strain . Accordingly, we hypothesized that people would use strategies that enable them to demonstrate to their partners that they have desirable traits or at least that they do not have undesirable ones. One such trait is good looks , so peopThe two sexes appeared to be in agreement over their willingness to employ the identified strategies, with the only significant sex difference being over the “Make concessions and compromises” strategy, where men indicated a higher willingness to use it than women.Similarly, the two sexes were in agreement over how effective they considered each strategy to be. Significant sex differences were found only for the “Show more interest in my partner” and the “Be less withdrawn and grumpy,” which were rated as more effective by women. We do not have a working hypothesis for the existence of these sex differences, and future research needs to attempt to replicate our results in different samples.Although there is overlap, the factor structure we have identified here is considerably different than the one Our findings have potential practical value for people aiming to improve their intimate relationships, and for mental health professionals wanting to help clients who face difficulties in their intimate relationships. This is even more so, if one considers that intimate relationships appear to be in crisis, with singlehood and divorce being on the rise . In partOne limitation of the current research is that it employed non-probability samples, so our findings may not readily generalize to the population. Furthermore, we used self-report instruments, which have several biases, including participants not being able to accurately assess how likely they were to use each strategy, and how effective each strategy would be on them. In addition, our research was confined to the Greek cultural context, and its findings may not generalize to different cultural settings. Accordingly, cross-cultural research is necessary in order to examine how cultural factors affect the identified strategies. Moreover, the mean scores for most of the identified strategies were high, indicating a high willingness to use the identified strategies for the purpose of improving relationships. However, the current research is not informative on the degree that this willingness materializes in actual use of these strategies. The high rates of divorce and relationship failures suggest that people may not use these strategies as frequently as their willingness to do so suggests. Accordingly, future research should attempt to examine the degree that people actually use these strategies, as well as the factors which predict whether they would do so, such a relationship satisfaction and having children.Intimate relationships constitute a fascinating aspect of human behavior, and in the current research, we have identified 14 strategies that people employ in order to improve them. We have also found that the two sexes and people belonging to different age groups were generally in agreement over which strategies they would use, and how effective they would be on them. The complexity of the phenomenon requires considerable more theoretical and empirical work if relationship enhancement strategies are to be better understood.


Dear Sir, In our article, we emphasised the remarkable improvements in surgery brought about by anaesthesia when we wrote ‘The introduction of anaesthesia was clearly ground-breaking’. William Osler, later wrote, ‘Search the scriptures of human achievement and you cannot find any to equal the beneficence of the introduction of Anaesthesia, Sanitation, with all that includes, and Asepsis’.We thank Charles Pither for his interest in our paper. His suggestion that we ‘forgot or downplayed the role of the anaesthetist’ is not correct.The point we were making in our paper was that the fear of inflicting pain did not stop surgeons from carrying out painful procedures in pre-anaesthetic days. Procedures including trepan, limb amputation, aneurism ligation, hernia repair, mastectomy and lithotomy were all in the surgeon's repertoire even before anaesthesia was introduced. Even ovarian cystectomy was performed in the pre-anaesthesia period. Horrendous though it was, pain per se did not kill patients, but postoperative sepsis did, and it was mortality from sepsis that deterred surgeons from operating. write ‘anaesthesiology as a field is well positioned to potentially benefit from advances in artificial intelligence as it touches on multiple elements of clinical care’. They also recommend that anaesthetists ‘should partner with other providers  and patients to help develop the strategy for the optimal use of artificial intelligence’. Furthermore, Zaouter et al. evaluated the use of pharmacological, mechanical and cognitive robots in anaesthesia, clearly advocating a role for robots of different sizes and structures in anaesthesia.Charles Pither goes on to suggest that anaesthetists will always be required, implying that they will never be replaced by artificial intelligence or robotic systems. It seems, however, that anaesthesia, like surgery, will inevitably benefit from these technological advances. Hashimoto et al.Nowhere did we predict, as Charles Pither suggests, that the surgeon would be ‘replaced by a robot’. While surgeons and anaesthetists will increasingly adopt innovative technologies to improve patient safety and outcomes, we believe that for the foreseeable future, surgeons and anaesthetists, not robots, will remain in overall control of operative procedures.


Research clearly demonstrates social determinants of health (SDOH) impact health outcomes. Provider consideration of patient SDOH in prevention and treatment planning is critical for improved health care quality and health equity. Despite awareness of the connections between SDOH and improved population health, research demonstrates few providers document patient SDOH.This qualitative study aimed to better understand the barriers and facilitators of SDOH assessment, documentation, and referral in different health care settings and roles.Individual semistructured interviews were conducted with practicing health care providers in South Carolina between August 25, 2022, and September 2, 2022. Participants were recruited via community partners’ web-based newsletters or listservs using a purposive sampling design. An interview guide with 19 questions was used to explore the following research question: How do SDOH impact patient health and what are the facilitators and barriers experienced by multidisciplinary health care providers assessing and documenting patient SDOH?Participants (N=5) included a neonatal intensive care unit registered nurse, a nurse practitioner, a certified nurse midwife, a family and preventive medicine physician, and a counselor  with careers spanning 12 to 32 years. Participant responses are presented according to the following 5 themes: participants’ understanding of SDOH for the patient population, assessment and documentation practices, referrals to other providers and community-based resources, barriers and facilitators of SDOH assessment and documentation, and SDOH assessment and documentation training preferences. Overall, participants were aware of the importance of including patient SDOH in assessment and intervention but noted a variety of institutional and interpersonal barriers to assessment and documentation, including time constraints, perceptions of stigma around discussion of SDOH, and limited referral protocols.Incentivizing inclusion of patient SDOH in health care must be facilitated from the top down, so assessment and documentation can be universally implemented in a pragmatic way that works for providers in a variety of roles and settings for the betterment of health care quality, health equity, and improved population health outcomes. Partnering with community organizations can serve to augment health care organizations’ resource and referral availability for addressing patients’ social needs. Social determinants of health (SDOH) are defined by the United States’ Healthy People 2030 (HP 2030) as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” HP 2030’s data-driven national objectives categorize SDOH into 5 fundamental domains: economic stability, education access and quality, health care and quality, neighborhood and built environment, and social and community context . IncreasPopulation health has become an increasingly critical focus of health care delivery, especially during the COVID-19 pandemic . SDOH faAn empirical study of clinical application of Z codes in South Carolina before and during the COVID-19 pandemic found Z codes were only documented for 1.23% of patients in a large statewide sample . FurtherThis qualitative study aimed to examine health care providers’ experiences with assessment and documentation of the SDOH impacting patient health and well-being. Through in-depth interviews, our goal was to better understand the barriers and facilitators of SDOH assessment, documentation, and referral in different health care settings and roles.Qualitative research methods were used to address the following research question: How do SDOH impact patient health and what are the facilitators and barriers experienced by multidisciplinary health care providers assessing and documenting patient SDOH?In total, 7 team members  and 2 clinical partners assisted in the development of a recruitment plan to leverage clinical-academic-community partner web-based newsletters or listservs in a purposive sampling design  deployedAn interview guide with 19 questions was iteratively developed by 7 team members  and reviewed by 2 partners to explore participants’ current knowledge about SDOH and use of International Classification of Diseases, 10th Revision, Clinical Modification Z SDOH codes. The interview guide was piloted with 2 providers, including a clinical partner .Individual semistructured interviews lasting between 30 and 45 minutes were conducted between August 25, 2022, and September 2, 2022, by 1 study team member (BY) via Zoom; 1 team member (JRR) sat in on 1 interview to take notes. Interviews were recorded and transcribed verbatim through Zoom transcription services and imported into NVivo  for analysis.For codebook development, 1 team member (BY) initially matched concepts to the interview guide using a deductive approach. Two team members (BY and MMM) then independently reviewed and coded 3 transcripts each for comparison and finalization using an inductive approach. Intercoder agreement resulted from iterative discussions between the 2 coders. One team member (BY) then iteratively coded all 5 transcripts using semantic thematic analysis ,15, and This study was approved by the University of South Carolina Institutional Review Board (Pro00122161). Recruitment language providing a description of this study’s purpose, eligibility, procedure, and incentives for informed consent was disseminated through statewide partner e-listservs. Transcribed interviews were deidentified , revised for accuracy, and imported into NVivo for data management by 1 team member (BY). Original interview audio files were securely stored in a password-protected, cloud-based storage application with limited team member access. Participants were provided a US $25 incentive for their time.Participants (N=5) included a neonatal intensive care unit registered nurse, a nurse practitioner, a certified nurse midwife, a family and preventive medicine physician, and a counselor . Participants’ careers in health care ranged from 12 to 32 years, with 1 to 25 years of experience in their current roles. Three participants currently work within a large health care system, 1 participant works for a university health care system, and 1 participant works at a rural, 2-physician practice. Two participants also serve as faculty members involved in training the health care workforce within a university system .Participants seemed to have a good understanding of SDOH and were able to reflect on how SDOH might impact their specific patient population. All participants reported SDOH are important to assess for improved treatment planning but described a range of assessment and documentation practices. Participants identified a variety of SDOH impacting their patients including general access barriers , health care access and quality (affordability and provider’s time), education and health literacy, poverty and material constraints, food insecurity, and social connectedness. For example, 2 participants gave an overview of the different SDOH affecting patient populations:The neighborhood around our practice has, you know, folks that have a lower socioeconomic standpoint, so that’d be one, lower education rate as a as another. So, food insecurity is another social determinant. We also look at social connectedness as another one, and finances as a fifth.Participant 4I would define social determinants of health as those factors that impact patients’ access to care, patients’ understanding of their care, and maybe the resources that are available to them. I think things outside of - yeah, those things that are sometimes kind of hard to quantify and it’s certainly hard to elicit.Participant 3Another participant focused in on health literacy as a salient problem among patients, further adding limited provider time reduces opportunities for health education:You know, so a lot of our patients, you know, you can break it down to the sixth-grade level, and it’s still over their head. You know, it’s like, you know, the population when it comes to understanding, having what I call “health intelligence”, are not even at the second-grade level. So, social determinants of health, you know, education is a joke, our healthcare system doesn’t allow the health care providers the time they need to teach the patients and then of course, on the patient side, they just gave up. Now, that’s not all of them, that’s just most of them.Participant 2Participant 5 explained how using SDOH can help understand patient challenges and improve outcomes:If I look at, just in general, my work in mental health, the patients are very often hindered from whatever they want, because of other things like finances, or they don’t have food. So, for example, I’ve served as a home health social worker, and I was only pulled into the cases where they weren’t getting better because of the social determinants of health. Obviously, if you’re not eating, your wound won’t get better, right? Obviously, if you’re about to be evicted and you’re taking care of your loved one who’s dying, you can’t take care of them, you’re working on the eviction.Participant 5The issue of access  highlighted by participant 1 illustrates the importance of supportive health care services that attend to the entire family (parent caregivers) as well as patients.I think the biggest social determinant and social justice problem that I see is with our patients – I mean, the parents of these patients – is their access, and their availability to be able to be with their babies at this very, very vulnerable time. So, making sure they have what they need and the equal opportunity to be able to access their child is a big problem that we see.Participant 1While 2 participants were familiar with International Classification of Diseases Z codes (Z55-65) specific to SDOH, 3 were not. Only 1 participant reported the use of these Z codes to actively document patient SDOH, indicating the codes were recommended by their EMR system to be added to the problem list and visit encounter. Three participants documented SDOH via provider notes or the patient education or care plan, and 2 participants indicated an automatic screener.All participants agreed that assessing and documenting patient SDOH was very important and beneficial for improved health outcomes; however, most (n=4) noted SDOH are not systematically or consistently assessed. One participant stated asking whether SDOH is standard social work practice. Another participant mentioned that while sometimes more basic questions are asked, there is often no in-depth assessment, especially for outpatient care:The focus is on the disease process and how to -- which medication to prescribe. I’ve seen it before, you know, I mean, they don’t really dig deeply these days. Now, if we’re talking about a medical student, or medical resident, or patients being admitted, man do they dig. But when you get out into a practice, like outpatient, stuff like that -- the social determinants really are boiled down to a few very minor things that are “yes” or “no” questions or basic answers when they fill out an application.Participant 2I think everybody, if we’re intervening with the patient, I think it is [our] ethical and moral responsibility to ensure that we’re addressing the needs of the entire patient, because it’s not just a medical need, or the daughter doesn’t just take care of the medical needs, or the nurse just doesn’t take care of nursing needs; I mean we take care of the whole patient in their family.... It doesn’t need to be this conversation of, “Oh, well we don’t talk about these things,” or “This is just the way that it is.” I mean, we’re all human beings and we all deserve the right to access equal access and equal opportunity.Participant 1When asked, “How often do you or does someone in your practice ask patients about social determinants of health?” no participants reported having a universal protocol to assess patient SDOH at each visit. All participants indicated they will either start to notice patterns or patients will specifically bring SDOH up over time, despite not actively screening for them. One participant stated they ask the patients questions about their lives in a conversational manner at each visit to glean information about SDOH, and 1 participant indicated an annual electronic screener all patients attending their practice receive. One participant said they ask at each initial appointment if the patients are affiliated with one of their grants requiring assessment of certain SDOH.When asked what is done when a need is identified, all 5 participants reported they refer patients to a variety of external providers and local community partners who provide health and social services such as new parent education, counseling and substance use services, and vocational rehabilitation. Specific national organizations participants mentioned included Ronald McDonald House, United Way, and First Steps, and 1 participant mentioned partnering with 2 community organizations through the NowPow platform . One parThree participants indicated they would make contact with an internal provider, such as a social worker, or to a provider who does semiregular drop-ins, such as a nutritionist, physical therapist, or podiatrist. Two participants reported directly addressing the need on-site at the time of the encounter:We do have that very close-knit relationship [within our care team] where we can just go and talk to [our providers] face-to-face and be like, “Well, we need to get somebody to come address this, or we just need to, you know, have an intermediate interdisciplinary meeting, where we have everybody there at the same time.” Things like that. As far as transportation, we can get with social work to try to get like taxi vouchers or bus vouchers or whatnot.Participant 1So, there are some organizations that will help. It’s just a matter taking the time and making the phone call. I find if you give the patients the information and ask them to cold call, they don’t seem to. So, we kind of take the groundwork, and [if] they have a contact person, I think it seems to work a little bit easier. We’ll bring them in the office. I’ll bring them in my office, and we’ll make the call and see if we can’t get them.Participant 3Participants offered their perspectives on barriers to assessment and documentation of SDOH , web-based courses, catered dinners, and destination conferences as their general preferences for training formatsWe do something like this [with our students], like they get X amount of stipend, like with their paycheck, and then they have to go to all the community sources and make sure they can get groceries. But then I gotta pay the light bill, and this is like, they realize how quickly sometimes their money can go. Even incorporating that, now you’ve been hospitalized, and you could incorporate that into a lot of nursing education.Participant 1From a standpoint on how to ask the question, we do well. I guess part of my job is actually to help train the residents and medical students on how to ask the questions. And, so we do more of video feedback for the residents, and such.... But, for the attending faculty like myself, that is not necessarily something that they do for us per se. So, I’ve kind of more learned on my own, when it comes to that.Participant 4While only 1 participant reported having training on the use of Z codes from the “billing aspect,” the majority of participants did not feel training on SDOH assessment and documentation would be very beneficial without a system-wide push for a standardized protocol.Four participants stated they would not benefit from training on how to ask patients about SDOH; 1 participant felt they would benefit from training to improve their knowledge of Z codes and more efficient documentation to save time.Yeah, I guess I think about, you think about behavioral change, or you think about practice improvement or quality improvement, is that the more that you can do it a higher functioning level where it doesn’t rely on the individual person to change that actually makes it a more sustainable model. And so, giving a doctor education on the importance of health literacy, I think in the end is the least helpful long term. It needs to be something where it is with, like in the EMR, how the social determinants of health from the screener say, you know, “here’s some ICD-10 codes you should add to your bill,” and all you gotta do is click a few buttons. Because, I can scan it and agree, like “yep, yep, yep”, and then I can move on.Participant 4Overall, participants in our study conceptualized the SDOH of their patient populations in accordance with HP 2030 and could indicate how individuals in their care were affected by the 5 HP 2030 SDOH domains. Microlevel social needs identified by participants included material constraints such as time , transportation, financial and food access barriers, and social disconnectedness. Identified SDOH at the macrolevel included poor education quality, with specific attention to a lack of health education that can contribute to limited knowledge of positive health behaviors and limited health literacy on the individual level. All participants mentioned the broader aspects of the SDOH domain of health care access and quality when describing the barriers to assessing and documenting SDOH during the clinical encounter .Participants realized the context of one’s life has a crucial role in the development and management of health conditions. All participants agreed assessing and documenting patient SDOH were very important and beneficial for improved health outcomes but most (n=4) noted it is not done consistently. Consistent with findings by Heidari et al , particiDespite the lack of formal methods of screening, all participants noted patient social needs are often revealed over time, whether through direct patient disclosure or indirect indicators of barriers to treatment adherence . While 2 participants delivered annual or semiannual formal SDOH assessments to some or all of their patients, all participants suggested a more conversational approach often served to elicit depth of information on patient SDOH. However, even in instances where SDOH information is gathered informally, it can be difficult to act upon the information, since resources can be difficult to find or unavailable. This can lead to providers becoming frustrated since they feel they cannot help their patients and are thus wasting valuable visit time.Z codes, while they present a way to quickly and consistently record SDOH information, are not billable to insurance so they may be supplanted by billable codes when numbers of codes are limited. Entering codes was also seen by participants as an inefficient use of time, especially in for-profit settings, since entering nonbillable codes takes time away from the entering of billable codes. Billing code disincentives have created unintended consequences for individual clinics to inquire about SDOH or to use Z codes that must be addressed at the system level. For example, validated screeners may provide a way to gather SDOH information but must be implemented as a system-level policy. Thus, especially in for-profit settings, the use of Z codes must be aligned with economic goals. Insurance companies can already support SDOH screening by using value-based models that incentivize longer-term patient outcomes. Making codes for SDOH billable would help further move medical services in the direction of more holistic care . EffortsParticipants perceived patient reluctance and apprehension of stigma as interpersonal barriers to the assessment of SDOH. There is some emerging evidence related to the stigmatization of the SDOH. Rather than an acknowledgment of the important ways in which the life context impacts our health and well-being, participants in this study alluded to the SDOH negatively, demonstrating SDOH are perceived as deficits rather than basic health and human rights, such as access to adequate food, income, education, transportation, supportive social networks, housing, freedom from racism, and freedom from other discrimination. This is in opposition to the intended assessment and documentation of patient SDOH as important social “vital signs” impacting health outcomes . AddressThe next most common perceived barrier was an inability to address the patient’s SDOH. Our findings are consistent with those of Kostelanetz et al , who repParticipants suggested trust and rapport facilitate the assessment of patient social needs and felt long-term patient-provider relationships and standardization of SDOH assessment can reduce patient perceptions of provider judgment and reduce a sense of a power dynamic. This creates significant tension for clinicians who predominantly practice within a biomedical model of care and have limited educational exposure or incentive to adopt a social-ecological model of health care that includes attention to the SDOH. Given the importance of patient-provider trust and rapport, clinician practice of cultural humility is necessary for equitable patient care. Cultural humility entails provider openness, self-awareness, and humbleness , and “inWhile systematically assessing and documenting patients’ SDOH are extremely important, ensuring there is a clear next step that involves assisting patients with social factors that impact health through referrals to community resources and organizations is vital for improved health outcomes . ParticiThis study has some limitations. First, we used purposive and convenience sampling to recruit participants. Second, the number of participants interviewed was quite small (N=5), limiting our ability to obtain findings generalizable to a specific health system, to the state of South Carolina, or to other US states. Third, participants had a range of years of experience within the health care field; however, some were newer to their current roles and thus had less experience within their current health care system. This poses a potential limitation for data source triangulation. Future research is warranted with additional providers to further explore assessment and documentation practices, barriers, and facilitators in additional settings in South Carolina. Examining provider and clinic practices by medical specialty and geographic location as well as proximity to referral resources will be important for supporting patients’ social needs following any assessment, documentation, or patient-provider discussions about SDOH. Despite these limitations, findings from our work will help providers and health care systems consider how to effectively integrate SDOH screening during patient-provider encounters, as findings offer important insights into providers’ perspectives and recommendations for SDOH assessment and the barriers and facilitators associated with it.SDOH have a clear and direct impact on individual and community health status. Clinical providers understand these ties; however, they struggle with the best approach to assess and document SDOH issues in clinical settings. Time constraints in clinic visits, perceived stigma of SDOH, and preference for a more conversational approach to the patient-provider discussion add complexities to data collection, which result in incomplete and inconsistent interactions across populations. Perhaps an institutional culture shift is required to ensure consistent screening and assessment of patients for unmet social needs and provision of appropriate resources, including connections to organizations in the community to assist with these needs. Unfortunately, the stigma surrounding SDOH issues, social isolation, and financial hardships continues to pervade society. Bringing these challenges into the open and talking to patients about them are necessary if the goal is to improve the overall health of patients.