The increase in meat consumption expected in the next decade will require more and more proteins for animal feeding. The recent amendments to the European “BSE Regulation” allow the use of insects and porcine-based meals in poultry farming, providing novel, sustainable substitutes for vegetable fodder. While the technological and nutritional properties of novel feeds containing processed animal proteins are widely recognized, far less is known about consumers’ acceptance of meat produced by animals fed on animal-based meals. In the present research, a best–worst survey was applied to estimate consumers’ preferences for chicken fed on plants, insects, or porcine-based meals using a sample of 205 Italian consumers. Furthermore, product price, type of farming, and “Free-from” labeling were considered in the analysis to evaluate the relative importance of feed ingredients compared to other important attributes of meats. The results show that the most relevant attributes are type of farming and “Free-from” claims, while type of feed represents the third attribute in order of importance. Notably, both insect and porcine flour are considered as negative characteristics of the product, suggesting that mandatory labeling signaling the use of these feeds would negatively impact on the value of chicken meat. Despite relevant differences between most affluent and developing countries ,2, meat Some substitutes of plant-based meals have been proposed in the last two decades, such as microalgae  and procWhile many studies focused on the economic and technical implications of the use of PAP as feedstuffs, far less attention has been devoted to consumers’ acceptance of this innovation to evaluate the market potential of meat produced from animals fed on this type of proteins . The remThe literature on European consumers’ attitudes toward insect-based fed shows some clear evidence. One of the first survey on this topic was conducted in Belgium  and founBuilding on previous studies, the present research aims to contribute to the literature on consumers’ acceptance of PAP as feedstuffs in two ways. Firstly, we measured preferences for the use of both insects and porcine-based feedstuffs in chicken farming. This will provide a first estimate of the effects of a mandatory labeling scheme on feed provision at the farm level, including all PAP allowed by European regulations. Secondly, we measured the relevance attached by consumers to feeding characteristics as opposed to other important extrinsic factors, namely rearing conditions, price and the presence of clean labels to communicate specific “Free-from” claims. This will provide relevant information on consumers’ demand for improved characteristics of chicken meat, thereby suggesting useful elements to policymakers interested in food labeling schemes, addressing communication about PAP in poultry feeding, and discussing the challenges and risks that this innovation might pose in terms of marketing and competition strategies.To meet the research objectives, an online questionnaire was distributed in Italy. A best–worst analysis was used to estimate consumers’ preferences for a 400 g package of chicken breast characterized by different types of feed provision , farming system , price , and “Free-from” labeling .www.qualtrics.com) and conducted during February 2022. The information presented here represents part of a wider data collection process aimed at exploring Italian consumers’ perception, attitudes, and knowledge of sustainable poultry farming. Participants were invited and recruited through snowball sampling, a non-probabilistic sampling technique, via online advertisements on the authors’ social media platforms. The selection criteria for participants included being at least 18 years old and being a meat eater; vegetarians or vegans were excluded from the study as the questionnaire surveyed participants regarding their most and least preferred attributes when buying chicken meat. After filling out an informed consent form, a concise instruction note explained to the participants that they were to look at nine variations of the same product and choose which attribute was their most favorite and which was their least favorite attribute for each product variation. The survey also included items aimed at evaluating consumers’ perception, attitudes, and preferences toward insect- and pork-based flour used as feed for poultry, and sociodemographic characteristics, with the former being part of a wider study and not disclosed in this paper. The average time for completing the questionnaire was 15 min; therefore, after carefully checking and excluding “speeders” (participants who completed the questionnaire in less than 5 min), the final sample consisted of 205 correctly compiled responses; the sample is composed of 58.54% of females, with a mean age of 40.09 years (SD = 15.84) and mostly residents in the North-Western part of Italy (43.02%) with at least upper secondary education (49.75%). To answer the research questions, an online survey was implemented via the Qualtrics software  approach was applied. The BWS approach is a method of measuring the relative importance of or preference for different attributes of a product or service. This survey technique involves presenting participants with a set of profiles of a targeted product, with each of this set being composed of different levels of a set of attributes established by the researchers, and respondents are required to state their most and least preferred levels of attributes among the presented profile ,36. The Furthermore, the BWS method allows the measurement of the maximum difference (maxdiff) between attribute levels on a common utility scale and can be developed in three different ways: object case, profile case, and multi-profile case. The present work focused on the profile case, also known as BWS Case 2 , in whicThe product used in the BWS questions was a 400 g package of chicken breast. To determine the attributes corresponding to consumers’ interest given the product used in the BWS questions, a discussion about the topic was organized within the research team, followed by consultations with experts on the field . Several extrinsic attributes that could be communicated via labeling emerged during the discussion and consultations. As part of price, the most cited attributes were (a) type of rearing; (b) animal welfare; (c) feed characteristics, (d) presence/absence of antibiotics, and (e) organic certification. The attributes and levels identified as most important were then classified to construct the best–worst profiles. The attributes and corresponding levels finally chosen for the survey are presented in Type of feeding” is crucial to the aim of the present research because it explicitly refers to the use of PAP in poultry farming as allowed by the new amendments of the BSE Regulation [Type of rearing”, which has been previously found as a driver of consumers’ food preferences [Price” was also considered in the analysis. The three price levels were identified by considering the sales prices for the 400 g package of chicken breast at different distribution outlets in the two cities of Naples and Milan . The average price , calculated considering all the references identified, represents the middle level. The other two levels  were calculated by subtracting and adding a standard deviation to the average price, respectively. The last attribute was the “Free-from” labeling, which was represented by antibiotics, GMO, and cruelty-free levels. The importance of clean labels and the preference accorded by consumers for products with “Free-from” claims have also emerged clearly from the analysis of the specific literature [4 (Lk) orthogonal main-effect design was used to construct the profiles, which resulted in 9 different profiles. A profile example is provided in The attribute “gulation . Accordiferences ,44. In tterature ,46. ConsI selected as the best (inB) and worst (inW) among all the questions for respondent n, as follows:Consumers’ preferences can be estimated from responses obtained from the BWS using different approaches, primarily using either a counting or a modeling approach. The first method involves determining scores that stand for respondents’ preferences by calculating the frequency of attribute-level b as the best and an attribute level w (with b different from w) as the worst in a profile C of attribute levels kl can be conveyed via a conditional logit model with the systematic component of utility u, as follows:The second approach uses marginal or paired methods, which can also be analyzed at either the sample or respondent level ,48,49. MbFeeding”, “Price”, and “Freefrom” are attribute variables related to the three categories of attributes chosen; “ExtIndoor” and “ExtOutdoor” are level variables related to the “type of rearing” attribute; “Pork” and “Insects” are level variables related to the “type of feeding” attribute; “Lowprice” and “Highprice” are level variables related to the “price” attribute; and, lastly, “GMO” and “Cruelty” are level variables related to “Freefrom” attribute.In model estimation, an arbitrary attribute variable is omitted , and theThe results of the BW scoring and the distribution of BWS scores are presented in Among the remaining levels representing extensive rearing systems, extensive outdoor rearing is preferred (332) over extensive indoor rearing (−1). No clear difference can be seen among the three levels of the “Free-from” attribute, which are all positively evaluated by the respondents . Considering the attribute related to the type of feeding, using pork flour is the least preferred (−325), followed by insect meals (−96), while conventional vegetable feeding obtains a slightly positive valuation (69). In a similar fashion, the lower price of 3.10 EUR is also slightly preferred (−25) over the average price of EUR 4.50 (−62), while the highest price of EUR 5.90 gets the worst BW scoring (−203).In the conditional logit estimation, the dependent variable is the utility that each respondent derives from choosing the best alternative in a profile of alternatives. The results shown in In our case, the type of rearing is considered a base attribute; therefore, the attribute “Free-from” provides the highest attribute impact. On the other hand, the feeding type and price are considered less important by the respondents. In regard to the different types of feed considered at the level scale, it is worth pointing out that the presence of the level “pork flour” leads to a decrease of 64% (0.365 odds ratio) in the utility of choosing the product. On the other hand, the level “insect flour” has a non-significant, although slightly positive, effect on the utility of choosing the best alternative.Furthermore, Specifically, the responses collected on the product profiles  and price (18%). The importance attached to the first two attributes is in line with previous findings. Using a conjoint approach, Martinez and colleagues  showed tThe second attribute selected by the respondents is the presence of a “Free-from” claim on the label. These products should appeal to consumers for whom an ingredient is perceived to be detrimental. The use of “Free-from” claims can be interpreted as an example of clean labeling, which is one of the most interesting trends in firms’ communication strategies toward consumers ,46.The third attribute in order of importance is the feed used. In this case, the three investigated elements  were selected as the best or worst option in only 22.5% of the cases, showing a lower salience of this attribute.Finally, price was selected as the best or worst attribute in only 17% of the cases. Although price in many studies stands out as a very important element of choice, as Lusk  argued, Further and more insightful considerations can be made considering the conditional logit model. The results are substantially in line with those already discussed in the case of best–worst scoring. The attributes with the smallest impact on average utility are those of price and type of feed, while those with the greatest impact are the type of rearing and, above all, the presence of a “Free-from” claim. In other words, the attribute with the greatest salience is the type of farming because its elements are the ones most chosen as the best or worst and, therefore, most likely to have caught the attention of the respondents. Nevertheless, the attribute generating the greatest contribution in terms of average utility is the presence of a “Free-from” claim. However, when considering the results of the specific levels related to the type of feeding, two further interesting results emerge. First, both insect- and pork-based flours obtain a negative best–worst scoring. Yet, protein flours containing pork are rated much more negatively, as also evidenced in One of the most qualifying results of the present work is the relevance of the free-form attribute. The use of clean labels and, in particular, “Free-from” claims has increased strongly in recent years. Many firms have ridden the wave of this trend and exploited “Free-from” clean labels, both to occupy specific market niches and as a tool for strategic competition with other firms and companies ,56. GlutIn the case of new feeds containing animal proteins, a similar mechanism may also be at work. Considering the results of the present research, this risk is particularly high in the case of feeds containing pork meal. Indeed, it has been observed that in both the BWS and the conditional logit estimation, feeds containing pork are associated with particularly negative scores and consistently reduce the average utility. As happened in the case of palm oil, the emergence of feeds containing pork flour could induce other companies to adopt “free-from” claim. This could potentially fuel the ongoing debate on the governance of public and private forms of information regulation, as companies may use different labeling claims to differentiate their products and gain a competitive advantage in the market. The present research has at least three limitations that are worth being acknowledged. One of the most relevant is the small sample size that is restricted to only Italian participants and recruited via the snowball sampling technique, which may limit the generalizability of the findings to larger populations and may not have enough statistical strength to detect important effects or relationships. Secondly, we did not consider any socio-demographic characteristics of the sample as potential explanatory variables. Future research could aim to replicate the findings in a larger and representative sample, as well as investigate potential moderators and mediators of the observed effects, including considering possible differences across gender and age and investigating the role of other socio-demographic characteristics. Finally, the present study did not use any monetary-based measures, such as consumers’ willingness to pay (WTP), to assess consumers’ preferences. WTP is crucial when conducting cost–benefit analysis aiming at determining an optimal investment strategy for food product companies seeking to develop new food process chains. Therefore, future research could benefit from incorporating price-related measures, such as WTP, for product attributes that will better capture the economic trade-offs involved in consumers’ decision making. In this regard, it would also be interesting to investigate how different consumer segments value various product attributes, which could help food companies tailor their marketing strategies to specific groups of consumers. Moreover, a further avenue for this topic could be a comparison between the relevance attached to alternative animal feeds by consumers in developed versus developing countries.The present study provides insights into consumers’ preferences for extrinsic attributes and food labeling related to chicken breasts from animals reared with alternative feeds. The findings show that the type of farming and the presence of a “Free-from” claim on the label are the most important attributes for consumers, with the type of feed and price having lower salience. This study also confirms that clean labeling is an important trend for firms’ communication strategies toward consumers, with “Free-from” claims being a particularly appealing attribute. The use of insect-based feeds in chicken farming is somewhat accepted by consumers, while pork-based feeds are rated negatively.Overall, the results of this study provide useful information for producers and policymakers, highlighting the importance of specific attributes in consumers’ decision making and the potential of clean labeling strategies. The findings can inform marketing and labeling decisions, as well as policies aimed at improving animal welfare, and the development of sustainable feeds for animal nutrition. Specifically, this first study suggests that mandatory labeling that signals the use of PAPs as feeds could have a negative impact on the demand for meat products and decrease in their value; hence, their use in the livestock sector needs to be accompanied by accurate communication strategies.


Challenges such as stigma and loneliness may increase vulnerability to Human Immunodeficiency Virus (HIV) infection and negatively affect the quality of life of people living with HIV (PLHIV) despite the massive investment in access to antiretroviral therapy. This study aims to determine the level of loneliness and stigma and explore the coping resources employed by PLHIV in a resource-constrained setting.This was a sequential mixed methods study conducted at the Cape Coast Teaching Hospital (CCTH) in Ghana between May and December 2021. A total of 395 adults were selected using a simple random sampling technique. HIV Stigma Scale and UCLA Loneliness Scale were used to collect quantitative data. A purposive sampling technique was applied to recruit 18 participants to saturation using a semi-structured interview guide. SPSS version 21 was used for the statistical analysis of the quantitative data. HIV-related loneliness and stigma levels were estimated, and bivariate and multivariable logistic regression were used to evaluate associated factors using a statistical significance of p-value (p < .05). In general, the thematic analysis approach by Braun and Clark was employed to analyse the qualitative data. Findings were then triangulated.± 12.53), 75.4% of the participants were female, with a prevalence of stigma of 99.0% (95%CI = 97.4–99.7) and loneliness of 30.1% (95%CI = 25.6–34.9). Tertiary-level education and instrumental support were associated with lower levels of loneliness. In contrast, comorbidity, personalised stigma, negative self-image, and self-blame were positively related to loneliness. Thematic analyses of the qualitative data produced a range of themes that showed that people living with HIV rely on personal resources, social support networks, and behaviour modification strategies to manage their condition. In particular, some of these strategies include; religiosity and spirituality, family and friends, medication and professional support systems.The mean age was 46.79 years (The results suggest that PLHIV in the developing world face enormous challenges, socially, psychologically and financially. Although there have been global efforts to make HIV services accessible, the findings suggest a need for integrating mental health services contextually to reduce loneliness and HIV-related stigma to improve quality of life. Human Immunodeficiency Virus (HIV) is one of the world’s highly stigmatised conditions, and it is estimated that 38 million people across the globe are living with it. About five million people in Western and Central Africa live with HIV . For exaHIV stigma and loneliness remain global health problems. Challenges such as stigma and loneliness may increase vulnerability to HIV infection and negatively affect the quality of life of PLHIV despite the massive investment in access to antiretroviral therapy , 3–6. PrGoffman explained stigma as an attribute that links a person to an undesirable stereotype, leading other people to reduce the bearer from a whole to a tainted one . Stigma Moreso, Goffman  outlinedStigma and discrimination affect PLHIV in diverse ways and are considered barriers to quality health care , 17. In On the other hand, loneliness is an unpleasant experience when an individual’s social network of relationships feels significantly deficient . It is aNumerous theories have been forwarded to further the understanding of loneliness. The interactionists view loneliness as multidimensional, suggesting that there are different types of loneliness, including emotional and social loneliness . LonelinFurthermore, the existential perspectives also differentiate between different types of loneliness, with the main one being existential, suggesting that loneliness is normal and part of human existence but can also result from anxiety and, thus, become pathological . HoweverA survey found that about one-third of older adults were lonely . These eThe incidence of loneliness is high among people living with chronic illnesses such as HIV compared to the general population due to stigma and discrimination . LonelinAlthough other studies have investigated HIV-related stigma, most of these studies have broadly focused on the effects of stigma on the individual, leaving a gap in knowledge regarding the association between stigma and loneliness. This article presents findings from a project on mental health assessment for PLHIV in a Ghanaian setting . This suThis is an explanatory sequential mixed methods study conducted at the Cape Coast Teaching Hospital (CCTH) in Ghana between May and December 2021. CCTH is the largest hospital and has the highest number of clients at the Antiretroviral Therapy (ART) clinic in the Central Region of Ghana. The hospital has a bed capacity of 400, and it is affiliated with the School of Medical Sciences and the School of Nursing and Midwifery at the University of Cape Coast, Ghana. Initially, the quantitative data was collected using a structured self-report questionnaire, and its findings informed the qualitative arm. The conclusions of the quantitative study informed the design of the interview guide. Subsequently, the qualitative component was conducted to triangulate the quantitative data and obtain a comprehensive picture of how PLHIV cope with loneliness and stigma.The population for this study included all adults (≥ 18 years) living with HIV/AIDS for at least 12 months who received care from the CCTH. Details of the recruitment process and sample size calculation for the quantitative aspect are as described by Opoku Agyemang et al. .In brief, the sample size was predetermined statistically with a 95% confidence interval of 363. However, the sample size was increased by 10% to make provisions for incomplete data. Finally, a simple random sampling technique was applied to obtain the required participants for the quantitative arm.Participants in the quantitative arm were not included in the qualitative study. Instead, a purposive sampling technique was used to recruit 18 participants for the study until data saturation. The inclusion criteria were; adults ≥ 18 years with a confirmed HIV/AIDS status for at least a year and receiving care at the Treatment Centre, as discussed in the quantitative arm. These individuals were approached during their routine clinic visits and provided detailed information regarding the study, including ethics, confidentiality and informed consent. Eligible participants who provided written informed consent to the study were allowed to decide on the interview place, date and time. Two consent forms were signed, one for the researcher’s records and the other for the participant. All interviews lasted for an average of 35 min. Saturation was reached by the 15th interview but confirmed with 3 additional interviews, totalling 18 participants.Data was collected using a self-report anonymous questionnaire and semi-structured interview guides for quantitative and qualitative data, respectively. The questionnaire had three sections. The first section focused on the socio-demographic characteristics of participants. The second section comprised the HIV Stigma Scale. The HIV Stigma Scale used in this study is the 10-item short version of the 40-item instrument designed to measure subjective perceptions of stigma by persons living with HIV/AIDS . The scaThe final section comprised UCLA Loneliness Scale . UCLA LoSeven research assistants with at least a bachelor’s degree were recruited to assist with the quantitative data collection. In addition, they were trained on the type of information and the ethical principles to uphold during the data collection. The questionnaires were administered privately to each participant by a trained research assistant in an office at the antiretroviral therapy clinic. It took approximately 20 to 30 min for each participant to complete the questionnaire. Participants who were not literate were assisted in completing the questionnaire. Three hundred and ninety-five (395) questionnaires were returned with complete data, yielding a response rate of 99%.In the qualitative arm, in-depth face-to-face interviews were conducted using a semi-structured interview guide. Before the interview, all participants were allowed to choose pseudo names. The interviews were conducted at an assigned office at the antiretroviral therapy clinic of Cape Coast Teaching Hospital. The time for each discussion was negotiated with the participant. Each interview lasted approximately 35 to 40 min and audiotaped, and two facilitators from the research team conducted it. Interview questions explored loneliness and stigma experienced by PLHIV and any coping strategies they adopted to overcome these challenges. Interviews and analysis continued until data saturation was confirmed by conducting three additional interviews.All data collection processes were conducted in the participant’s preferred language, either in English or the local language (Fante). In addition, each researcher kept a field journal in which personal reflections and biases were recorded.SPSS version 21 was used for the statistical analysis of the quantitative data. Frequencies and percentages were used to estimate the prevalence of HIV-related loneliness and stigma. Bivariate and multivariable logistic regression were used to evaluate socio-demographic factors associated with HIV-related loneliness and stigma. Statistical significance was based on the p-value (p < .05) and associated 95% confidence interval (95% CI).In the qualitative arm of this study, each interview was transcribed verbatim into English by the interviewer fluent in both English and the local langue (Fante) and then checked for consistency and accuracy. Then, transcribed interviews were coded, after which themes and sub-themes were generated. Next, each team member independently read the verbatim transcript to identify patterns. Afterwards, the group met to confirm the expected theme participants expressed. The themes were then categorised according to the objectives of the study. Finally, results are presented using quotations from participants to validate the phenomena.In general, the thematic analysis approach by Braun and Clark was employed to analyse the data . The sixFamiliarisation with the data refers to reading and rereading the transcript to immerse yourself in the data.codes are identified through systematic analysis of the data.Searching for themes is constructed by reviewing the codes to identify areas of similarity and overlap between codes about the research question.to check the data quality, the developing pieces are evaluated about the coded data and the entire data.what is specific and unique about each theme is clearly stated.Producing the report: data collection and analysis are done concurrently. Writing and analysis are interwoven.Trustworthiness was ensured by checking the findings to ensure the transcriptions were accurate and assessing the consistency of themes by different research team members. Two team members read the transcripts and assigned codes to various categories of data. All codes identified had significant implications for the research question. The participants validated the findings through member checking . The resThis study was performed following the Helsinki Declaration, and the Ethics Review Committee of Cape Coast Teaching Hospital, Ghana, approved it (reference: CCTHERC/EC/2021/028). The purpose of the study, anonymity, voluntary participation and confidentiality of the information were explained to participants to seek their written informed consent since only adults were involved. Participants who formal education, the information was translated into the local language (Fante) and they then thumbprint the informed consent form in place of the signature. Participants were made aware that they could withdraw from the study. All COVID-19 protocols, such as; handwashing, social distancing and wearing of facemasks, were observed during the study.± 12.53), and 75.4% of the participants were female , and the variables accounted for 26% of the variance in loneliness. The final regression model showed that a tertiary education level  was associated with a lower likelihood of loneliness than no education. Likewise, the presence of a comorbid condition was associated with a higher chance of loneliness  and negative self-image  had significant positive relationships with loneliness. Among the coping strategies, instrumental support  and self-blame  had significant negative relationships with loneliness.Table As shown in Table The analysis produced two main themes; psychological experience and available coping resources. Subthemes of the psychological experience include stigma and loneliness.In addition, participants described a range of available resources and strategies they adopt to cope with the disease. These include support networks, medication adherence, isolation/avoidance, self-efficacy and diversionary activities, as shown in Fig. The psychological impact resulting from HIV/AIDS is primarily related to HIV-related stigma and loneliness and reflects the findings from the study’s quantitative arm. Therefore, this section will present the qualitative results and integrate them into the discussion section.Participants reported various forms of HIV-related stigma. These included self or internalised stigmata, public stigma, and, to a lesser extent, stigma from professionals. Stigma leads to poor health-seeking behaviours, disempowerment, reduced self-efficacy and decreased quality of life.“When I cough, I normally don’t share cups with anybody. I have my spoon; I used my plate; I use my everything since I have the disease, so that’s it,” Participant Adjoa.Respondents also reported self-stigma. Several respondents expressed that living with HIV made them feel worthless. This was described in various forms in the words of respondents as follows;“No matter what it is, there will be some discrimination sometimes; Mummy, for example, is the one I spend much time with, but at times, she tells me to be very careful with her. As you know, she gets angry sometimes”. My brother, when he comes to visit, he doesn’t sleep overnight; he tells us he’s busy, but I think it’s because of me, but I don’t bother, not that he goes about telling people, but always that’s what he says, he’s busy” Participant Adjoa.She further observed that discrimination is inevitable for one to have the disease.“As I said before, I have not told anyone apart from my mother and siblings and my two uncles. Nobody knows; even my friends don’t know. Because I have this thing, I am not too public, although I used to be. I stop outings, even the beach. I quit going to the beach because of that. I have to be very careful,” Participant Adjoa.“Yes, because it makes me feel unclean; how people talk and behave towards you when they hear you have this disease is even embarrassing. People will hear about it and broadcast me; I feel shy and sad too,” Participant Ama.“I can’t tell anyone and am unwilling to do that because this disease is embarrassing”. Participant LizzyFor fear of public ridicule and discrimination, she doesn’t disclose her HIV status apart from her family.“In this life, there are people that whatever they hear, they spread it everywhere, so that’s why I don’t want anybody to know apart from my family”. Participant Adjoa.“My children have even suggested I go to a private hospital for treatment so that people won’t get to know, but because of diabetes or maybe when it worsens, they will still refer me to this place, so I decided to be here. I will feel embarrassed if people get to know about it”. Participant Ama“ People think that if you involve yourself in prostitution, that is how you get it, so I was wondering what people will think about me when they know about it”. Participant Serwaa“They may even avoid you; you can’t buy food or something, and they won’t sell to you. They keep pointing fingers at you anytime you pass by, and because of the disease, some older adults wouldn’t come here. So the stigma and discrimination will not even make people come here”. Participant Rita.Participants narrated the negative attitudes towards them by the general public, often based on false beliefs, fear and prejudices. The participants indicated they were stigmatised since they were diagnosed with HIV/AIDS. Some participants said even their family members stigmatised them.“Sometimes too, when I go to my customers for the food stuffs I sell, they refuse to sell to me because they thought I can’t pay them early or may not pay them at all because of how lean I have become”, Participant Serwaa.Another participant also reported this experience:“Yes. Because some people can’t keep their mouths shut, they will discuss it wherever they go and disgrace you. In the beginning, people said all sorts of things about the disease, so when they know you have it, they make it look like you did something bad that has landed you in that trouble,” Participant Serwaa.“There is no problem coming here, but I get worried I may meet someone I know who does not have the disease and will broadcast me. So if I see such people, I hide my face from being seen until the person leaves,” Participant Akosua.Participants are somehow paranoid about what people say regarding their condition:“When I went to the hospital and found out I have the disease, they asked me to go and treat it, so I lost my job; yes, I had to accept it even though they relate well with me”, Participant Adjoa.However, a participant experienced professional stigma:“Me, I don’t get help from anyone. Even in my family, most Muslims are only used to their Muslim brothers and sister. If you go to them, they only listen to your message and tell you it will be well, but they don’t help you in any way, so the little I earn is what I manage with my children”. Participant Adjoa.The participants expressed how HIV/AIDS negatively affected their interpersonal relationships. The condition made it difficult for them to associate well with others, including finding a life partner. The respondents demonstrated this feat in the following narratives;“We have challenges with relationships, so if they can get us contacts of people who also have the condition, it may help us because if you marry someone who does not have the condition, sometimes, you can’t take your medicines when he is around.” Participant Millicent.“I would wish that time for consultation, especially among the youth, if any man who also has the disease and needs a wife, they could link us because if you go for someone who does not have the disease, they will leave you if they find out… and also they can help get work to do to support us” Participant Yaa.A participant narrated the challenges in finding a partner:“I don’t have tight friends I go to or sometimes, maybe we meet at the market in place morning, then I go to my house but to go to their house, I don’t do that. I don’t live with my family; I live outside Ghana, but when I come home, we are fine”. Participant Elorm.“The reason is that the way they describe the disease makes people isolate themselves. They will also be pointing their fingers at you. This can get you thinking, so I better keep it to myself”. Participant Akosua.“Yeah, there are several worries; for instance, since my husband died, I am the only person catering for my children. I can’t marry again, at least for the person to support me financially”. Participant Elorm.Some participants reported a lack of friendship leading to loneliness:This theme characterises the various dimensions of support available to respondents to help them manage HIV/AIDS in the community. Under this theme, five  sub-themI have no such problem; I live in my own house, so I don’t encounter those things that can make me uncomfortable. I am free, and I don’t think about it at all. I know it has happened already, so I don’t worry about it anymore,” said Participant Emmanuel.“Some participants demonstrated self-sufficiency by stating that they were not bothered by the disease HIV/AIDS) because they were living in their own house. Expressly, one respondent stated;“As I am saying, people have different kinds of sickness, but they are walking around, so if I have this disease, it doesn’t mean I am useless”, Participant Sandra.“… I have accepted the situation. …this is what has befallen me, and no matter what I do, I have gotten the disease, so I have to look for a way to protect myself and go through it, so I am not bothered. Some people have not yet accepted their condition, so they are roaming from one prayer camp to the other, but I have accepted my fate that I can’t do anything about it,” Participant Esi.Another respondent indicated, Some participants also opined that they were not in this alone since other people they perceived to be better off in society had also contracted the disease. To these participants, people are living with other conditions freely in the community, so their case was no exception. Thus, they had to accept their fate and use the appropriate mechanisms to deal with the disease (HIV/AIDS).The second sub-theme identified was the support network. Four sub-themes were generated: family, religion, healthcare workers, and peers. Some participants revealed how they received financial support, encouragement, companionship, and inspiration from their family members, friends, healthcare workers, and religious organisations. Below are some experiences shared by some respondents.people who know me encourage me, and I also make sure to take my drugs well”, Participant Serwaa.“…For some participants, family members were a source of inspiration, encouragement, and financial support. In particular, the participants indicated that they gain financial support from siblings, in-laws, and their children. Additionally, some married participants said they enjoyed companionship from their spouses.Another participant averred,“…one of my brothers is a medical doctor at Korle-Bu; sometimes he sends me money for other drugs and upkeep”, Participant Yaa.One male respondent also added,“…mmm, apart from my siblings, I don’t get help from anybody. They support me financially. At times, they buy things for me… Even my in-laws are all good to me,” Participant Kwame.Lastly, one male respondent added that he could cope because of the companionship he received from his wife. He said,“I was fortunate my wife didn’t have it yet; she supported me till this time”, Participant Daniel.“…my mother reminds me to take my drugs and encourages me to eat well. My other siblings who stay at a different place too, we communicate on the phone, and I visit them, we interact well,” Participant Kwame.The inspiration participants received from their families were expressed in the view of one participant as follows;“The nurses made me understand that if I take my medicine well, I can live comfortably, but who kept me going is my reliance on God”, Participant Lizzy.“First of all, I thank God because it wasn’t easy for me since I was diagnosed with the disease. It Is only God who has kept me going,” Participant Kwame.Some respondents relied on their beliefs and engagement with religious activities to cope and live meaningfully with HIV/AIDS. The respondents presented their views regarding God to portray how their faith is rooted in their religious background while living with the disease. The opinions expressed by respondents are evident in the following narratives;“…the nurses and the doctors are all good. Even when I default, they caution me and take good care of me. They are nice; when I compare how the nurses treated us when my mother felt sick in our hometown, I say the nurses here are good. Last time they suggested I transfer because I come from afar, but I refused because I like how they care for me here,” Participant Kofi.“The doctors and nurses have been very supportive. They treat me well anytime I come to the hospital, especially the elderly ones among them; she is always nice to me, even when she sees me in town. They are all good; even those who pick up our folders when we come to the clinic are nice to us. Sometimes when I cannot come for my medicines, they collect them and bring them to my house,” Participant Joyce.A female respondent added, Supportive healthcare workers and the healthcare system enhanced participants’ ability to cope with HIV/AIDs. Some participants stated that the encouragement the doctors and nurses gave them and the services provided at the clinic kept them going as reported by a participant;“…that my friend also encourages me. Sometimes when I don’t have money to come to the clinic, she even gives me money to come. She ensures I am doing better,” Participant Rita.“…some of my friends also help me sometimes even though I have not told them anything”, Participant Yaa.Some respondents shared that friends and peers encouraged and supported them financially, enabling them to cope well with the disease burden.“…I listen to music a lot, which takes away my worries. I like watching movies too, so I don’t think about it,” Participant Yaa.Other respondents also focused on their work to keep them busy from worrying about their situation.Again, my work also engages me a lot and makes me busy. I am a teacher, so sometimes some students can behave to amuse you, which takes my attention from the disease,” Participant Esi.“I focus on my work, I am always busy, so I don’t have time to be thinking about the disease”, Participant Kofi.Another vital sub-theme emerged from the data related to respondents’ activities to redirect their attention and worries about living with HIV/AIDS. Some of these activities include music and watching movies. A female participant narrated;“…the way people make you feel when they know you have it (HIV) makes life difficult for you. At times, you don’t feel comfortable working among people,” Participant Yaa.“…I have to avoid places where people are likely to gossip about me”, Participant Lizzy.Another vital sub-theme from the data suggests that participants use isolation and avoidance to cope with the condition. They sometimes avoided working among people to escape gossip about their current status. One participant narrated;“I am encouraged by the fact that there is medicine to take to live healthily. In the past, if you get it (HIV), you die early, but I have lived with it for many years, and I am still healthy,” Participant Elorm.Another participant added:“I think the medicine because when you take them, you look ok. Also, the way I perceived the disease when I went for counselling and the teachings the nurses gave me made me understand that the disease is not as strange as people think” Participant Kofi.us. They counsel you well before treating you, so I listen to them and eat what they teach me. Participant Esther.Another participant indicated, “I follow the teaching the doctors and nurses give The last sub-theme that emerged from the data was the availability of antiretroviral. This sub-theme concerned participants’ reliance on antiretroviral for survival and healthy living. The participants expressed this as follows;The findings revealed a high prevalence of stigma among PLHIV, with an overall majority of 99%. Most study participants were females, consistent with previous studies , 49. As Similar studies indicate that PLHIVs experienced internalised stigma, which affected their relationship negatively and increased their sense of loneliness , 52, 53.Globally, HIV-related stigma remains high in the general population . This maThe study further revealed the occurrence of loneliness 30.1%) among PLHIV. Similar observations were made in the qualitative arm of this study, where participants reported loneliness influenced by stigma. Some reported experiences included; a lack of support from family and friends and a lack of partners. Other studies among people with chronic conditions also indicated the moderate prevalence of loneliness , 51. The.1% amongThe current study found no significant differences between males and females in the prevalence rates of stigma and loneliness. This finding corroborates observations by Flickinger et al., where stigma had no significant association with age and gender in the PLHIV .However, comorbidity and education were found to be significantly associated with loneliness. Specifically, PLHIV who had other health conditions were likelier to express loneliness. Also, PLHIV with tertiary education were less likely to express loneliness than those without formal education. This evidence suggests that formal education of PLHIV to a tertiary level may have increased their health literacy and formed a network of friends with a better understanding of HIV/AIDS infections, thus reducing stigma. On the other hand, HIV-related stigma may lead to shame and non-disclosure, leading to loneliness , 60. SocFurthermore, the qualitative arm of the study, in particular, revealed a range of coping strategies as protective factors for living with HIV/AIDS. Goffman describes stigma and has a lot to say about its management. How does the stigmatised individual respond to situations? Goffman claims that, in some cases, it will be possible for the individual to attempt to correct what he sees as the basis for his failings. For example, when a physically disabled person undergoes plastic surgery, the blind person seeks eye treatment and illiterate remedial education . Thus, tConversely, conditions that cannot be hidden from the public create discredited identities. The main focus, in that case, is managing and concealing or disguising the condition to pass as ‘normal’ to avoid becoming discredited and experiencing the resultant stigma, also known as ‘anticipated’ stigma . BecauseAffirming self-worth, support from family and reframing HIV status in a bright light have been noted to positively impact coping with loneliness and stigma associated with HIV . In addiFurthermore, the study findings revealed that PLHIVs who were self-sufficient and lived in their own house appeared to cope better with their condition than those who relied on others for basic needs. This finding is in congruence with a study that reported that PLHIV who are financially independent and engage in income-generating activities experience reduced feelings of self-stigma .This study was conducted in a resource-limited setting where resources at individual and national levels are constrained, and people struggle to make a living. Although antiretroviral medications are provided freely, some people cannot afford to visit the clinic for medications as a result of financial constraints, and this can influence adherence and recovery. Furthermore, the African continent is highly religious, where people put faith above all things in moments of difficulty. Thus, religion and spirituality appeared as central sources of hope for coping with HIV/AIDS. Faith in God as a coping strategy reflects similar studies in the literature .In addition, our findings revealed that doctors, nurses and a supportive healthcare system reduced the effects of loneliness and stigma on PLHIV. Encouragement from healthcare workers and quality service provided at the ART clinic served as coping mechanisms for PLHIV. PLHIV in ART experienced less stigma than those not in ART . It is cIt is evident in this study that participants value institutional support from healthcare professionals and, in particular, doctors and nurses to improve their quality of life. In addition, establishing effective communication and person-centred therapeutic relationship with clients will promote treatment adherence and reduce stigma and related factors such as loneliness. This finding is reported in a similar study which emphasises that a relationship of trust between patients, doctors, nurses and other team members is one factor that positively influences adherence .HIV-related stigma in all its forms and loneliness remains a challenge and negatively impacts the lives of PLHIV. The qualitative and quantitative findings reveal that HIV-related stigma and loneliness remain pervasive and affect the quality of life. Therefore, there may be a need to relook at HIV-related psychosocial interventions regarding their effectiveness across socio-cultural settings. Also, it was evident from this study that internalised, or self-stigma, was commonly reported among PLHIV, and thus there is a need to target evidence-based, context-appropriate interventions. Also, some contextual coping strategies in terms of support networks, cultural beliefs and values may provide valuable channels of supporting and complimenting contemporary approaches for people with HIV/AIDS to improve their quality of life.This study is cross-sectional, but a follow-up with a longitudinal study may give a better picture of how participants experience stigma and loneliness over time.The participants were recruited in a hospital treatment centre where people attend for their ART. However, this approach may miss out on individuals unable to participate due to stigma and loneliness.Although consistent with the literature, especially in Africa, most of the participants are women and Christians, which may require further investigation to explore the experience of other demographic groups.


Human populations rely on cultural artefacts for their survival. Populations vary dramatically in the size of their tool repertoires, and the determinants of these cultural repertoire sizes have been the focus of extensive study. A prominent hypothesis, supported by computational models of cultural evolution, asserts that tool repertoire size increases with population size. However, not all empirical studies have found such a correlation, leading to a contentious and ongoing debate. As a possible resolution to this longstanding controversy, we suggest that accounting for even rare cultural migration events that allow sharing of knowledge between different-sized populations may help explain why a population’s size might not always predict its cultural repertoire size. Using an agent-based model to test assumptions about the effects of population size and connectivity on tool repertoires, we find that cultural exchange between a focal population and others, particularly with large populations, may significantly boost its tool repertoire size. Thus, two populations of identical size may have drastically different tool repertoire sizes, hinging upon their access to other groups’ knowledge. Intermittent contact between populations boosts cultural repertoire size and still allows for the development of unique tool repertoires that have limited overlap between populations. Further, the presence of more learners can also reduce tool loss, facilitating cultural accumulation; smaller populations are at higher risk of losing technologies because fewer individuals know each tool [Human populations can accumulate massive repertoires of complex tools, artefacts, and technologies, varying in size and complexity ,2. Many ach tool ,18. Addiach tool , a numbeach tool ,10,20–23ach tool ,14,24,25ach tool . In thisach tool . Previouach tool . Here, wach tool . We use . 2Pinv per individual per time step. Each new tool is associated with a positive selection coefficient s, which is drawn from an exponential distribution with parameter β (meaning E(s) = β). We use the approximation that the probability of fixation of an adaptive allele is s [s, and that it immediately reaches its equilibrium frequency in the population. Afterwards, we assume established tools can still be lost in the population with a probability Ploss, which is divided by the number of individuals in the population. Thus, an isolated population will reach its equilibrium repertoire size when Pinv · β · N = (Ploss · x)/N, where N is the population size and x is the repertoire size. From this equation, for a given repertoire size of an interconnected population, we can calculate its ‘effective cultural population size’, that is, the population size at which an isolated population would be expected to have the same repertoire size. For simplicity, we did not consider in this model inter-dependence in invention, spread, or retention of tools whose functions are related. These are worthy of future exploration in the contexts of the proposed phenomena.We used a simplified version of the agent-based model proposed in   were chosen such that they would yield reasonable repertoire sizes for moderate population sizes. similarly, migration rate values , are of no specific anthropological significance but demonstrate that even minor demographic events, that members of the population at a given time may not be aware of, can have a substantial effect on cultural repertoire size. It should, however, be noted that qualitatively similar results can be found for a wide parameter range.The parameter values we chose for this proof-of-principle model  [f to 1 for simplicity, since we found that changing f had virtually the same effect as changing Pmig . For each tool carried to another population, we assume the tool establishes in that population with the same probability s that was drawn from the exponential distribution described above when it was invented.Migration between populations occurs with a probability culture) –33. In tRepertoire sizes at equilibrium were calculated by averaging the repertoire sizes between time steps 100 000  and 200 000 . Within the same time range, the average number of tools unique to the focal population was estimated by sampling the number of unique tools once every 100-time steps and averaging them.. 3−6 to 10−5 per individual, corresponding to between 0.0002 and 0.02 migration events per time step depending on the population size). For isolated populations, our model clearly predicts larger populations will have larger cultural repertoires. When migration is introduced, however, we find that the rate of migration has a pronounced effect on the repertoire size of the focal population of 200 individuals. When migration occurred between the focal and the neighbour populations, larger population size in the neighbour led to an increased cultural repertoire in the focal population. This concept can be described in terms of an ‘effective cultural population size’: the size of an isolated population that would be expected to have the same cultural repertoire size at equilibrium as the focal population (a). Similarly, while even low connectivity led to an increase in effective cultural population size, this effect was stronger as the connectivity increased. These results demonstrate that a group of fixed size can have a tool repertoire characteristic of a much larger group, depending on the composition of its contact network.As proof of principle, we examined the tool repertoire size of a simulated focal population of census size 200. The focal population was connected to a neighbour population of varying size  with varying probabilities of migration .b, we show that, in many cases, connectivity to other populations not only increases the focal population’s overall repertoire, but surprisingly can also increase the number of tools that are unique to it, i.e. those tools found only in one population and not the other at a given time. In this example (corresponding to the cell framed in black in figure 1a), when a population of size 200 is connected to a neighbouring population of size 400, with an individual rate of migration of 5 × 10−6, its average repertoire size increases from 40 tools to approximately 135, of which approximately 55 are unique to it.Furthermore, in figure 1a: the cultural repertoire of a population of size 200 increases both when it is connected to a larger population and when those connections occur more often. . 4Our results indicate that a population’s tool repertoire size increases with access to other populations’ cultural repertoires. In our model, each individual has the same probability to migrate, which means that a focal population has more encounters with individuals from larger populations. Furthermore, each migrating individual carries a given fraction of its population’s repertoire, meaning that those from larger populations carry more tools. Thus, populations that communicate with individuals from large groups experience an influx of novel tools, even when these interactions occur rarely.When a small population is in contact with a larger population, one might expect that, culturally, it would simply become a ‘satellite population’ of the larger group, carrying primarily some subset of the large population’s repertoire. Interestingly, this is not always the case. Contact with a larger population can not only increase a population’s absolute repertoire size, but also increase the number of tools that are unique to the focal population. This is because, first, some of the tools that are transmitted to the focal population are subsequently lost in the neighbour and thus become unique tools in the focal population. Second, the relative population sizes may lead to asymmetric migration rates, which keeps the smaller population distinct: migration rate is defined per individual in our model, and there are thus few individuals leaving the small population. Accordingly, most of the tools that originate in the small population remain unique to it.N is Ploss/2N, which is larger than the probability of simultaneous loss in two N sized populations, which is (Ploss/N)2. Under these assumptions, as populations are more interconnected, it becomes very rare for tools to be lost in the meta-population. We call this phenomenon ‘cultural rescue’, and believe it may play a meaningful role in the cultural dynamics of real meta-populations. Importantly, however, this phenomenon depends on the mechanisms by which tools are lost. In the version of the model used here, the ‘cultural rescue’ effect appears because we implicitly assume that the probability that two individuals from the same population lose a given tool is higher than the probability that two individuals from different populations lose that tool simultaneously. In other words, individual-level loss events of a tool within the same population are more interdependent than loss events across populations. An alternative model in which tools are lost from a population when they are independently lost by all individuals would lead the relationship between population size and the probability of loss to be exponentially decreasing. In such a model, very high migration rates between the populations would drive their effective cultural population sizes to simply approach the sum of their population sizes, and the cultural rescue effect would not appear. A further complication may arise if cultural loss is not considered a completely stochastic phenomenon, but rather is more likely, for example, when environmental conditions make certain tools less useful [Interestingly, we find that for very high migration rates the effective cultural population sizes of two interconnected populations can be larger than the sum of their population sizes. This result, while not intuitive, can be understood by considering the mechanisms of migration and tool loss. When migration rate is very high, most tools are shared between the populations. Thus, whenever a tool is lost in one population, it is reintroduced rapidly by migration from the other. For a tool to be lost from the meta-population it thus needs to be lost in both populations nearly simultaneously. In our model, the probability of tool loss in a population sized 2s useful . In suchWe suggest that empirical studies that examine overlaps between populations’ repertoires and reconstruct common origins of their tools and practices may help elucidate underlying evolutionary mechanisms of tool repertoire size variation. However, detecting infrequent contact events between populations may be extremely difficult. Here, we demonstrate that, especially when a population of interest interacts with a large population, even rare migration events can contribute to its cultural complexity, obscuring the predicted links between its population size and the size of its cultural repertoire. Moreover, although one might expect that population connectivity would lead to highly homogenized cultural repertoires ,34,35, h


Thousands of Eastern Europeans find employment caring for older individuals as transmigrating live-in home care workers in private households in Germany. Studies have shown that the stressors threatening their well-being are multifaceted and include inequalities and a high practical and emotional workload, but research on protective factors is still scarce.This qualitative descriptive study focuses on both the stressors and factors that promote care workers’ well-being and contribute to their psychological resilience. In guideline-based interviews, 14 female and one male care workers were asked about their stressors and the factors that help them cope.Identified stressors included separation from their own family, strained relationship with either or both the care recipient (dementia) and their relatives , and permanent availability and lack of free time due to a 24-h care schedule. Resilience factors were both external and internal and included positive social relationships, self-determination, experience in care work, and intrinsic job motivation.Live-ins reside in an ambiguous setting, exposed to both structural and individual strains. However, external and internal resilience factors contribute to a generally positive attitude toward their job and indicate the agency of this precariously employed group. A socially anchored appreciation of their work and an officially controlled expansion of free time are mandatory to improve the working conditions of live-in care workers. The phenomenon of care migration to countries of the global north , 2 and lLive-ins caring for the elderly in Germany usually transmigrate several months per year between their workplace and their home country. Reliable data on the number of migrant care workers working in private households is lacking, and numbers differ between 150,000 and 300,000  to even Health research on live-ins is scarce. Thus, in the following section potential stressors of related groups will be depicted. Women and gender studies highlight a multitude of inequalities live-ins experience, e.g., a lack of social protection or the emotional and care inequality with regard to the eventuality that caregivers may give less attention to their own relatives in favor of caring for strangers . An inteThis study is guided by a resource-oriented viewpoint that asks for factors that promote care workers’ well-being and contribute to their psychological resilience. Inequalities and strains are neither neglected nor relativized but are instead used as the starting point for the search of possible individual solutions and structural implications. In guideline-based interviews, one male and 15 female care workers were asked which stressors and strains they experienced and which factors contributed to their resilience. This study expands knowledge on the less frequented field of live-in care workers in Germany from a health research perspective by using a qualitative descriptive design. To our knowledge, this is the first study to attempt understanding German-based live-in migrant home care workers´ experienced stressors and resilience factors.To date, the majority of caregiving research refers to negative health aspects and risks, neglecting its positive aspects and the employees’ resources . Only a Looking at care workers’ psychological resilience can be another way to enrich the less frequented field of health research on live-ins and to structure the themes inductively and deductively found in data material. This study is part of an interdisciplinary research project on resilience DFG FOR-2686) that has guided the research interest of the authors. The term resilience is often utilized to describe promising answers to various challenges and crises . Definit86 that hTo answer the research questions, qualitative guideline-based interviews with live-ins building on two explorative expert interviews, were conducted. This study used a descriptive qualitative design to summarize “the informational contents of data organized in a way that best fits the data” . That isTwo explorative expert interviews with managers of brokerage agencies were conducted in February and March of 2020 (50-min long each) and used to construct an interview guideline for the live-in interviews. These managers arrange the employment contract between East-European care workers and German families and provide administrative support. These interviews provided a profound insight into the living and working conditions of live-ins in Germany and therefore opened the field of interest . From thThe transcripts were analyzed qualitatively using focused interview analysis, especially theme-oriented analysis . Coding This research followed the criteria of the Consolidated Criteria for Reporting Qualitative Studies . The intA total of 16 migrant live-in care workers  took part in this study. One interview was excluded due to a lack of German language skills, which left 14 women and one man. All persons were Polish; the average age of interviewees was about 55 years, ranging from 36 to 68 years. The participants had an average of 12.6 years (range: 4–23 years) of working experience as a live-in in Germany; 12 of the 15 interviewees worked for more than 10 years in Germany .“The worst thing for me was when I spoke to my children, and my child cried. In Germany not there. And I am afraid of this sentence, and I wish that it will never come [laughs]” .D5, a 37-year-old mother of two children, feels guilty and explains: “I often go to Germany, also for my children, but I am afraid that my children will say one day: Mom, you were too much for us” .Furthermore, the intimate relationship with a partner or spouse can be threatened by the separation. After working for 17 years in Germany, 50-year-old D14 stresses that “the separation, when my husband is in Poland and I am not there […] this is slowly getting Four interviewees mentioned the challenge of having their own parents or parents-in-law in need of care at home. For example, D15 needs to organize hour-wise care for her mother in Poland as she is not there to help. This challenging situation takes a lot of her free time, as she always has to coordinate help from far away.Stressors in the relationship with the person cared for: Cognitive neurodegenerative diseases of the care recipient and multiple challenges. A wide range of stressors concerning work life was mentioned in the interviews. For instance, 12 of the live-ins reported that their relationship with the person they cared for can contain stressful moments. Primarily, interviewees declared the challenges that come along with diseases of the person they care for, particularly cognitive neurodegenerative diseases, such as Alzheimer’s disease and dementia (n = 9).For example, 56-year-old D2, who has worked in Germany for 23 years, describes a “terrible” job experience :“My last patient had […] dementia, Alzheimer’s, and Parkinson […] She was really aggressive and had hallucinations. For example […] she said ´Do you see the dogs on the tree?´[…] And really uncomfortable was when she was completely wet […] she said `I am not dirty, you are dirty´ […] And she did not want me to clean it up. Always a battle […] and she was really aggressive, she wanted to beat me all the time” .Answering the question, what she would change if she could wish for something regarding her work as live-in, D6, who had 12 years working experience in Germany, said:“I just wish no Alzheimer’s, that is difficult, and no stroke. I prefer that the person can still stand up a bit, walk a bit by herself, talk a bit, something like that. That is just good” .D11, the only man in the sample and the person with the least experience in care work in Germany (four years), also answered this question by referring to the challenging aspects of dementia.Other diseases, such as bulimia, alcoholism, or cancer of the persons cared for, were also mentioned as stressful factors that influence the relationship between the live-in and care recipient and thus affected the live-ins´ well-being.Participants also spoke about general difficulties with the person they cared for, such as missing sympathy, issues with the older person giving up control, lack of trust of them in the live-in, or a feeling of insecurity and alienation while living in someone else’s household. Singular statements stressed the challenges of being friendly all the time, caring for those of a different gender or age, or those with divergent interests.Twelve of the 15 interviewees talked about minor or major problems with the family of the person they cared for. These problems consist of violations of the rules and arrangements by the relatives, such as demanding the live-in to cook for the whole family or work in the household of the relatives. Sexual harassment, cultural racism toward Polish workers, and financial fraud were addressed as well. D15, a 65-year-old woman who has worked in Germany for 20 years, talked about the son of a person she has cared for:I was there” .“I had a job where I was just half a year. The son of the grandma was really impertinent, and I always had to ask for the money. And he had forgotten it; then he didn’t have it with him [….] At the day of payment, he said I wasn’t there for 24 hours, but just 12 hours. But I said, The son ignored the time D15 was at rest or waiting for active tasks; however, this availability time is working time, as another interviewee underlined: “You have to work many hours like a fireman […] The fireman also sits sometimes and plays something. But as soon as there is a call, you have to get up, for example at midnight” . Other relatives of the care patient also lacked a sense of awareness for the complex reality of being a live-in by demanding they stay longer than they wanted to—ignoring their needed family time in Poland.D10 talked about her first experience as a live-in in Germany. Today, at 36 years old and with a degree, she reflects on her first stay in Germany eight years ago:no single day off in six weeks. Because the family did not want to care for their relative, even if they lived right next to the house. They had time, I saw that, but they just did not feel like it” .“I can still remember very well. I had Glaring workers’ right violations, like D10 mentioned, as well as simple ignorance of the live-ins needs and wishes were depicted as stressors and strains regarding the relationship to the relatives of care recipients.Being present seven days per week and nearly 24 h per day is an immense stressor for the well-being of care workers. In 12 interviews, live-ins mentioned difficulties caused by a lack of breaks, interrupted night’s rest, a missing private life, the general length of the stay in Germany, or the feeling of isolation.Women and men working as live-in in Germany usually stay between six and 12 weeks in Germany, followed by a comparable amount of time in their home country, according to the interviews. As an exception, one interviewee stays two months in Germany and just one week to 10 days in Poland (D15). D14 stays four weeks in Germany. Moreover, two of the interviewees permanently stay in Germany, returning to Poland only for holidays (D8 and D9).D10, for example, explains the feeling of missing privacy and leisure time while being present around the clock:“The most [difficult] is, that you do not feel so free. That disturbs me the most. I cannot decide on my life, because everything, everything is planned for the person in need of care. That is of course clear. But for example, leisure time, two hours, but you always watch the clock, because you have to do that […] Because you have to be in time for the coffee and you just have to subordinate, yes? You care for other people, that is proper like this, but sometimes it is way too much” .D9, a 56-year-old with 10 years of experience working as a live-in in Germany, emphasized the lack of leisure time as well. Being asked what she would change if she could wish for something, she answers: “My wishes for my work were just a bit more free time [laughs]. Just two hours a day. I have too less time for myself. For example, to sit for myself or doing other things, going to the hairdresser” .Being the only one responsible for a person in need of care comes with sleeping difficulties. D1 stresses: “During the nights we sleep, yes, but with one ear you hear. Is something going on? Is it not? And that is why you cannot bear it longer [than six weeks]” .never again so long”  and D6 says: “In the beginning I was two months, sometimes three months, but that is too difficult, three months. And the last time I was always six weeks, that is okay” . The interviewees realized how challenging and stressful the time in Germany can be and decided to reduce their stays to an amount that better fits their personal resources.D4, D6, and D14 said that in the beginning of their work in Germany, they miscalculated the time they could bear to stay in Germany: “So when I came for the first time, in 2003, […] my first job was for three months. That were two times three months. And afterwards I said Singularly mentioned burdens for the live-ins were the death of the person cared for, having no friends around, an insufficient payment, own psychological problems, lack of German language skills, feeling of guilt when losing patience in handling persons with dementia, desire for their home country, and no stable place to live, that is not living constantly in either Poland or Germany. Furthermore, several interviewees criticized the brokerage agency that placed them with families. They were reported to not provide sufficient information about the working place, give wrong promises toward the legal status of the interviewee, or exploit women with a lack of German language skills by paying them less than they pay better skilled live-ins. Finally, one interviewee fundamentally criticized the system of brokerage agencies in Germany and Poland in general:“The Polish agencies work with the German agencies. And this system is close to the border of legality […] There are many juridical problems. […] I hope […] one day our government or the German government will stop the exploitation […] That is a jungle, a real jungle. Everybody does what he can or wants to [laughs]. Of course, that does not get controlled, those are private houses, nobody enters.” .D10 convincingly addresses the unclear legal situations the live-ins often face that often go along with missing official control .Besides the wide range of private and work-related stressors, the interviewees also explained how they coped with challenges and what contributed to their general positive attitude toward the job. These answers can be seen as an expression of the live-ins´ subjective resilience factors. Despite the mentioned challenges, 13 of the 15 interviewees expressed general contentedness with their job. That is, live-ins within different legal conditions—self-employed, family-employed, and brokerage agency-employed—said that they were generally content with their job.An important aspect contributing to this general contentedness and thus to the individuals’ resilience were social relationships.The relationship with the family of the person cared for and the care recipient is important for the live-ins. As already shown, a strained relationship with these groups can be an enormous stressor; on the other hand, a good relationship can contribute to their contentedness and resilience. Twelve of the interviewed live-ins indicated a generally positive or even very good relationship with the relatives. Good relationships with the relatives were, in these narrations, characterized by being grateful and respectful toward the live-ins and their job. D12 for example is 59 years old and has traveled to Germany for work for 18 years. She intended to work as a live-in as an intermediate solution when she first came to Germany. She had lost her job in Poland and wanted to find something else in her home country. Still, the first family she lived with in Germany played a big role, besides from the financial incentive, in her change of mind:everywhere [describes places] […] Such a nice family. […] I think, through this family I have decided, to come to Germany again [smirks]” .“For me it was nice, every weekend a son stayed with the mom, and the other one took me in his car, and we jaunted. I was Describing her relationship with the family of the person she cares for, D15 states, “The children are friendly. They call, and when we meet they say ´Nice to have you here´” .D6 explains the importance of the families’ respect toward her and her tasks: “The family needs to understand, too, how difficult this work is. […] The family needs to understand, that I need some time, rest time, for myself and they have to understand, this is real work. That is important” .D6 underlines the importance of a real and true will of the patients´ relatives to understand her, her needs as well as the difficulty of her job.Similar to the importance of a good relationship with the relatives of the care recipient, the relationship with the person cared for can not only be a stressor, but also an interpersonal resilience factor. All interviewees mentioned positive aspects of their relationship with the person they care for or have cared for. These aspects include, on the one hand, a good functional status of the care recipient, that is, no Alzheimer’s disease or other forms of dementia, allowing normal communication, and, on the other hand, intimate friend- or family-like relationships, where they could have fun together, learn from each other, talk about problems, and have sympathy for each other in general.In a detailed description, D16 reports a close relationship with an older woman she had cared for:“I met a woman who was [high age] […] and I thought, that the work would maybe not be lasting very long, because the lady was already very old. But it was four years. […] And that was a special time. The lady was very wise, very intelligent, and a very cheerful woman, and she is in my heart till today. […] I am really happy that I met these people. I learned a lot and she was really wise and cheerful. […] And I was really happy that I could stay with her till the end” .a real long time. Unfortunately, she died. Six years I had her […] That was nice […] Like a family, a real family.” . By repeating the term “family”, D13 expresses the high emotional value of the patient she cared for during a long period.D13, a 68-year-old who has worked as a live-in for 12 years, describes a relationship with a care recipient that was family-like: “A single patient I had for Also contributing to the resilience of the live-ins, the relationship with the care worker’s own family and friends was also frequently mentioned (n = 13). Eleven interviewees explained that they call their partners or children in stressful situations. When asked what they commonly do whenever they feel stressed or what they do in concrete stressful situations, the interviewees mentioned the emotional support of their relatives: “Talking to my children and having a good cry” ; “Then I call home and call my children”  or “I often spoke to my parents. And they always said ‘Everything will be fine. You’ll come home’ and those words meant a lot to me […] That was a big support” . When asked what gives them strength in their life, seven interviewees explicitly named their family. Singularly, pets were also mentioned as precious, family-like supports.Self-determination. Next to interpersonal factors that are conducive to the live-ins´ resilience, supportive aspects can be found within the individuals themselves. As the foregoing text has shown, a multitude of stressors can affect care workers’ well-being. Still, the abovementioned quotations related to the length of the stay in Germany were influenced by a central element of the live-ins´ possible resilience factors. Despite their often challenging, even stressful working and living conditions, the interviewees showed a high sense of self-determination. Twelve of the 15 participants expressed a strong will, the ability to determine their desired working conditions on their own, and the ability to communicate their wishes and needs.never again so long” . Furthermore, she wants to take control over her leisure time:To repeat D14, for example, dictates the length of her stay in Germany: “So when I came for the first time, in 2003, […] my first job was for three months. That were two times three months. And afterwards I said other women. […] When I feel like it, […] I go for a walk in the morning, too. Not just these two hours in the afternoon. When I am looking for a new job, I broach this right from the beginning. I want to feel like a free human being, too. […] Till now this works” .“For me, with my experience, I can say that from the beginning in a family, I need more than Next, to determine the length of the stay in Germany or their leisure time, interviewees also regulate further conditions of their work, such as access to the internet. D11 explained the importance of the internet for corresponding with his family:“I do always phone to my wife and children. […] I do always have internet and that is important. When I ask the coordinator of the brokerage agency about a new job, I do always ask `Is there internet or not?´. […]The family needs to have internet. I wait […] for one or two weeks, but if there is still no internet, that is impossible” .In case the working conditions do not fit their expectations, seven interviewees talked about the decision to quit a job. For example, D7 was misinformed by the brokerage agency about the functional status of her next care recipient. She herself is a dainty person but was confronted with the request to care for a man weighing 150 kg.I do, when it is broken?” .“I said, ‘I am sorry but I don’t manage to do this.’ […] The coordinator of the brokerage agency replied: ‘You have to, I don’t have anybody else.’ […] I said ‘I don’t have to.’ I take my luggage, wait for the bus and go home […] I just have one back […] and what do I am the care worker here. […] I am no cleaning lady, no cook, I can do that, but I do not have to”  and “I am the care worker for the person in need of care, but not for the whole family” , indicating that she strongly sets limits.Responding to relatives of the care recipient that want her to do more than she has agreed to, D7, a 56-year-old who has worked as a live-in for eight years, says: “In line with this sense of self-determination, D10 stresses:“You have to take care of your rights. You are a human being too, not a slave. You don´t have to work for the daughter, […] ironing or whatever. When you have a contract, you have to stick to it. And you have to respect other people, but they have to respect you as well” .D5 accentuates a different dimension of self-determination. She explains that she is responsible for herself and for her decisions:“The worst thing is indeed the separation from my family. However, you always have to see the glass half-full, not half-empty. Because when I go to Germany, this is my voluntary decision. I go to Germany to earn money and you have to make the time nicer somehow. For example, I can sit here in the corner and cry, because my family is far, far away. I have to make the best of it” .D8 explains the positive effect her work in Germany has had on her independence: “I am self-reliant. I do not depend on anybody. That gives me strength as well. That got stronger since I left the house” .In a very self-reflective manner, D8 describes the effect of her stays in Germany on herself. Self-reliance, independence and strength are attitudes she thus gains by her work.As aforementioned, the average care work experience of the participants was 12.6 years, and the majority (n = 12) had worked for more than 10 years in Germany. Nine individuals mentioned that their live-in care work experience is supportive in managing their stressful and challenging working and living conditions. Within this time, they became accustomed to their separation from their families, learned how to adapt to new situations, and particularly cultured techniques in handling persons with dementia, Alzheimer’s disease, or other diseases. D11, for example, cared for a person with cancer, which required him to perform mucus aspiration occasionally—a work he had never done before: “That was really difficult. I had to watch out […] There was a lot of mucus. I always had to do a mucus aspiration. […] But now I have big experience [smirks]” .D10 explains the habituation that comes along with years of experience: “In the beginning, I had no idea how it [the job as a live-in] works. But as I said, the work is similar, and with time practice comes and you are used to it” .D7 describes what she has learned while caring for people with dementia:“The main thing is, you have to be patient. […] You always have to try to use medium tones or a bit calmer. And learn. Learn and every day there is something new. For people with dementia, Alzheimer’s or something else like Parkinson, the people go to bed, but you don’t know about tomorrow. What is the problem the next day?” .In addition, D15, who reported about the care recipients’ relative who did not pay her on time and ignored availability time as working time, resumes: “I just thought at that time, I will pick my next job in a better way. And if there is a relative […] who seems strange to me in the first talk, I will not do it” .Using the restricted leisure time in a way that is best for them can be seen as a learned experience or adaptation technique that helps live-ins to cope with their stressful everyday life. When asked what they do in their restricted leisure time, interviewees enumerated a long list of hobbies. Next to meeting friends, reading, and listening to music, especially physical movement, such as going for a walk or riding a bike, was mentioned most often (n = 13). D16 illustrates: “I am really active. I do jogging, and the most important for me is having a bike [smirks] […] Movement […], going for a walk, riding a bike, jogging, yes, that’ s the best for me” .When asked what she does whenever she feels stressed, D14 replied: “I go for a walk […] I need the air” . “I have to go for a walk every day, always. I do Nordic Walking, I ride a bike” . And D12 explains: “I like walking, going for a walk, that’s good for me. Refueling oxygen [smirks]” .Leaving the house, to move around, not looking for someone but for himself or herself and to get some freedom can be considered a resilience strategy. At the same time, it mirrors a main stressor: being present in the house of the person cared for 24 h (except for a 2-h break). Going for a walk every day reflects the limited resources the live-ins do have, as well as the experience and agency to care for themselves.Participants’ motivation to work in Germany as a live-in was most often financial stimulus (n = 14), demonstrated by occupational hopelessness in Poland, the wish to renovate or buy an apartment or house, debts, an insufficient pension, and, very often (n = 8), the need to financially support children and grandchildren. Next to this extrinsic motivation, eight of these interviewees additionally mentioned an intrinsic motivation: enjoyment of their work, altruism, and the meaningfulness of their job. Intrinsic motivation can be seen, according to these interviews, as a resource in handling adverse working conditions. Six interviewees explained that they like helping others.like helping these people, these sick people. […] I feel very good, when I help and these people are content” .D11: “I D4 explains the combination of extrinsic and intrinsic motivation:“This job means a lot of stress. Because money is not everything. I do this job not just because of the money, it’s just that this job makes me happy. Because I can do something for somebody, helping a bit” .Similar to D4, D2 says:“If I didn’t have fun or feel like it at work, I would never do this job. But I have a heart like a barn, as my mother said […] [smirks]. That is why I work with sick people, because I think, that is the right thing. It is better than cleaning, because cleaning, that are dead things. People are people. There I know that I did something good for them. And that’s a giant satisfaction for me” .Furthermore, as eight interviewees mentioned, the extrinsic motivation to financially support their children and grandchildren can also be read as an expression of altruism directed to their family, as can be seen in the following quotation from D5, who answers what gives her strength in her life:“I think, my family, because I have a goal. I came to Germany to reach my target. That is money in this case. And I think when I got the money, I can offer something better to my children, like a house or […] a new laptop. […] All that what I didn´t have, I can offer to my family” .D5 wishes to fulfil material wishes to her family. The job as live-in in Germany offers her the option to do so.Less often mentioned were the following intra- and interpersonal factors that positively contribute to the live-ins´ resilience: their own health sensitivity , sufficient German language skills as the premise to express self-determined wishes and needs, external professionals supporting live-ins by doing night-shifts or cleaning, and religiosity/spirituality.Live-in migrant home care workers in Germany live and work in an ambiguous setting. On the one hand, they are confronted with a wide range of individual and structural stressors that might affect their well-being. On the other hand, intrapersonal and interpersonal resilience factors can mediate a subjective positive attitude toward their job.The participants of this study differed from the majority of live-ins in Germany in that nine individuals of the sample were officially employed by the family—contrary to the majority who are not permanently employed . That isThe spatial separation from children, partners, and parents is the main stressor with regard to the private life of the live-ins. Participants miss their family and feel guilty toward children left behind and responsible for older relatives in need of care. This finding supports the criticism toward structurally caused “emotional and care inequality” . This isIn line with the findings of Heng et al.  who inveThe relationship with the family of the care recipient can be challenging as well. In line with other studies, violations of rules and workers’ rights , 41 wereIn general, being present nearly 24-h a day is a major stressor affecting the live-ins´ well-being. This permanent availability comes with limited nighttime rest, a lack of free time, and restrictions on their private life. This is consistent with challenges reported by other migrant home care workers , 40 and These daily hassles and structural difficulties challenge the live-ins´ resilience. This study supports the recent direction concerning the definition of resilience, that a multitude of internal and external factors can contribute to a resilient process , 29.In line with other researchers, these findings highlight the importance of positive social relationships to the well-being of live-in care workers. A good relationship with the relatives of the care recipients based on respect and appreciation of the caring person and their work is fundamental to their well-being , 40, 41.Predominant within the interviews was a sense of self-determination of the participants. They set limits regarding their working conditions, quit if they did not fit, communicated their wishes, and understood themselves to be independent human beings. Work experience also supported the live-ins´ well-being, as adaptation techniques and strategies toward challenges can be cultivated. The target-oriented utilization of restricted leisure time  is consiPsychological resilience, according to these findings, is based upon both external  and internal  factors. Reducing the phenomena of resilience to singular traits or outcomes does not, in our opinion, adequately reflect its complexity.To our best knowledge, this research is the first to access both stressors and resilience factors of German-based live-in migrant home care workers. Still, as is usual in qualitative research, the findings of this study do not claim representability and therefore cannot be generalized. The participants of the study had sufficient German skills and mostly lived within legal conditions—different from other individuals who come to Germany without any language skills or contract. Only one interviewee did not have any official status, that is, she was not registered as a care worker by either the family, a brokerage agency, or herself. As the COVID-19-pandemic appeared right after the start of the study, interviews had to be conducted via telephone (except for three), which was different from the atmosphere of conversations held in person. Still, this factor might have positively contributed to the willingness to participate, as interviews could take less of the interviewees’ limited free time. All interviewees came from Poland, so statements about persons from other countries cannot generally be concluded from the findings. Five of the 15 interviewees were contacted via one brokerage agency, and five were affiliated with a welfare association. The former was responsible for the high percentage of participants who were family-employed as this brokerage agency exclusively works with family-employer contracts. Statements about the impact of the brokerage agencies on the answers of participants cannot be made; still, to achieve as open a conversation as possible, the interviewer, Author 1, underlined the anonymity of the interview before the beginning. In addition, the majority of the live-ins has a long care work experience (more than 10 years)–statements on the representability of the findings for women and men with less experience cannot be made. We were aware that a conflict of interest could be assumed in the expert interviews with the managers who, on the one hand, are interested in better conditions for live-ins, but on the other hand also have financial interests in this employment model. However, these managers have the largest overview of the living and working conditions of live-ins in Germany, and the expert interviews were helpful for an exploration of the field and the creation of the interval guide. An open question was included in the guide to allow the live-ins interviewed to fill in previously missing topics.Home care workers do not have the same level of protections by workplace safety policies such as those in hospitals and nursing homes ; this isS1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.