This area includes Cicia Island, which deserves particular attention since, years before the design of the Lau Seascape Strategy, its population developed its own informal ridge-to-reef scheme, involving a combination of certified organic agriculture and locally managed marine closures. Based on 1 month of ethnographic fieldwork, this paper presents this scheme and highlights local perception and conceptualization of its positive effects on both the land and the sea. These reflect the iTaukei (Indigenous Fijian) concept of vanua, which intrinsically connects the health of the land, the sea, and their (human and non-human) dwellers, while stressing the importance of addressing land-sea processes and management efforts beyond an ecological perspective, i.e. through an engagement with the iTaukei relational ontology.Many Pacific countries and territories embrace an officially recognized ‘ridge-to-reef’ approach to environmental management. This is the case of Fiji, where the Lau Seascape Strategy 2018–2030, led by Conservation International, aims for integrated natural resource management across 335 895 km Lau Seascape Strategy 2018–2030 (LSS),In the South Pacific region, many coastal communities embrace officially recognized ridge-to-reef or R2R) approaches to environmental management. This is well illustrated by the GEF  Pacific Ridge to Reef Programme that involves the United Nations Development Programme, the United Nations Food and Agriculture Organization, and the United Nations Environment Programme as implementing agencies. As part of this multi-agency initiative, 14 Pacific Island countries aim to “maintain and enhance [their] ecosystem goods and services  through integrated approaches to land, water, forest, biodiversity and coastal resource management that contribute to poverty reduction, sustainable livelihoods and climate resilience”.R approacRidge-to-reef approaches aim to incorporate land-sea processes into endeavours to “foster coral reef resilience” . It is anchored in the iTaukei (Indigenous Fijian) concept of vanua, which refers to socio-ecological units as well as to a complex theoretical whole composed of socio-cosmic relationships , the various beings  that dwell in this territory, and the socio-cultural settings and socio-political organization that shape this territory . Then we will highlight local perception and conceptualization of the positive effects of this scheme on both the land and the sea. This will allow us to emphasize that, in the frame of the concept of 2 but an exclusive economic zone covering more than 1.2 million km2, Fiji (or the Republic of the Fiji Islands) is a large ocean island state  surrounded by coral reefs , a high school (in Mabula) and three primary schools , and a Fisheries station and an ice plant officially opened in January 2019 . There is currently no formal tourism operation on Cicia . This paper also relies on a triangulation with secondary sources, in particular on ridge-to-reef management within and beyond the South Pacific and on the iTaukei concept of vanua.In addition to this fieldwork period on Cicia, this paper draws on the previous research experiences of the authors in Fiji. Elodie Fache carried out five months of fieldwork between 2016 and 2018 on Gau, Fiji’s fifth biggest island, located in the Lomaiviti Province   during Christmas time, or visits from government officials. These openings were said to last from one day up to one week, during which finfish are the main or only target  by way of regulations under Sect. 9 of Fiji’s Fisheries Act. These discussions generated ambivalent feelings since, we were told, so-called ‘gazetted MPAs’ would facilitate the surveillance of Cicia’s waters and thus help reduce poaching, but would not allow for periodical harvesting of marine resources as Bose ni Tikina) approved the idea of engaging in organic farming at the island level, and the use of chemicals  was therefore banned from Cicia. In 2013, the island was declared organic, not through a third-party certification process, but through a Participatory Guarantee System, based on the direct involvement of farmers in the organic guarantee processMata ni Tikina), the headman of each village (Turaga ni Koro), and other representatives from each village. During our fieldwork period in 2019, the organic certification was granted to about 200 registered farmers, all village-based virgin coconut oil (VCO) groups, and Selavo Agro Business . While Cicia High School was not certified, its nearly 80 students – among which about 50 boarders – were also enthusiastically applying organic farming principles within the school ground.In 2006, the District Council . It also aims to revitalize customary behaviours and values, as illustrated below.However, the global label ‘organic’ is not restricted to farming practices on Cicia, but also creatively used in relation to other activities , instead of ‘green’ (drokadroka), the sea is ‘poor and unproductive’ (dravudravua or drava). As expressed by a religious leader: “if the land is rich, the sea too is rich” , or by a customary leader: when the land is ‘sautu’, the sea too is ‘sautu’ . Sautu is usually translated as ‘peace and abundance’, with peace between people as well as between them and all other elements of the vanua  being the precondition of this status, and abundance of children, animals and plants being its most visible outcome.Our study did not assess this combination of marine closures and organic agriculture through an ecological lens, but endeavoured to understand its effects as perceived and conceptualized by the inhabitants of Cicia. Interestingly, our interviews highlighted that one of the main drivers of this island-level organic transition was the increasing depletion of marine resources: this changeover was considered as a solution for the recovering of marine resources. Some of our interviewees explicitly reckoned that, since the use of chemicals was banned, corals are growing well, seaweeds are abundant and green, and more seafood is available near the villages. It is also recognized that excessive burning on land leads to a depletion of fish in the sea, whereas the ban on burning results in an abundance of fish. Indeed, their view is that when the land is ‘dry’ , and consumed. The days before balolo appear, the reef is said to be drava, ‘poor and unproductive’, as it is hard to get fish. Once the balolo show up, different fish species come to feast on this delicacy and spawn in turn, and people can therefore catch a lot of fish. Balolo do not only allow an increased availability of fish on the reef, but also an abundance in yam gardens. Indeed, the breadfruit leaves that are put in contact with balolo for their cooking are then placed on yam mounds in order to increase the flesh of yams and keep them healthy. This was and remains crucial, as in Fiji’s coastal areas yam is not only a staple food but also a pillar of iTaukei cultural practices.The converse is also true: when the sea is plenty, the land is plenty too. This is best illustrated by the effects of the yearly arrival in Cicia’s waters of “The organic status of your inner being will also affect the organic status of your customary fishing rights area and land.” The above-mentioned customary leader went a step further in the conceptualization of these land-sea interrelations in organic terms:iTaukei Fijians we met on Cicia and in other parts of the country), now tend to be marginalised, first and foremost the sharing of subsistence resources with relatives, other community members, and sometimes people from other groups . This was (and to some extent remains) a pivotal iTaukei behaviour and value , a small pelagic species, is now fished in Tarukua. Formerly, when this culturally significant fish, supposed to be plentiful in Apriltugadra no longer invite others to join them but catch them discreetly, and no longer share their take at the village level but consume it within their own household. As a consequence, interpreted most interviewees, this fish is now lost and rarely seen in Tarukua’s waters.balolo: when it does not appear, this is often related to the fact that some people sold it instead of sharing it. More generally, this exemplifies how, from a local perspective, turning away from goodwill sharing and reciprocity has concrete consequences in terms of resource availability. Interestingly, in July 2021, while Fiji was under a Covid-19 lockdown, posts on Facebook announced that tugadra was spotted in Tarukua’s tabu area by two persons, who reported this information to the chief (Tui Tarukua), which was followed by a call of all villagers and a collective fishing party. The catch was then shared equally between all households. These posts, illustrated by many photos, generated a lot of comments, many of them presenting this event as ‘a blessing’, and one as a sign that both the sea and the land are ‘sautu’.Indeed, more individualistic behaviours and values have progressively developed among iTaukei concept of vanua, “the world is one big entity and all things in it are associated”, with “life and its vitality depend[ing] on how all things relate and are affected by each other”; in particular, “life is complete and wholesome when all elements – air, wind, seas, rivers, plants, animals, fishes, people, the dead – are ‘synchronized’” , with “everything” including the land-sea territory and its various inhabitants (vanua), spirituality/worship (lotu), kin relations (veiwekani), school and development. Conversely, when these marine species do not show up as scheduled in the traditional Fijian calendar  and spirit gods  to the whole vanua and that is essential to achieve a state of sautu. Without the agreement and support of the customary chiefs, none of the projects instigated by members of the vanua are possible. It was therefore crucial for CI to involve the forum of customary chiefs of the Lau Province (“the Masi ni Vanua o Lau”) in the design of the LSS, which also included the specific objective to “facilitate the installation of chiefs/leaders on each island” . How does this fit with the LLS goals, for instance, to protect archipelagic waters and seamounts (CI “bula sautu”/ “sustainable livelihoods” relate to the pursuit of peace and abundance (sautu) through a relationship of mutual respect and reciprocity between all dwellers of the vanua?A research pathway worthwhile investigating in future studies would be the (dis)connections between Cicia’s pre-existing scheme and this LSS that advocates an approach to environmental management “from ridge to reef oods” CI . While moods” CI , p. 11, tabu areas, while the overall fishing pressure remained high in the iqoliqoli. Some of our interlocutors thought that the ‘organic island’ concept was not yet fully understood by the population of Cicia, and that therefore the island was not 100% organic. For instance, they observed that unorganic/processed food was still sold and bought in the local grocery stores (wheat flour, soybean oil, canned fish, etc.; Fig. iTaukei Fijians that capitalist development is an immoral pursuit that challenges both the Christian and traditional relations, morals and obligations inherent in ‘the Fijian way’ (Toren During our fieldwork period in 2019, Cicia islanders pointed out that they were still facing several challenges in implementing their informal ridge-to-reef scheme. Poaching sometimes occurred in the y’ Toren . We wereHowever, this local experiment appears as significant at three different levels. First, it provides lessons that could inform the implementation of the LSS and, more generally, Fiji’s natural resource management policies. Second, it illustrates how people in the South Pacific region enact their “Oceanian sovereignty”, i.e. are asserting their right to make choices about the future of their land-sea territories and the ocean, through their fluid responses to the challenges confronting the wellbeing of the region across human and non-human domains (Bambridge et al. iTaukei concept of vanua that conveys an inseparability between the land and the sea as inherent parts of an all-embracing entity (Fig. iTaukei Fijians relate to specific fish and plant totems (Nabobo-Baba Through this case study, this article brings more-than-ecological insights into land-sea connectivity in Pacific island settings, articulated around the ity Fig. . Previouity Fig. , in corrity Fig. , and in


This article explores the story of Einar, a Faroese man who always lived within a 500-meters radius on the island of Suðuroy, who never felt “stuck” or “immobile” in the literal sense of the word. Studies have shown that staying is a process, as much as mobility; yet while mobility studies mainly show that imagination is an incentive to move, we argue that imagination may also actively support staying. Combining sociocultural psychology with mobility studies, we propose to explore the entanglement of symbolic mobility (a form of imagination) and various forms of geographical (im)mobility. Based on ethnographic fieldwork and hours of conversation, we present the case study of Einar’s life on his island. We follow the sociogenetic development of the island, and the expansion and contraction of the imaginative horizon over time. On this background, we then retrace the life of Einar and show how, within this transforming context, his imagination developed thanks to resources he could use from the mobility of technologies, ideas, and other people. Interestingly, at different bifurcation points, his symbolic mobility almost led him to move away but, at another point, helped him to refuse geographical mobility. Hence, he was always symbolically mobile while staying. We finally propose directions for generalising from this case study, and implications for cultural psychology and for mobility and migration studies. This article presents parts of Einar’s life-story. Einar is a Faroese man in his 90s who chose to live in the same village, Tvøroyri, on the small island of Suðuroy – one of the 18 islands that constitute the Faroe Islands, a small archipelago nation located in the North Atlantic Ocean – for his entire life. Oliver first met Einar in 2019 at a communal event on Suðuroy. A friend, who had brought him and a colleague there, pointed to an elderly man with bright white hair and large square glasses, sitting at the edge of the crowd and said, “you must speak to him”, explaining that he had never moved away from the island. She introduced Oliver to Einar, who is incredibly lucid, curious, speaks at least three languages fluently, and has an impressive knowledge of the Faroese history. Over the period of a year, Oliver met Einar several times and spent many hours talking about living on the island, travels, significant events, and, importantly, what made him stay at different points of his life. Although Einar sought to move away a couple of times, social and affective ties and a progressive differentiated imagination led him to stay in the village – a place marked by high incoming mobility on one hand, and emigration on the other. His story demonstrates that staying is a continuous process Hjälm, , and we aspirations  the socio-economic matrix, however we put less emphasis on this more widely studied phenomena  in order to build a dialogical case study , and the Faroese weather made the trip to Tórshavn  long and potentially perilous. During the stormy winter months, the journey was simply not possible and, still today, I have experienced being ‘stuck’ on the island or not able to return due to the forces of nature. In a second phase of the fishing adventure, two villages on Suðuroy, Tvøroyri and Vágur, rose to become powerhouses in the Faroese economy , were captivated by the foreign ships arriving.Those merchants – we just call them merchants, they were also owners of ships – they realised, together with foreign people, that this waterfall [on the southern side of Suðuroy] could be used to develop a powerplant.Suðuroy position as one of the fishing centres meant a lot of oceanic traffic, and Einar would always try to get on board the ships to meet the foreign anglers. Experiences like this might have functioned as windows to the world beyond the island’s natural barriers, as radio was still unreliable and newspapers scarce. This constant inflow of people (anglers) and goods  seem to have provided with resources for imagining alternatives to the present – to imagine faraway places – with tangible and, sometimes, material implications. For instance, as he explains, it also brought in a lot of ideas and technologies, which further expanded the possibilities on Suðuroy as well  possibilities were, to a large extend, centralised around fishing and its seasons. The capacity to realise an imagined mobility was, for many, constrained by infrastructure and the economic situation. At the same time, we propose that this myriad of entangled mobilities along with societal changes expanded the imaginative horizon, opened new pathways and provided people, like Einar, with resources for imagining. The parochial and fatalistic horizon that had arguably set the bounds of villagers’ imagination, in the sense of “not thinking about” emigrating because it appeared in the realm of impossibility, slowly began to expand outwards as encounters with the world increased and the socio-economic situation improved. This broadly fits the proposition made by de Haas and others  as preventing him from pursuing that path. We may stop to examine this use of a biological justification to support his choice and what it reveals. As said, it seems, in Einar’s environment, fishing was perceived as a “proper” line of work and becoming one was “very natural”. We dare say that the pull towards the ocean was strong back then. Hence, faced with these social expectations – to work as an angler or to move away – Einar appears to have used, consciously or not, an irrefutable argument. After all, he is not opposing the normative expectations by choice, rather his genetic mark-up that does not allow him to work on the ocean, and it is futile to argue against biology.[…] my mother, she cried so bitterly for 14 days […] if I left, she would also leave. Not with me, then she did not want to live anymore. But what could we young people do? We could not just walk around doing nothing.Due to the diversification of the economy following the Faroese industrialisation Gaini, , along wEinar eventually cancelled his plans and chose to stay on the island, despite the fact that, as he said, he could just have left and blamed it on being young, but “that was not me”, Einar adds. He reckons that this decision disappointed his father a bit, who had hoped for Einar to move abroad to “develop”. In fact, none of the three brothers moved away from the island. So, when Einar started to imagine becoming a blacksmith and began to plan transnational mobility, his social and affective relations delegitimises that imagination  lives of other people, particular his mother and two brothers. We thus saw Einar deploying his imagination partly in resistance to the imaginative horizon; yet were sociocultural norms can be resisted, perhaps social and affective ties less so. Also, we observed how he could use various social, cultural and financial resources to transform geographical immobility into imaginary and social mobility – and as we will see, further symbolic mobility.Wartime isolation from Denmark gave an extra momentum to a wave of nationalism that had been building since the late 19-century Sølvará, , which eThere was a need for customs officers almost 24/7 […] because there were foreign shops […] and many people on board. So, there was a tremendous development on that front, and I learned a lot on one or the other hand.For Einar, this geo-political change opened a new field of possibilities locally: He became one of the nation’s first five customs officers starting in 1949. This placed him at the very juncture of incoming ships, anglers and goods. Einar chose a profession connected to the fishing industry, which the imaginative horizon was, to a degree, centralised around, allowing him to maintain a life-long interest in ships and everything they brought with them without becoming an angler. Here Einar found many resources to nourish his imagination and, hence, symbolic mobility. Though the industry was struggling to modernise in the 1950s, there was amble mobility in and through Suðuroy:[…] I do not why we [him and his brothers] are so stupid not develop our foreign ways, but that is our little problem, but we are glad for that problem.Einar’s position at the juncture of mobility provided him the opportunity to learn from the countless encounters with anglers from distant places mobilities, in changing social circumstances. Einar life took place in times characterised by an expansive imaginative horizon, high levels of emigration, and imperatives to journey abroad to “develop”. However, we showed how Einar’s imagination of what lies beyond the island increased and became progressively differentiated though his encounters with incoming technologies, ideas, and anglers, which could be used as resources in his symbolic mobility. Einar seems to have felt that the world was coming to him and that he could explore it from afar. Thus, we believe, Einar’s story demonstrates that, first, imagining life elsewhere does not necessarily trigger geographical mobility, but it may also equally engender processes of staying. Second, it shows that staying is an active process unfolding throughout people’s life trajectories, and which can neither be separated from its entanglement in a web of human as well as non-human mobilities, nor from individual socio-economic positions, experiences, social and affective ties, and imagined futures. Social and affective relations appeared to have counteracted the imperatives to be mobile and delegitimised Einar’s imaginations of becoming a blacksmith, further underline his decision to stay. Studying the relation between mobility, immobility and imagination along people’s trajectories highlight the many negotiations and ambivalences involved in the process.We suggest that differentiating between symbolic and geographical mobility and immobility contributes to mobility studies, as it offers an analytical tool to unpack the imaginative processes that both triggers, and are triggered by, movement and stasis of the self as well as others, technologies, and ideas. Further, we argue that exploring this entanglement requires a contextual, perspectival and dynamic approach. Here we propose that the notion of imaginative horizons can capture different forces impinging on people’s imagination and (im)mobility throughout time, while still recognising that people are uniquely located in these situations, and draw upon available socioeconomic and symbolic resources, to feed their symbolic mobility. In short, we demonstrate the link between processes of staying and other, entangled, mobilities at the intersection of imaginative horizons and unique individual trajectories of imagining.Generalising from this case study also has implications for sociocultural psychology mobility across times and spaces. We need to account for the different entanglements of mobilities, imaginative horizons, social and affective relations, and unique life trajectories when studying different capacities to imagine and to capture that the promise of being mobile for one person might mean staying for another.


We evaluated (a) opinion of Syrian and Turkish healthcare workers (HCWs), and perceptions and attitudes of Syrian refugee mothers, pregnant women, fathers and grandmothers on age-appropriate breastfeeding, (b) the effect of cultural characteristics, migration and pandemics on Syrian’s infant nutrition, and (c) the suggestions of HCWs and Syrian family members to improve breastfeeding practices in the Syrian refugee society in a qualitative study.The qualitative study consisting of structured focus group discussions (FGDs) was held in four provinces in Turkey where Syrian refugees live intensely in September and October 2020. Seven different types of online FGDs were held with Turkish HCWs working in maternity hospitals, Syrian HCWs working in Refugee Health Centers (RHCs), Syrian pregnant women, mothers, fathers, and grandmothers. In total, we carried out 46 FGDs with 335 individuals. Thematic analysis of the transcripts in a deductive-inductive fashion was carried out with MAXQDA 11.Most Syrian HCWs did not get any training on breastfeeding counseling. The short duration of breastfeeding in Syrian refugees was seen to be related to the cultural characteristics, and migration. Some cultural characteristics can be summarized as “believing that breastfeeding harms mother’s health”, “adolescent marriages”, “wanting to have as many children as possible”, “giving anise to infants and not breastfeeding at night”, “prelacteal feeding”, “believing that milk is not enough”, “over controlling mother–child interaction by grandmothers, which limits the interaction”, “short pregnancy intervals”, and “not using modern family planning techniques”. We found out that migration increased the tendency for adolescent pregnancies, deepened the poverty, and decreased family social support. We did not observe any change in breastfeeding practices during pandemics.Breastfeeding counseling programs should be designed in consideration of cultural characteristics of Syrian HCWs and family members. Continuing health education programs for family members with socially appropriate interventions to prevent adolescent marriages are important. Breastfeeding is significant in achieving Sustainable Development Goals #2 and #3, which aim for ending hunger, promoting healthy nutrition and wellbeing –3. The WLactation is a natural process that starts without any external intervention. However, it has been reported that social and cultural determinants, personal habits have an impact on breastfeeding in human beings –20. BreaSyrian refugees’ perceptions, attitudes, and socio-cultural factors about breastfeeding are not well known. None of the published literature was able to diagnose and explain the genuine reasons behind poor breastfeeding practices in Syrian refugees. Present studies included only mothers and mostly prevalence reports from one hospital or province. However, to effectively promote breastfeeding, the perceptions, attitudes and socio-cultural factors that influence breastfeeding practices in specific populations should be well understood. Among migrants and refugees in Turkey, Syrians have the largest fertility rate; about 10,000 Syrian babies are born monthly . TherefoThis qualitative study, a joint project between WHO, The Ministry of Health (MoH), and the Hacettepe University, included structured, online focus group discussions (FGDs) . The EthWe used purposive sampling method and included four provinces, and two districts from each to ensure triangulation, reduce bias, and obtain a diverse information from participants.We selected four provinces; Gaziantep, Hatay, İstanbul, and İzmir, which host about 31% of the Syrian refugees in Turkey . With thWe designed two distinct main groups with seven subgroups for FGDs;Group 1  Parents, whose children were cared for by someone else, (b) Family members whose relatives participated in previous FGDs, (c) Family members having at least one relative who were HCWs, (d) Family members working in the hospital or RHC as a secretary, interpreter, cleaner or driver.Topic guide questions for HCWs, mothers and fathers and grandmothers Table  were preTopic guide questions were written in English and translated into Arabic; they were retranslated back into English to ensure reliability. Then, they were edited by scientific reviewers and WHO Ethical Review board. The pilot implementations of FGDs with mothers and Syrian HCWs were performed face-to-face in Ankara in September, 2019. Thus, the topic guide questions were tested and improved.The MoH provided written communication about the study and the contact information for the research team to selected hospitals, and Refugee Health Centers (RHCs) from the selected provinces and requested the invitation of targeted participants to take part in the study. A volunteer HCW from each RHC announced the study, selected the family members to participate among the ones who agreed and met inclusion criteria. FGDs were conducted in Turkish for local HCWs and in Arabic for Syrian HCWs and refugees; female interpreters for female refugees and male interpreters for male refugees interpreted FGDs.All FGDs were conducted in September and October 2020. Zoom link was sent to HCWs before the meeting and they attended the FGDs where they wanted, whereas voluntary family members were called to the RHCs at the appointed time to provide a safe, private environment that families could access easily. Participants signed informed consent forms before the study. During FGDs, all personal identifiers of participants were masked by nicknames. All data including a short socio-demographic questionnaire and FGDs collected using these nicknames only. A nurse in selected RHCs ensured that the zoom link was established, the nickname of the participant written on screen and the family participant was connected with RHC’s computer. One participant per family attended the FGDs. One appointed HCW in each hospital and RHC collected the file including the signed informed consent and filled questionnaire and sent images of the file using WhatsApp.Due to the COVID-19 pandemic, we used the Virtual FGDs with audiovisual software. We selected the ZOOM platform, because of its wide diffusion, intuitive interface, and interactive functions. To allow everyone sufficient time to express themselves, we limited the number of participants, into 6–10 participants for each 60–90 min FGDs. Interviews were audio-recorded with the nicknames.Each FGD session was performed by two researchers, supported by bilingual translators. SSY, an experienced qualitative researcher, moderated the meetings. The second researcher (MEN) was trained for collection techniques and all FGDs were performed with the same structured open-ended questionnaire. Both researchers, took notes regarding study participants’ verbal and non-verbal cues during sessions of FGDs and achieved intersubjective agreement for observer triangulation.n = 4) were trained on the study subject including standardized research questions. Controversial expressions in the translation were also checked by the other two translators through audio-recordings’ data and a consensus were achieved.Prior to FGDs, bilingual translators  and transcript of audit data were included to ensure data triangulation. Two coders were present for analytic triangulation and the categories and themes that emerged were confirmed by inter coder consensus.First, one researcher (MEN) anonymously transcribed audio-recordings verbatim. The text transferred to software and then two researchers  read the text while listening to audio-recordings for any mistake and to proof-read. Three researchers  at team meetings discussed differences in data and modified the transcription if necessary.Thematic analysis of the transcripts was carried out. Categories, codes were developed in a deductive-inductive fashion. SSY constructed a codebook, and linked in categories  prior to data collection and modified it while in the field. Two coders (MEN and SSY) independently analyzed the text in the light of research questions, read the text over and over, highlighted central terms and concepts, marked and wrote memos. Then, two coders either assigned the code to every segment of text or identified recurrent themes and defined appropriate codes and associated the text passages with them. The third researcher (SY) read the text line-by-line, checked the codes for similarities and differences and noted every discrepancy between MEN and SSY, and used team meetings to discuss these discrepancies and to make decisions about which way the data should be coded. ‘Consensual coding’ was done to ensure that all the coders  agreed in their understanding of how to apply the category system. Some codes were grouped together according to their similarity, while other codes started out too broad and were sub-divided. When there was no need for additional categories, the category system was fixed. As the data was compiled, data saturation was checked and cross-checked with the previous FGDs and it was seen that the data saturation was achieved at the end of the study. Some statements were selected to give their core with thematic summaries. Coding and analysis were performed using MAXQDA 11 .There were a total of 335 participants  to FGDs. Overall, 15.1% of Syrian HCWs and 45.8% of Turkish HCWs indicated that they received a WHO-Breastfeeding counseling training  had two children under two years old, three mothers were pregnant and current breastfeeding rate was 77.6% the last child. From 37 pregnant women, nearly half (n = 15) had one child younger than 24 months of age and only three of them were breastfeeding their last-born child. In the fathers’ FGDs, nine fathers had two children younger than 24 months and the current breastfeeding rate was 65.8% for the last child. In the grandmothers FGDs, the current breastfeeding rate was 81.6% for the last grandchild.One-third of mothers were married before 18 years of age. Overall, 8.5% of parents and 39.5% of grandparents were illiterate. Demographics of mothers, pregnant women, fathers, and grandmothers participating to FGDs were given in Fig. “Usually mothers prefer breastfeeding because they are under the protection of Turkey, their finances are tight, and breast milk is less costly and more natural. ”Most HCWs stated that Syrian mothers were generally breastfeeding their infants. Half of the RHCs staff reported that Syrian mothers breastfeed due to financial difficulties but started complementary food as early as 2–3 months of age.“I want to breastfeed for 2 years, I plan like that but as he is not full with my breast milk currently I am both breastfeeding and bottle feeding, I want but I can’t. ”Nearly, all mothers in FGDs reported that they gave breast milk to their infants for some period of time. However, they claimed that sometimes when breast milk was not enough or the baby won’t latch, they supplemented with infant formula or cow’s milk before 4 months of age.Most pregnant women planned to give breast milk after birth. Those with previous poor breastfeeding experiences or with twin pregnancies had anxiety about breastfeeding.Nurses and midwives at maternity hospital stated that they give babies to mothers as soon as possible and encourage breastfeeding in the maternity hospital. The majority of HCWs reported that Syrian mothers gave colostrum to their infants, whereas, some mothers tried to give the baby something other than breast milk in the first three days after birth. Some HCWs reported that mothers with low pain thresholds and a tendency to sleep more preferred to feed their infants with sugary water and infant formula replacing breastfeeding.“I breastfed 1 hour after birth. Then, for the first 3 days, I gave cumin mint chamomile tea with sugar water. ”Since the baby could not learn how to suck on the first day, I started breastfeeding on the second day. I also gave sugary water in the first three days. ”Mothers and grandmothers stated that all mothers give colostrum. However, only one-third said they exclusively breastfed for the first three days. Some family members believe the milk won’t be enough the first three days; so, the baby should be supported. In addition to breastfeeding, the first three days after birth Syrian mothers also give supplementary food, such as sugary water, packaged fruit juice, infant formula, anise, dates, honey, cumin, and Zamzam (religiously blessed plain water).“Since the mother is tired and in pain after birth, we give sugary water to the baby. We boil anise, or we can boil something with dried herbs like chamomile or mint. Anise also allows baby to sleep calmly and peacefully. .”Those pregnant women who had given prelacteal feeding in their previous deliveries said that they will do it again because they will face problems like low milk supply.“Right after 40 days of birth, I gave yoghurt in the form of ayran and started to make him taste the meals little by little. ”Most Syrian participants stated that Syrian mothers tend to start complementary foods as early as 40-days after birth with foods such as rice water, diluted cow’s milk, pudding, yogurt, tea, or boiled fruits. Especially where mothers work in agriculture, grandmothers care for babies and start complementary foods early.“Now my baby is 13 months old. I recommend breast milk, I also breastfeed. I have started complementary foods for more than 2 months. ”In one-fifth of babies, complementary nutrition could be delayed until the age of one. Those who are in a good financial situation want their babies to be chubby and they use infant formula. Although most Syrian mothers start complementary feeding early, bottle feeding and late weaning are also prevalent. Boiled rice, boiled fruits, cow’s milk, black tea was among the most common complementary foods. In addition, babies were not allowed to feed themselves until after 18–24 months.HCWs from RHC indicated that they observed the breastfeeding duration among Syrian mothers is shorter than 24 months, even 12 months, mostly, due to the short interpregnancy interval. Syrian mothers usually stop breastfeeding at the age of 6–18 months. Only a few breastfeed until the age of two.“I didn’t breastfeed my son. I will not breastfeed my daughter up to the age of one and a half, that would be too long. I think it will be more beneficial if I breastfeed until the age of one and then switch to home meals. .”“Doctor, I will not tell you what it takes for a baby to be breastfed until the age of two, because in my opinion, a child should not be breastfed until the age of two. Because if a child gets used to breastfeeding, he or she will not be inclined to additional foods. This will ensure that he does not sleep comfortably or straight, so it will be a problem. ”One-third of Syrian mothers believed that babies should be breastfed until the age of two, and one-third suggested breastfeeding could be stopped at 18 months. Even, some mothers thought that “breastfeeding longer than 12–15 months is not correct”, “in case of new pregnancy breastfeeding should be terminated”.“Of course, it is normal for us not to continue for up to two years, because at the age of one and a half, all teeth are grown, the child bites the mother’s breast. .Some fathers believed that babies should be breastfed until the age of two years, but their wives stop breastfeeding before the 12th month. In addition, one father established an interaction between breastfeeding duration and teeth development.Half of the grandmothers stated babies should be breastfed until the age of two, and the other half, until the age of 1.5 years.“We give breast milk to the baby after birth and give very little sugar water to prevent jaundice.”For the first 3 days, it is necessary to give sugary water with breast milk so that the intestines are cleaned.”Syrian HCWs and family members indicated that most parents in Syria traditionally believe sugary water is nutritious and it cleanses the intestines and prevents jaundice. Anise is used for nutrition, pain relief and to calm infants to sleep. Anise is also given to reduce mother’ pain and increase milk production just after birth. More than half mothers and grandmothers reported that night sleep is very important for both mother and baby and this situation is supported by preparing special herbal teas; mostly anise, some cumin, papaya tea and even a mixture of them. It was seen that breastfeeding at night was not desired even in the neonatal period.“I saw several times that they rub dates in babies mouth before breast milk. When I asked why, they even said something like babies should break the fast with this. .”Some HCWs at hospital stated that their babies were born with religious fasting and they broke the fasting by giving babies a piece of dates.Most Syrian HCWs and family members participating FGDs reported that infant’s gender or birth order did not influence his/her breastfeeding status. However, few mothers said that female infants are breastfed less because they want them to be thin and more delicate. Some HCWs and mothers stated that the first-born children were breastfed for a shorter period of time because they wanted the second to come immediately and to have more children.“Babies are always in the arms of their relatives. They do not attach their babies much, they do not smell. Therefore, they cannot adapt to their babies. .”Some nurses and midwives at maternity hospitals reported that social support among Syrians, especially for adolescence pregnancies can sometimes be excessive; other family members provide care for the baby so that the mother can rest, which might reduce contact with the mother and prevent mothers’ attachment to the baby.“Bottle feeding provides comfort to the mother. Especially when she goes out, she can leave the ready-made milk in the bottle and go. If a mother is a clean person, by God’s willing, nothing will happen; but, if the mother is not clean, anything can happen to that baby. ”Some mothers believed that when the child cries, the mother should quit all her work and breastfeed. Therefore, this prevents mothers from doing their work and steals time from other children and husband. Yet, they suggested everyone who can hold a bottle could feed the baby. They also complained that breastfeeding disrupts the night sleep. Most mothers feel shy to breastfeed outside and preferred to use a bottle when they go out.“The Quran says up to two years, of course this is the right of the child, but the mother also has a right. For example, if she gets weak after breastfeeding for a year and two months, or if she has a pregnancy, then she should stop breastfeeding. ”Most Syrian HCWs and Syrian parents in FGDs reported that the biggest reason to limit breastfeeding was “malnutrition and fatigue of the mother and a new pregnancy”. The biggest obstacle to breastfeeding was short birth intervals and adolescent pregnancies. Adolescent mothers lack basic nursing skills, they cannot adapt to motherhood and accept the baby. Most Syrian family members believed that breastfeeding should be discontinued in case of new pregnancy.“In the past, in our mothers' time, there were no such infant formulas. I think it's very wrong to breastfeed for 2 years nowadays. I think so, at least 6 months to 1 year will be enough. I saw it in my nephews. They become weaker as they rely on their mothers for food. Mothers cannot do anything to them either. ”Most parents used negative statements when discussing breastfeeding until 24 months. They think that it is unnecessary, it will weaken the mother. Overall, parents believed that breastfeeding after 18–24 months will cause the child to become dependent on the mother, reduce appetite and prevent adequate nutrition.“I had fasted in Ramadan when I was pregnant, I had no problem. But after fasting a while, breast milk became insufficient and then it stopped and when she was 2 months old; I had to return to bottle. ”Although it is not mandatory for women who are breastfeeding to fast in Islam, almost all mothers in FGDs claimed they fast in Ramadan both during pregnancy and breastfeeding periods. They stated that they could start fasting after the baby was 40-days old, but they also admitted that during Ramadan the mother becomes weak and even the milk production stops. But regardless, they continue fasting.Syrian mother wears makeup in front of the mirror, because she will meet her husband. She wears special clothes. ”““I observe a situation that mothers prefer their husbands a little more than babies. When I visit them at the ward, they ask after their husbands after the delivery. They refuse to breastfeed the newborn and tell me that they need their husbands not the baby. ”.According to both Syrian and Turkish HCWs, Syrian mothers have aesthetic concerns; they are afraid that their husband will bring another wife and consider the needs of their spouse before those of the infant. Some nurses and midwives from maternity hospital stated that mothers who have just given birth pay great attention to their self-care and try to look beautiful for their husband.High-income mothers tend to give infant formula. Other mothers have to breastfeed because they cannot get formula. ”.“The HCWs reported that mothers from higher-income families tend to use infant formula and those with a lower income are forced to breastfeed for financial reasons.While one-third of the pregnant women did not think that breastfeeding had any effect on family dynamics, half of the pregnant women believed that breastfeeding supports the family’s economy.Delivery room nurses and midwives stated that they tried to give breastfeeding counseling with an interpreter and body language. However, when they turned their backs, the grandmother had taken the child from the mother. They observed that the frequency of milk insufficiency is less. In addition, they stated that Syrian mothers did not report breastfeeding difficulties and did not ask for help.While most of the mothers reported the support of grandmothers on breastfeeding, some received support from husbands, relatives, and their older female children. One-fifth did not have any support. These mothers complained that they immigrated with their husbands, their families remained in Syria and they could not find anyone to consult with. Only a few reported that they consulted the HCWs when they have breast-nipple problems. Five mothers stated that they were also trying to solve their problems through resources on the internet.“The father shouldn't have much to do, this topic is a matter of the mother’s decision, I think the father shouldn't have anything to do, as the mother knows how long her body can endure. ”“In my first child, my husband asked me to breastfeed until the age of two but when the child was a year and a half old, my body grew lean, I became weak, we also entered the month of Ramadan so I had to wean but I don't know what will happen with my second child. ”All Syrian family members in FGDs stated that mothers decided the duration of breastfeeding. Since “breastfeeding is a big burden” on the mother, and it might affect her health, this right belongs to the mother. They stated that “like all household chores such as cooking, cleaning, the duration of breastfeeding should be determined by the mother as she is the ‘manager’ of the house”. Some mothers stated that they consulted their husbands, mother-in-law and their mothers. Despite the fact that a few mothers claimed that their husbands and mothers pursued them on continuing breastfeeding, all Syrian participants claimed that the final decision is with the mothers.“In fact, we compare breastfeeding for up to two years to a growing tree. In other words, a child who does not suck for two years is like a tree that does not give fruit, in fact, when we wean breastfeeding, there is a lot of nutrient deficiency. I remember, for example, I was breastfed until the age of four or five, I even remember that period, I do not know that I have been to the hospital so far (laughing). ”“Breastfeeding is of course a good thing, it is rewarding. It will have a beneficial effect on the baby. If the mother is well-fed, the baby is also fed from the milk. ”Almost all Syrian parents in FGDs believed breast milk is important for a baby’s nutrition. All family members know that breastfeeding has positive effects on a baby’s health; they got sick less, they grow and develop better.“Breast milk is good for the baby and they should get until the age of 1.5. But mother’s psychological status is important; if they don’t feel good, babies might be affected, they might get sick, they might get diarrhea. .”Some mothers believe that breast milk may not work the same way for all babies.“At first, I didn't like breastfeeding, I had a hard time. But when I saw that we established a connection with the baby, I started liking it very much. ”All family members stated that breastfeeding has a positive effect on the attachment between mother and baby.“Breastfeeding a child is a little difficult for me, my teeth broke and I lost a lot of weight because of this. But on the other hand, it helped my child a lot, it helped my child's development, but it was very harmful to me. ”“ . . . you see how many times the baby sucks during the day. That's why the mother will be tired as the baby pulls everything from her body, so she needs to pay attention to her nutrition. If she pays attention, her problems will decrease; otherwise breastfeeding will of course tire a mother too much. ”“I am now six months pregnant and I'm still breastfeeding my nine-month old baby. Of course, my baby is in a very good condition as I give him a healthy breast milk. However, foregone conclusion, I get tired, I am affected and weak. Actually, I am thinking of weaning, but I cannot do anything because the baby has gotten so used to it. ”Some Syrian HCWs from RHCs and most family members believed that breastfeeding does not have a positive effect on maternal health; they believed it weakens and tires the mother; it causes maternal tooth decay and hair loss. A few mothers complained that breastfeeding caused the mother's breasts to get bigger, asymmetric, and sag.I think Syrians tend to reproduce because of the war in their country, because of human losses. .”““ . . . but I think they came to a foreign country by immigration, so they may be suffering from depression. .”“I think the most serious problem is the lack of interpreters. The majority of interpreters in the hospital are male, so they are rightly hesitant to talk about these issues (contraception). ”Turkish HCWs believed that the Syrian refugees instinctively reproduced more because they fled the war and suffered many losses. They said that the depression, economic difficulties and communication problems due to immigration affect breastfeeding negatively. They reported that they could not communicate due to language problems and that the interpreters were insufficient. They said that mothers do not want to talk about special issues such as contraception through a male interpreter, so there is a need for female interpreters.“In Syria, women were not working outside the home, but now they are working nearly 10 hours a day and they cannot pay attention to breastfeeding. ”“Previously, mothers were breastfeeding but because of the economy, early marriages, living alone, having no grandmothers, not getting support, being too young, bad nutrition of the mother, no breast milk comes after delivery, how can a baby to be breastfed in this case. ”Syrian HCWs said that some refugee mothers, on top of household responsibilities, had to work due to financial difficulties. Especially the mothers working in agriculture started to work as soon as possible after giving birth and spent almost half of the day at work. Therefore, they said that they could not breastfeed for a long time. They said that children could not go to school due to economic difficulties and security reasons, which resulted in bringing the age of marriage earlier than already young age of marriage in Syria after migration. Consequently, increasing adolescent pregnancies and lower education level make breastfeeding difficult. In addition, they reported that the psychological distress and loss of social support as a result of migration adversely affected breastfeeding.“Regarding the nurturing of the baby, the mother is the same here as in Syria. Mom doesn't change. We are only experiencing social difficulties; we are having a lot of trouble caring our children here. One's own homeland would be different, we are experiencing a social problem here. We experience difficulties even in our behavior towards our children due to the environment. ”“When I was in Syria, I would immediately ask my mother or mother-in-law if the child would cry a little. I used to go to them before the doctor for my child, but they are not here. ”On the other hand, mothers mostly complained about the loss of social support, in addition to economic difficulties and adjustment problems.To support breastfeeding, the first suggested solution by Syrian HCWs was “training” HCWs and pregnant mothers, admitting spouses and grandmothers in pregnancy training schools and providing Arabic training with female interpreters. Most Syrian HCWs from RHCs did not have breastfeeding counseling training and they would like to receive training.“Although the contraception is rejected as a sin, and the parents do not know much about it, they still believe that they can use contraception if it is explained. ”“I would suggest this, I would stop unconditional aid. For example, the “Kızılay” (Red Crescent) distributes aid cards. I wouldn't give those cards unless mothers provide a minimum of two years of breastfeeding. ”Another proposed solution from both Syrian and Turkish HCWs was providing family planning. Improving maternal health services, eliminating communication problems using reward-punishment methods were other recommendations.“If the mother's nutrition is not good, the milk she gives will not only harm the baby, but also harm herself because the mother is not well-fed. I had to stop breastfeeding because I had nutritional shortage; when I stopped breastfeeding some of them were in six months or in nine months or 15 months. In such cases, we were buying milk from the pharmacy. ”Among the suggested solutions from Syrian parents’ FGDs, the most emphasized was “improving the health of the mother”, that the mother should eat well, pay attention to what she eats and take her vitamins.When asked for suggestions for a short gestational interval, “family planning” was the first solution. While most of them used the traditional contraception methods such as withdrawal, only a few stated that they know about and use modern methods.HCW in hospitals stated that the number of visits by Syrian mothers to maternity hospitals, which is less than recommended in pregnancy follow-up protocols in Turkey and limited with emergencies and delivery, did not change due to COVID-19. A doctor in hospital indicated that nothing has changed since the pandemic, the aware ones continued to come. Low number of antenatal follow-up visits resulted in fewer training sessions, including breastfeeding provided for mothers. Almost all HCWs in hospital reported that Syrian mothers wanted to be discharged immediately due to the fear of COVID-19.“In the first 3 months, the follow-ups decreased a lot. Usually, there was a 1-2 month delay in the vaccinations of children. Initially mothers were afraid, but then they started to come. Syrian HCWs at RHCs said that at the beginning of the pandemic, families hesitated to visit the center, they postponed their children's vaccinations and routine follow-ups, but two or three months later they were back again to catch up with the missing vaccinations and follow-ups.Most of the fathers had financial difficulty, there was a shortage of food in their houses, and they faced problems buying complementary foods.The infants' feeding was not affected. Their follow-up to hospitals decreased but they did not delay their visits to RHCs. ”.““We couldn't take the babies for vaccinations at first, but after the disease started to decrease, we did. When we needed medicine, we bought it from Syrians . Most mothers stated that they were afraid to leave the house during the pandemic, but they took necessary preventive measures and continued going to hospitals for childbirth and vaccination. They claimed to have difficulty in getting an appointment in hospitals. Therefore, they prefer to visit RHCs. They reported that when the RHCs were closed, they visited private Syrian doctors and purchased medicines from other Syrians when needed. A few people said that because of financial difficulties and because they stay at home for longer periods, mothers tend to breastfeed more. Some Syrian family members reported that during the pandemic breastfeeding or infant feeding was not affected. Only one mother stated that her breast milk production was reduced due to poor access to food.According to the information we obtained from HCWs and families, the breastfeeding problems in Syrian immigrants are as follows Fig. : a) mixeThis study observed that EBF up to 6 months and continued breastfeeding up to 24 months were rarely practiced among Syrian refugees. Infants are exposed to food without essential nutrients for growth and development. Similarly, Demographic Health Survey reported 13.7 months median duration for breastfeeding and 3.1 months for EBF among Syrian refugees in Turkey .Cultural characteristics, migration, and low health literacy were found as main risk factors for short breastfeeding duration Fig. .The total fertility rate among Syrians in Turkey is 5.3 births per woman . SimilarDespite the known benefits of breastfeeding to mother and baby , 34, mosSyrian mothers give anise to babies as a prelacteal feed and continue to give anise to control crying, which is perceived as tiring, and to promote night sleep. Prelacteal feeding and reduced nocturnal breastfeeding might hamper the cycle and the quantity of prolactin secretion, which reduces milk production and the suppressive effect of lactation on ovulation. Feeding herbal tea to soothe infants is a prevalent behavior in Arab communities , 41.We observed that mothers prioritize fasting during Ramadan, and this might lead to dehydration of mothers and reduction of breast milk .Adolescent marriages are prevalent with low maternal education, low health literacy, and poverty among refugees. Among Syrian women in Turkey, the prevalence of adolescent pregnancy is 40% . AlthougIt was observed that the effect of social support on breastfeeding among Syrian immigrants changed according to the age of the baby. However, previous studies reported social support in mother migrated from Syria affected duration of breastfeeding and age-appropriate feeding attitudes in Turkey , 50. In Culturally appropriate health education supported by social norms is necessary to support breastfeeding among Syrian refugees in Turkey Fig. . MothersSyrian refugees prefer to receive health services from institutions that provide services in their own language, therefore, they have no communication problems in RHCs in Turkey. On the contrary, structural barriers  impeding Syrian refugee women's access to healthcare were reported in Canada . HoweverFor the first time, the opinions and practices of HCWs, Syrian mothers, fathers, grandmothers about breastfeeding were collectively included in the qualitative survey. Having seven different respondent groups helped us to improve data validity with data triangulation and provide a rich understanding of breastfeeding challenges. The outcomes of this study will provide evidence for designing and implementing culturally acceptable and linguistically appropriate interventions for promoting breastfeeding for the Syrian refugees which will be for the benefit of the community at large in Turkey . HoweverThe results of this study are important in addressing the gap in breastfeeding where immediate interventions are needed . The obs


Bell’s palsy is a relatively rare neurologic disorder with a limited selection of helpful therapies. This case report describes the author’s initial three-month experience living with severe Bell’s palsy, including a detailed history and timeline of the initial development of symptoms, treatments pursued, and psychological stress during the disease progression. A particular focus is placed on the emotional burden Bell’s palsy can have, exploring possible avenues to improve physician to patient education on mental health and well-being during initial and delayed recovery. Initially described by Sir Charles Bell in 1821, unilateral Bell’s palsy, also known as “idiopathic facial palsy” or “acute facial palsy of unknown cause,” is a non-progressive neurological disorder of cranial nerve VII, commonly referred to as the “facial nerve” ,4.Bell’s palsy, often characterized by a sudden paralysis of the facial muscles innervated by the facial nerve, commonly results in the temporary weakness of the affected side. While symptoms generally present with unilateral facial weakness, rare occurrences of bilateral facial weakness have been reported. Surprisingly, the true cause of Bell’s palsy remains unclear. Several proposed causes have been examined, with the reactivation of an existing or dormant viral infection as the cause with the most popularity within the scientific community ,6. FortuThis case report describes the author’s initial experience living with Bell’s palsy, including detailed descriptions of symptom onset, adaptations, and the often-omitted impact on lifestyle and quality of life. While this account covers only three months, I hope this autobiographical case report provides those afflicted with this neurologic disorder with greater clarity as to what can possibly be expected, while also serving as an additional resource for colleagues managing those with Bell’s palsy. Throughout this case report, “I” will refer to myself, Kyril Cole.I was diagnosed with Bell’s palsy in September 2021, at the age of 28 years, with no significant past medical history. I presented to a neurosurgeon with a three-day history of right-sided post-auricular pain, a right-sided cervicogenic patterned headache, and right-sided neck pain initially thought to be occipital neuralgia, in addition to a six-hour history of right-sided facial weakness. On physical examination, I was found to have severe weakness in all facial expressions on the right side of my face, including movements in my forehead, nasal, periorbital, and perioral areas. Based on the acute onset of symptoms and physical findings, I was diagnosed with idiopathic facial palsy and started on prednisone the same day. Before initial symptoms, I took no medications and was current on all vaccinations, including my coronavirus disease 2019 (COVID-19) vaccination. Childhood illnesses were significant for only a varicella-zoster viral infection at the age of five years. I had no past surgical history, head trauma, medication allergies, or family history of Bell’s palsy or other neurological conditions. In terms of social history, at the time of diagnosis, I was a full-time MD/MBA student, married, enjoyed hikes and outdoor activities, and ate an entirely plant-based diet with appropriate vitamin supplementation. Over the past three months since my initial diagnosis, I have pursued all recommended treatments and suggested therapies; however, I have yet to regain any motor function to my right-sided facial muscles. Progression of symptomsMy symptoms began three days prior to the facial weakness, which began with a dull ache in and around my right ear, with sharp pain behind my ear, which would radiate down my neck. A headache accompanied this pain with a cervicogenic pattern on the right side of my head. After two days of this pain, I spoke with a colleague who gave a few possible explanations, with occipital neuralgia as the most likely diagnosis given my recent gym workouts. However, I noticed my soup at dinner had a dish-soap taste on the third day of discomfort, which did not agree with occipital neuralgia.The following day, I awoke to brush my teeth and use mouthwash, only to find myself spilling mouthwash all over the counter. Upon examination in the mirror, I realized I could no longer fully smile or purse my lips. Additionally, my ability to close my right eye had been severely reduced. During the same day, I confirmed suspicions of Bell’s palsy with a neurosurgeon. I received a prescription for a steroid, beginning within 72 hours of the onset of symptoms as clinically suggested . ThroughAfter 48 hours of the onset of symptoms, a complete understanding of my physical challenges became apparent. These included a rapid onset of right-sided facial paralysis , loss of taste to the front right two-thirds of my tongue, right eye dryness, continued right-sided postauricular pain, drooling in my sleep, paralysis of my right platysma and occipitofrontalis muscles, blockage in my left nasal passageway, and hyperacusis in my right ear.Treatments pursuedWhile no effective cure exists for new-onset Bell’s palsy, steroids have shown to be effective at increasing the probability of recovery of facial nerve function . Within After the prednisone, valacyclovir, and acupuncture therapy had ended, I still had no initial improvement in my symptoms. A magnetic resonance imaging (MRI) scan with and without intravenous contrast was pursued two months after my initial diagnosis to ensure no other pathology was present mimicking the presentation of Bell’s palsy. A T1 image with 15 ml of gadolinium contrast demonstrated enhancement at the right internal auditory canal (IAC) fundus Figure . Fluid-sImpact on physical and social activityPrior to the onset of Bell’s palsy, I was living a hectic yet active lifestyle. This included multiple hikes each week, daily hour-long workout sessions with my wife at the gym, academic and professional courses 60 hours each week, and everyday errands with the family. However, once the symptoms and facial palsy had solidified, I realized just how difficult each of these daily activities would be. Due to my right ear hyperacusis, any loud or high-pitched noise would cause significant pain to my ear. I could no longer go to the gym due to the volume of music, nor go to movies, football games, or bars with family and friends where sounds were far too loud. Even the clanging noises from stacking the cleaned dishes in the cupboard caused me a great deal of ear pain.Similarly, my right eye no longer produced the tears needed to lubricate my eye, nor could I close my eye sufficiently to keep the moisture in. Studying on the computer screen or watching TV became a significant challenge and strain on my eye, requiring constant artificial tear application. Enjoying a walk outside with even moderate sunlight or wind caused great discomfort. Eating became a significant challenge, as my mouth could not open enough to eat things like sandwiches, pasta, desserts, etc. without making a giant mess and causing me to feel embarrassed. Lastly, sleeping became a difficult challenge, as I would struggle to tape my eyelid closed well enough for a comfortable sleep each night, in addition to my nasal breathing largely blocked off. Through these and other challenges, my illness quickly became an isolating time in my life. Impact on psychological wellbeingMany of those afflicted by Bell’s palsy have significant improvement within three weeks of their initial symptoms, reaching a full recovery within three months . ReadingAnother feature of Bell’s palsy often overlooked is the impact the physical changes to the face can have on a patient’s psychological well-being. Initially, my new physical appearance was difficult for me, as I could not laugh or express my feelings through animated facial expressions. My appearance was difficult to contemplate, as any emotion was removed from one side of my face, and the other side overcompensated, causing me to look nothing like my original self. Personally, this made online meetings and courses challenging during the COVID-19 pandemic, as it is unprofessional not to show your face on camera. However, it is emotionally taxing to explain to each person what has happened to my face. The challenges of my physical appearance also transitioned to physical encounters, as many would stare and attempt to figure out what is wrong with my face, or they would ask if I had a stroke, dental work, or any facial trauma. These encounters made me want to remove myself and not interact with others, furthering the depression caused by my other social and physical limitations. However, I have become more comfortable with my appearance and understanding of how best to approach others with time.This case report describes many of the facial palsy-related challenges identified in the literature, including unilateral facial paralysis or increased weakness, hyperacusis, loss of taste, dry eyes with absent tear production, drooling, difficulty eating or drinking, loss of typical facial expressions, headaches, inability to close the eye on the involved side, absent corneal reflex, eye irritation, post-auricular pain, inner ear pain, in addition to unilateral occipitofrontalis and platysma muscle paralysis . While sStudied risk factors that put the patient at higher risk for developing Bell’s palsy include a family history of Bell’s palsy, current or recent pregnancy, Lyme disease, head trauma, diabetes, upper respiratory infections, or past viral infections (including herpes simplex virus type 1 and varicella-zoster virus) . InteresThough not curative, several treatment options have been studied to help relieve the symptoms associated with Bell’s palsy. Kim et al. performed a retrospective study on 1710 Bell’s palsy patients, comparing the effectiveness of steroids plus antiviral agents vs. steroids alone in treating severe Bell’s palsy patients over 40 years old. Subgroup analysis showed the combination therapy resulted in significantly higher recovery rates than steroids alone  . A randoMedical professionals are proficient at describing the pathophysiology of the neurologic disorder, current best treatments to reduce nerve inflammation, and the limitations in knowledge of the cause. However, in my experience, physicians do not mention the emotional toll that Bell’s palsy can have on one’s life, especially in cases of severe Bell’s palsy  lasting over three months. Sugiura et al. looked at the stress levels of Bell’s palsy patients from initial presentation through full recovery. They found the psychological stress response score of patients with facial palsy to be high on the first hospital visit, suggesting the importance for physicians to treat the psychological aspects of Bell’s palsy . To helpThe limitation of this case report is that I can report only the first three months of my experience with Bell’s palsy, given the timeline of the requested autobiographical reports and the recency of my Bell’s palsy onset. A longer timeline with a full recovery and reviewed response to physical therapy would benefit such a case series. A strength of this case report is my detailed description of each portion of my experience thus far, including an in-depth look at the timeline of symptom onset, medications and therapies utilized with their timelines, and the images demonstrating the physical changes in my facial paralysis. Another strength of this case report is the explanation of the emotional toll Bell’s palsy can have on everyday life, something that is often overlooked in medical reports -5.This autobiographical case report illustrates the typical initial progression of Bell’s palsy symptoms, with the addition of a detailed timeline and description of each step in the progression of my facial palsy. Apart from the various medical articles on Bell’s palsy, few pay particular attention to the emotional, physical, and social toll the disorder can put on the affected individual’s life. Specifically, those who suffer from severe Bell’s palsy, such as my case, would benefit significantly from initial explanations and recommendations on psychological well-being from their treating physician. Consultation with psychologists, psychiatrists, therapists, or other emotional guidance counselors should be encouraged for those affected by delayed recovery from Bell’s palsy. This approach could reduce overall stress from the disorder and potentially assist in hastening any delayed recovery.


As the world confronts the COVID-19 pandemic and its consequences, including an associated mental health crisis, finding meaning and building positive processes and capacities will help strengthen future mental health , higher psychological wellbeing , lower psychological distress, and better social wellbeing”  with appropriate sample sizes that compare optimism and hope-based interventions to already validated gold standard treatments.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.This work is funded by national funds through FCT—Fundação para a Ciência e a Tecnologia, I.P. (UIDB/05704/2020 and UIDP/05704/2020) and under the Scientific Employment Stimulus—Institutional Call (CEECINST/00051/2018).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor declared a shared affiliation with one of the authors AQ at time of review.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Low back pain (LBP) remains the leading cause of disability worldwide. A better understanding of the beliefs regarding LBP and impact of LBP on the individual is important in order to improve outcomes. Although personal experiences of LBP have traditionally been explored through qualitative studies, social media allows access to data from a large, heterogonous, and geographically distributed population, which is not possible using traditional qualitative or quantitative methods. As data on social media sites are collected in an unsolicited manner, individuals are more likely to express their views and emotions freely and in an unconstrained manner as compared to traditional data collection methods. Thus, content analysis of social media provides a novel approach to understanding how problems such as LBP are perceived by those who experience it and its impact.The objective of this study was to identify contextual variables of the LBP experience from a first-person perspective to provide insights into individuals’ beliefs and perceptions.We analyzed 896,867 cleaned tweets about LBP between January 1, 2014, and December 31, 2018. We tested and compared latent Dirichlet allocation (LDA), Dirichlet multinomial mixture (DMM), GPU-DMM, biterm topic model, and nonnegative matrix factorization for identifying topics associated with tweets. A coherence score was determined to identify the best model. Two domain experts independently performed qualitative content analysis of the topics with the strongest coherence score and grouped them into contextual categories. The experts met and reconciled any differences and developed the final labels.LDA outperformed all other algorithms, resulting in the highest coherence score. The best model was LDA with 60 topics, with a coherence score of 0.562. The 60 topics were grouped into 19 contextual categories. “Emotion and beliefs” had the largest proportion of total tweets , followed by “physical activity”  and “daily life” , while “food and drink,” “weather,” and “not being understood” had the smallest proportions . Of the 11 topics within “emotion and beliefs,” 113,562/157,563 (72%) had negative sentiment.The content analysis of tweets in the area of LBP identified common themes that are consistent with findings from conventional qualitative studies but provide a more granular view of individuals’ perspectives related to LBP. This understanding has the potential to assist with developing more effective and personalized models of care to improve outcomes in those with LBP. Low back pain (LBP) is the leading cause of disability worldwide ,2. ApproOptimizing management of conditions such as LBP requires consumers to be engaged in their care. To enable this, health care providers need to have an understanding of the full context of the condition from the consumer perspective. “Contextual variables” here refer to any type of useful information about the context of an individual’s pain experience, such as physical, emotional, social, and/or occupational variables . A betteWith the current advances in online and web technologies, social media has emerged as a new and rich source of first-person health care data -16. SociOur study approach was to undertake content analysis of Twitter data by applying topic modeling. Content analysis is a widely used technique for qualitative research  that enaTwitter was used as the data source rather than other social media platforms, blog posts, or news articles because individuals use this platform for expressing and sharing their feelings and opinions on health-related topics by posting short messages that can be easily collected through application programming interfaces (APIs) or other open sources -17,26. WOur data processing and analysis consisted of 4 steps see .We removed duplicates, retweets, URLs, and tweets related to marketing and advertisements, which reduced the data set from 7,892,210 to 2,825,645. We filtered the data further by removing tweets that did not contain first person pronouns . As a reWe replaced contractions with their expanded forms . We converted the HTML characters to ASCII characters and removed hashtags, Unicode strings , numbers, and punctuation. We replaced abbreviations, elongated words , and emoticons and emojis with their equivalent English expressions. We then performed spelling correction, lowercasing, tokenization, and lemmatization, created n-grams, removed stop words . We again removed the duplicates and the remaining data set was 1,249,576 tweets.After completing the abovementioned steps, we excluded tweets with less than three words because in topic modeling, the document size is important to achieve high accuracy . This reTopic modeling is a technique used to provide a summary of a large collection of documents by extracting “topics” that represent the dominant themes . It alloLDA is a generative probabilistic model that assumes each document can be represented by distribution over topics and each topic by distribution over words ,38. DMM To use these models (except for NMF), we used a Java-based open-source library for short text topic modeling algorithms called STTM (version 1.8) , whereasChoosing the right number of topics is a crucial step in topic modeling because it can affect the accuracy of results. The quantitative approach computes the coherence score and perplexity, which helps in determining the optimal number of topics . The cohAs a quantitative approach, we calculated the coherence score of each model on different numbers of topics ranging from 5 to 200, based on the PMI score ,48. The Additionally, we used a qualitative approach to select the most representative topics. We manually examined the topics, their top 20 terms, and a random sample of tweets in each topic. We also created a word cloud for each topic and evaluated word clouds and their sample tweets. We identified the number of topics that provided us with distinct and meaningful topics; if we exceeded this number of topics, we started to notice an increase in duplicates and overlapping topics. We used both quantitative and qualitative approaches to select the optimal number of topics.Topic labeling is a process of representing the meaning of a topic by assigning each topic a descriptive word or phrase . AlthougLDA assumes that each document (tweet) is a mix of topics with different proportions . We wereTo improve the results of thematic analysis, low-order topics can be grouped under broad, higher-order categories . Higher-Two domain experts , actively working clinically and researchers in the area of LBP, independently examined the selected topics from the previous step where each topic included the top 20 words to determine face validity. As previously described, in topic modeling, the top words of each topic provide the description of that topic, thereby assisting the domain experts with inferring its meaning . The expThe total number of collected tweets about LBP was 7,892,210 from 2,420,258 unique users from 2014 to 2018. The average number of words in each tweet increased from 2017 onward , in lineAfter performing comprehensive data preprocessing, the final number of retained tweets was 896,867, which represents 11%  of the original raw data we collected, with a vocabulary size of 29,539. The minimum length of tweets was 4 words and the maximum length was 20 words.After testing 5 topic modeling algorithms and the number of topics based on the coherence score and our manual examination, we selected the best model that included 60 topics, detected from 896,867 self-reported tweets about LBP. The 60 topics were examined and manually given a topic label. The common and duplicate labels were then grouped into higher-order categories. Word clouds for the two categories of “pain regions” and “sleep” after combining the related topics are provided in Independent examination of selected topics by two domain experts and reconciliation of any differences resulted in 19 contextual categories, with details presented in The proportion of tweets for each higher-level category over the years showed that all 19 categories had been discussed by individuals with relatively similar frequency every year see . HoweverIn this study, we identified 60 specific topics from 896,867 tweets about LBP and grouped them into 19 categories that relate to contextual variables of LBP. The top category was “emotion and beliefs,” with 157,563/896,867 tweets (17.6%), followed by “physical activity”  and “daily life” , while “food and drink,” “weather,” and “not being understood” had the lowest proportions of tweets . There were 11 topics within the category of “emotion and beliefs”; of 157,563 tweets in this category, 113,562 (72%) expressed negative sentiment. Our results were consistent with the general findings from traditional study methods in the area of LBP but provided more in-depth detail on the context of LBP from the individual perspective.Our study examined contextual variables to provide a novel insight into first-person perspectives of the LBP experience and confirmed the broad areas that have previously been identified using more traditional data collection methods from qualitative and quantitative studies. For example, psychosocial factors have an important role in LBP  and, froOur study also highlighted areas related to the pain experience in individuals that have not been adequately explored in the literature but that play an important role in the effectiveness of LBP interventions and self-management behaviors, such as the “not being understood,” “religion,” and “food and drink” categories. We found that although the category of “not being understood” had the smallest proportion of tweets with a total of 9180 tweets, it had the top five words: “make,” “people,” ”stop,” “thing,” and “complain.” This is consistent with a previous systematic scoping review that examined what patients want from their medical care, which reported that patients felt misunderstood and wanted legitimation of their LBP . PatientThe category of “food and drink” is novel and interesting. The tweets included words relating to the type of food , mealtimes (such as breakfast and lunch), and the process of bringing or making food. Although they reflect important daily habits of eating and drinking, they may also highlight issues around pain affecting an individual’s capacity to eat and drink and/or problems associated with weight and in particular obesity , which iThere are well-described sex differences in the prevalence of back pain . AnalysiThere are some limitations to our study. Although the keywords were taken from existing studies about LBP and approved by domain experts, some keywords, such as “back hurt” and “back pain,” were very broad. Therefore, the data collected might not have been specific to LBP. Selection of the right keywords in Twitter data analysis is very important to avoid unrelated data that could reduce the accuracy of results. Filtering and cleaning of Twitter data is also crucial for achieving high accuracy of results. In our study, we performed vigorous data cleaning, but our manual examination showed that there was a group of tweets that contained a few lines from the lyrics of a famous hip-hop song (Bad and Boujee) by Migos. These lines included “…So my money makin' my back ache.” One of our search keywords was “back ache.” Although there are many tools and methods available to automatically perform data cleaning, it is always necessary to manually inspect the results.Twitter users tend to be younger and might not represent the general population; therefore, the results must be carefully interpreted . SimilarTo determine the optimal number of topics, we used the coherence score, a widely used method, and then manually examined and compared the models. This process can be further improved by using other measures such as heuristic approaches  or perplWe also recognize that manual labeling of topics can be subjective. Two domain experts with extensive knowledge were involved in the labeling and examination of selected topics but future work in this area could involve a greater number of and more diverse domain experts to further reduce this subjectivity.Our findings provided useful insights into individuals’ beliefs and perspectives regarding their needs and concerns related to LBP that complement the information available in the literature. Considering the contextual factors identified in this study rather than simply focusing on a biomedical model of LBP could address the needs of patients more holistically, help with improving LBP outcomes, and increase patient satisfaction. These findings have the potential to assist health care providers and clinicians with developing more effective, personalized therapies for LBP. There is also the potential to use social media to identify any major changes in community beliefs and needs regarding LBP that can be addressed in a timelier manner.