Part of this competency is the precept that communications about public health crises should be designed and delivered in a way that maintains trust and social cohesion, shares evolving science, and builds a broad base of support for measures that can save lives and livelihoods2.Communication is a key part of the practice of public health and is a core competency required to be taught by schools of public health across the United States3. The public’s willingness to follow basic tenets of infection prevention and mitigation is at risk.During the COVID-19 pandemic, however, our world has faced unprecedented communications challenges, ranging from new communication modalities  to dramatically increased speed of knowledge creation and dissemination, to intentional campaigns of mis- and dis-information. A complex set of factors including politicization, distrust, division, and obfuscation—as well as basic errors in public health messaging—have occurred4.To do better in the future, we must rigorously evaluate the quality, quantity, and efficacy of public health communication during the COVID-19 pandemic. “The Language of Crisis: Spatiotemporal Effects of COVID-19 pandemic dynamics on health crisis communications by political leaders,” by Benjamin J. Mandl and Ben Y. Reis provides an important, but very preliminary, step at looking at the connections between public health communications by political leaders and public health outcomesThe Mandl and Ries paper used transcripts of governors’ speeches over a limited time frame (March–June 2020) to examine correlations between speech characteristics and COVID-19 rates. They applied basic natural language processing techniques to identify semantic categories and sentiments, and then correlated these language characteristics with COVID-19 case counts, both across space (across states) and across time (within states).Their work yields some interesting insights.First, during the earliest wave of the pandemic, governors’ speech patterns became simpler and more negative as COVID-19 cases increased. Higher COVID volumes also correlated with higher likelihood of governors’ using language about hospitals, prohibitions or policies, and religion. This finding is intellectually interesting, but not particularly informative for politicians, researchers, or communicators.5, and is the opposite of what public health teaches us about behavior change. Given the crucial role the public plays in the collective response to a pandemic, an overfocus on government actions can result in a “we have no control” mindset and hinder resilience and community solidarity. The public’s responses to public health messaging in a crisis are heavily driven by pragmatism and self-efficacy6. Messaging that emphasizes community and individual action increases adherence with crisis response measures; reminders that one is part of a group reduces stress and anxiety; and people want to know what lies within their capacity to act and fits within the circumstances of their lives. The paper’s finding therefore points out a major area for improvement in public communication, and an opportunity to work with politicians.Second, high COVID volumes did not correlate with sentiments of helpfulness or community, nor with word patterns that discuss preventive measures. Indeed, governors’ language became more impersonal and less empowering as the crisis worsened: they increasingly spoke about “what is government doing for you” rather than “what can you do for yourself” or “what can you do for the common good.” We note that this tendency is the opposite of how healthcare professionals communicated during the COVID-19 crisisThird, as is often true for the earliest work in a field, the paper creates more questions than it answers.A critical limitation of this paper is that the authors evaluated speeches from only a very short period: the earliest months of the COVID-19 pandemic, when the world was virtually shut down and when we knew very little about the SARS-CoV2 virus. Our body of understanding and our set of tools to handle the pandemic is infinitely more complex today than it was during the period of this study. Our COVID-19 response is now also infinitely more politicized. We cannot help but wonder whether the observed findings would hold up across the initial wave of cases in more conservative states, from July–August 2020. We also wonder whether these findings would hold up across time, as all states changed their policies and measures. Ideally, this analysis would be repeated during summer 2020, winter 2020–2021, and again with the latest delta and new Omicron wave. We suspect that the correlations would be attenuated or even reversed during later time periods.Another issue is that the findings seemed to be driven largely by a few states with both high volume of cases and high volume of gubernatorial speeches . It is difficult to know whether the correlations reflect politics, unique gubernatorial personalities, or actual case counts. Adjusting the analyses for political exigencies seems not just wise, but important.8.Additionally, as the authors acknowledge, more advanced forms of linguistic analysis—to allow consideration of not just basic semantic categories such as “good” versus “bad”, but also more complex latent constructs—would be preferred. Others have already shown that this work is possible and we look forward to seeing it extendedMost importantly, this paper leaves us with the question of “so what?” The authors made the basic methodological choice to look backward, hypothesizing that caseloads influenced the governors’ words. Far more interesting, and useful, would be looking forward in time: examining the correlation between governors’ speech characteristics and future public health policy or (better yet) actual behavior and case counts.Lastly, to get a more complete picture of how public speech and case counts intersect, we would also need to examine not just governors’ public speeches, but other forms of crisis communication, especially public health-led communications—and, ideally, public-driven online posts  as well. These forms of communication are perhaps more influential on—and more responsive to—local case counts than that of political leaders.Many have opined about the failures of public health communications during the pandemic. This analysis provides one, albeit limited, insight into why and how we have erred. We hope that future analyses will both demonstrate the effect of our words and provide insights as to how we—as leaders, as communicators, and as a society—can do better.Further information on research design is available in the Reporting Summary


Kornadt, Eva-Marie Kessler, Susanne Wurm, Catherine E. Bowen, Martina Gabrian and Verena Klusmann., was originally published electronically on the publisher’s internet portal on 11 October 2020 without open access. With the author(s)’ decision to opt for Open Choice, the copyright of the article changed on 05 January 2021 to © The Author(s) 2021 and the article is forthwith distributed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third-party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit


Depression has become a major social issue of global concern, which has seriously threatened the quality of an individual’s life. Although the relationship between community environment and depression has aroused heated debate, the empirical research on the relationship between community environment perception and public depression is still relatively insufficient. Data for this study are from China Family Panel Studies in 2016, which were conducted by the institute of Social Science Survey, Peking University. This paper has tested group differences in the influence of community environment on public depression, as well as the mediating role of subjective social class between community environment perception and depression, so as to further explore the social psychological effect of community environment. The empirical study found that there are group differences in the impacts of community environment perception on depression. Specifically, men, rural residents, and people aged 60 and under are more likely to be depressed which were affected by the perception of community environment. Furthermore, we have found that the subjective social class can partly mediate community environment perception and depression. That is to say, the perception of community environment can induce depression by influencing the individual’s subjective social class. Among them, community living environment and community public facilities have the greatest impact, community emotional attachment and community security situation have the second impact, and neighborhood mutual aid and neighborhood relationship have the least impact. In other words, the community environment is deeply endowed with a social psychological effect. To ameliorate the public’s depression, it is necessary to consider the construction of community physical environment and the cultivation of harmonious community culture as powerful measures not to be ignored. In short, the important role of community environmental intervention in alleviating the public’s depression caused by social class cognition deserves attention. Mental disorders have become a major social issue of global concern. At present, depression has become one of the most widespread mental disorders, already presenting a worsening trend year by year and seriously threatened people’s life quality . The etiAs the basic field of modern residents’ life, community environment and human welfare are closely intertwined. Community environment refers to the degree of overall environment quality and appropriate degree to people’s physical and mental health development. For example, the perception of community environment is measured by the respondents’ cognitive evaluation of various elements of the community environment . It is fHypothesis 1 (H1).People with worse perception of community environment are facing more serious depression.How people perceive their social status is considered a predictor of physical and mental health . SubjectHypothesis 2 (H2).People in lower subjective social class are facing more serious depression.The influence of community environment on individual depression has been well demonstrated by previous studies. For example, housing equity inequality worsens social trust  and diviHypothesis 3 (H3).Subjective social class plays a mediating role between community environment perception and depression.As far as we know, although the relationship between community environment and mental health has been well confirmed in previous literature, there is still no further research to explore the impact of subjective perception of community environment on public depression. In conclusion, community environment not only has a physical spatial effect, but also has certain psychological and social benefits, which may be more conducive to understanding the possible path of public depression under different social, cultural, economic, and political backgrounds. The social psychological effect of perceived community environment can also induce public depression. To address these gaps, the present study explores the intrinsic mechanism of community environment and social cognition related to depression. In order to explore the influence of community environment on depression, this study aims to introduce a new perspective to explain the mechanism. Specifically, using the data from the 2016 China Family Panel Studies (CFPS) and regression estimation method, we empirically investigate the mediating effect of subjective social class between community environment perception and depression. The perception of community environment affects the public’s subjective social class, thus enhancing the scope and intensity of public’s social comparison. People with poor perception of community environment are more likely to be dissatisfied with their social class and more likely to suffer from depression.Data used in the current study were obtained from the 2016 China Family Panel Studies (CFPS), a continuous large-scale nationwide survey conducted by the National Survey Research Center of China, which employed a stratified multistage probability proportional to the size sampling design and covered 25 provinces across mainland China, by tracking and collecting data at the individual, family, and community levels. The CFPS 2016 consists of adult questionnaires and children’s questionnaires, which covered society, economy, population, education, health, social relations, cognition, and attitude in China, and basically reflected the panorama of family economic and social life in China and were well representative of the whole country. Considering the complexity and comprehensiveness of environmental quality perception and subjective class perception, this study only used the adult survey, including 33,296 adults aged 16 and above. After sorting the data and eliminating the missing important variables, 4997 effective samples were selected. Data are available through the Institute of Social Science Survey Data Archive website.Community environment perception was an independent variable. Referring to previous studies, community environment is defined as community happiness index, neighborhood problems, neighborhood interaction time , communiSubjective social class was a mediating variable, which was measured by the Likert 5-point rating scale. A question  was selected, which reflected subjective social class in this study. Respondents were asked to rank the degree of the choice from “very high” to “very low”, which assigned a value from 1 to 5 successively. A higher score represented a lower subjective class perception.Depression was a dependent variable. The Center for Epidemiologic Studies Depression Scale had been widely used as an effective method to measure individual depression, which contained 16 questions to measure negative feelings  and four questions to measure positive feelings (such as “I don’t feel inferior to others”). Respondents could answer “hardly (less than a day)”, “sometimes (1–2 days)”, “sometimes often (3–4 days)”, and “most of the time (5–7 days)”, which assigned a value from 1 to 4 successively to represent the responses of negative emotion items. While the response assignment of positive emotion items was scored reversely. The total CES-D score was from 0 to 80 theoretically and a higher score represented more serious depression. The Cronbach’s alpha coefficient for the scale was 0.848 in this study.Covariates must be controlled in the process of data analysis, due to their well associations with the public’s mental health, especially depression or due to their potential to confound the relationship between community environment perception and depression. The related control variables included age, gender, household register, health condition, marital status, nature of work, and education. According to the needs of data analysis in this study, the original data were further processed. In terms of age, the values of 0, 1, and 2 were separately assigned to age groups 16–44, 45–59, and over 60, respectively. In terms of gender, “female” was assigned a value of 0 and “male” a value of 1. In terms of household registration, “rural-registered residence” a value of 0 and “city-registered residence” was assigned a value of 1. In terms of health condition, “general” and “unhealthy” were assigned a value of 0 and “relatively healthy”, “very healthy”, and “extremely healthy” a value of 1. In terms of marital status, we assigned “unmarried” and “cohabitation” a value of 0, “married with spouse” a value of 1, and “divorced” and “widowed” a value of 2. In terms of nature of work, we assigned “agricultural work” a value of 0, “non-agricultural work” a value of 1, and “jobless” a value of 2. In terms of education, we assigned “primary level” a value of 0, “intermediate level” a value of 1, and “high level” a value of 2. Illiterate, semi illiterate, and primary school were collectively referred to as primary level education, which was assigned a value of 0. Junior middle school, senior middle school, technical school, and professional high school were collectively referred to as intermediate level education, which was assigned a value of 1. Junior college, undergraduate degree, master degree, and doctor degree were collectively referred to as high level education, which was assigned a value of 2.Before statistical analysis, the original data are filtered. The data with three standard deviations higher or lower than the average score and the missing values were eliminated. The SPSS software  was used for descriptive statistics and correlation analysis.We used the stepwise linear regression analysis to test the mediating effect of subjective social class between community environment perception and depression with maximum likelihood estimators and 95% bias-corrected confidence intervals (CIs) using 5000 bootstrapped samples repeatedly. Specifically, model 4 in the SPSS macro process plug-in developed by Hayes , is usedAs shown in p < 0.01) and subjective social class . Moreover, subjective social class is significantly positively associated with all dimensions of community environment perception. These results provide good preliminary support for the hypotheses. In addition, depression is also significantly positively associated with all dimensions of community environment perception. These results provided a good preliminary support for the hypotheses.The descriptive statistics and correlation coefficients for the study variables are presented in p < 0.001). On this basis, we used linear regression to test the group differences of community environment perception on public depression . In contrast, male depression was significantly higher than female in all dimensions of community environment. The results showed that the perception of community environment improved male depression to a certain extent.Firstly, we discussed the impacts of community environment perception on public depression of different genders (models 1 and 2). The results showed that, compared with women, male depression was more likely to be affected by the perception of community environment . Urban residents were more likely to be depressed by community public facilities  and community living environment  than rural residents. However, rural residents were more susceptible to community public security , community neighborhood relationship , community neighborhood mutual aid , community emotional attachment  than urban residents. The results showed that community environment perception improved the depression of rural residents to some extent. Rural residents’ depression were more affected by community public safety, community neighborhood relationship, community neighborhood mutual assistance, and community emotional attachment, while urban residents’ depression were more influenced by the community public facilities and community living environment. In other words, the impacts of community environment perception on depression were different between rural residents and urban residents.Secondly, the difference of community environment perception on depression among different registered residences (models 3 and 4). We found that compared with urban residents, rural residents were more likely to be affected by the perception of community environment , followed by the public aged 16–44 , and the least affected were the public aged 60 and over . The same change trends were also consistent in community public facilities, community living environment, community public safety, and community emotional attachment. However, in the dimension of community neighborhood relationship, the public aged 45–59 were the most affected , followed by the public aged 60 and over , and the public aged 16–44 were the least affected . In the dimension of community neighborhood mutual assistance, the public aged 60 and over were the most affected , followed by the public aged 44–59 , and the public aged 16–44 were the least affected . The results showed that community environment perception has greatly improved the depression of the public aged 60 and under to some extent. The depression of the public aged 60 and under were more affected by community public safety, community neighborhood relationship, community neighborhood mutual assistance, and community emotional attachment. While, the depression of people aged 60 and over were more affected by the perception of community neighborhood relationship, community neighborhood mutual assistance, and community emotional attachment.In addition, we discussed the different impacts of community environment perception on public depression across age (models 5–7). We found that the depression of the public aged 45–59 were the most affected by community environment perception , and hypothesis 1 is verified. Community environment perception has a significant positive effect on subjective social class , and hypothesis 2 is verified. Meanwhile, subjective social class also has a significant positive effect on depression . Community environment perception affects subjective social class, which reaches 5.8% explanatory power. The influence of community emotional attachment on the individual’s subjective social class has reached 5.1% explanatory power, the other five dimensions of community environment perception have also exceeded 4% explanatory power. This suggests that subjective social class plays a mediating role between community environment perception and depression, which accounts for 5.45% of the total effect. This indicates that the influence of community environment perception on depression is partly due to the role of subjective social class, and community environment perception can explain 16.80% variation of depression. Accordingly, the worse the perception of community environment, the more the severity of public depression.First of all, community environment perception has a significant positive effect on depression , which show that the construction of community physical space environment is the primary indicator to measure people’s perception of community environment. The higher the quality of public space and facilities, the more conducive to promoting people’s mental health . SecondlOur results not only inspire our understanding of this problem in the context of social culture, but also enrich the internal mechanism of the relationship between community environment and depression. In this study, we use limited variables to evaluate the attributes of community environmental factors. Unfortunately, there is no more abundant and reliable data to test these mediating mechanisms of other socio-cultural factors, such as relative deprivation, “face effect”, and positive social comparison. Therefore, it will be an important research topic in the future. Meanwhile, these results strongly support the effectiveness of community environmental intervention in reducing public depression. The results strongly suggest that cognitive optimization can effectively improve the individual’s social and psychological functions . It is aIn the current study, we find that community environment has an important impact on depression through situational psychosocial mechanism, and the perception of community environment affects depression through the mediation of subjective social class. The perception of community public facilities, community living environment, community public security, community neighborhood relationship, community neighborhood mutual assistance, and community emotional attachment significantly affect depression through the mediating role of subjective social class, but the effects are different. The community environment not only has the spatial physical attribute, but also has been endowed with the social psychological effect. The direct effect of community living environment and community public facilities is the biggest, which means that strengthening the optimization and improvement of community physical environment and improving the public’s positive life experience is the primary task. The significant influences of community emotional attachment, community security situation, community neighborhood mutual assistance, and community neighborhood relationship also tell us that strengthening community culture construction, promoting public community emotional social support, and community interpersonal communication are favorable measures to improve the public subjective social class perception and suppress depression.A contextualized perspective is important to better understand the underlying situational psychosocial mechanisms through which community environment perception has a significant effect on depression. Our results resonate with this point and suggest that the social and cultural psychological background should be considered when studying the impact of community environment on depression. We propose that community environment affects depression through which the mechanism is not a general research problem, but a contextualized problem. Our findings not only improve our understanding of the impacts of community environment on depression, but also have policy implications on how the “healthy China 2030” program related to community environment and people’s well-being. We strongly recommend that the national environmental protection department and civil affairs department should improve the construction of community living environment and public facilities, so as to inspire people’s comfortable experience of community physical living space. Moreover, it is quite necessary to strengthen the construction of community culture to enhance people’s community emotional social support system.This study makes a preliminary exploration on the social psychological effects of community environment. As the data are cross-sectional data, there is still a lack of dynamic mechanism investigation. It is suggested to carry out a detailed analysis of longitudinal panel data in the future, so as to further obtain reliable conclusions of tracking data.


Consumer tests are classified in terms of the location of testing as laboratory tests or central location tests (CLTs) and home use tests (HUTs). CLT is generally used in sensory tests due to the ease of test control, whereas HUT has higher validity because of real consumption. However, the lack of test control in HUT is a major issue. In order to investigate the error occurrence and efforts required to minimize errors, three groups of tests were designed differing time and order control and evaluation was conducted using six snacks with texture differences. Errors related to time, order, and consumer or sample number were higher for more controlled conditions, however, most errors were recoverable using identification information except for cases of no response. Additionally, consumers preferred to consume all snacks in the evening at home, which differed from the typical 9 a.m. to 6 p.m. evaluation time in CLT. However, the timing differed for consumers with self-reported snacking time. The research title that included the term ‘home’ might have influenced the participants’ choice of location for evaluation. Overall, there was no significant difference between the results of groups despite different time and order controls, which could increase the applicability of HUT. Acceptance tests are crucial for food companies as acceptability can be used as an estimation for the possible repurchase of products by customers. These tests are usually conducted at sensory laboratories under a controlled environment using samples and preparations, which have been used to predict potential long-term purchases . ConsumeIn this respect, several comparative studies between CLT and HUT have been done as the context effect suggests that the results would be different depending on the test location ,5,8,9,10Several studies using HUT have dealt with the real situation in many ways, however, minimal information is available about the mode of implementation. Therefore, the information required to build structural standardization is inadequate. Accordingly, it is important to examine the various factors in HUT. The use of a maximum of three samples is encouraged for two reasons: better understanding of the experiment for participants and digression from the natural situation ,13. SampProduct information on the package should be considered in HUT design. Consumers noticed package cues during repeated consumption . Mahieu For procedures, samples were provided through the lab stopping by , visits CLT has a fixed time limit for participants to evaluate samples, thus, hedonic scores could be affected . In contSome challenges from the past remain, however, with the development of internet technology, the data can be collected and checked on a real-time basis. Furthermore, HUT is being used more owing to the prohibition of public gatherings due to the COVID-19 pandemic. These can be an alternative method of testing in the new normal era. Although sensory evaluation has started moving out of the controlled laboratory environment in order to reflect real consumption, COVID-19 accelerated the speed of change. HUT is a necessary form of consumer test. There is a lack of studies done on these tests, hence, they need to be investigated further for development and standardization. In addition, many studies mention the importance and common limitations of HUT, however, the information on methods for overcoming these limitations is not enough. Therefore, it is imperative to review the kind of errors that could occur while conducting HUT and find the amount of control/effort required to minimize the error.The objectives of this study were as follows: (1) to determine if home-use tests could be an alternative to central location tests or laboratory tests, (2) to study the kind of errors that could occur while conducting home use tests, and (3) to suggest critical control factors.A total of 300 Korean participants  were recruited through the online bulletin board in Pusan National University or word-of-mouth and enrolled utilizing an online survey tool . Participants were asked to use QR codes. The demographic information of the consumers, along with their snacking frequency and usual snacking time on a daily basis, are shown in Jeltema et al.  divided Participants were divided into three groups. Each group had 100 participants and their sex, age, and address were considered in order to balance their proportion. If the address provided for delivery of samples was the same, we considered the participants to be living together and assigned them to the same group to minimize confusion during evaluation. Group A was the ‘No control’ group for time and order, thus consumers were allowed to proceed with the evaluation at any time and in any order they wanted. Group B was the ‘Order control’ group that consisted of participants who were instructed to evaluate in a preassigned testing order. However, they could evaluate whenever they wanted. Group C was the ‘Time and order control’ group that had a preassigned order and evaluated one sample every 2 days, three times per week. No instructions were given regarding the minimum amount of consumption and presence of other people with the participants while conducting the test. The instruction manual used pictograms in the description for ease of understanding. Participants were simply referred to quick response (QR) codes on the instruction manual or click links that were sent via text messages. The ‘No control’ and ‘Order control’ groups used QR codes provided on the instruction manual, whereas the ‘Time and order control’ group received messages including the link to the online questionnaire at 10 am on Monday, Wednesday, and Friday for two consecutive weeks. If the participant did not respond to the questionnaire for more than 72 h since the last evaluation, a reminder text message was sent to finish the assigned evaluation. Participants in the ‘Time and order control’ group were reminded 2 days later to maintain the evaluation intervals with other participants in the same group. The participant evaluation was terminated if they ignored the message three times consecutively. A schematic diagram of test design for comparing three home use test settings with differing test controls regarding evaluation time and test order is found in Consumers filled out their identification number and product number each time and selected the time and location of their evaluation. The questionnaire was composed of queries regarding the product acceptability, texture characteristics, and prior knowledge of product. Overall acceptability, liking for the packaging, flavor, and texture were evaluated by using the nine-point hedonic scale (1 = “dislike extremely” and 9 = “like extremely”). Flavor intensity, texture intensity, and afterfeel intensity were measured using the nine-point scale (1 = “extremely weak” and 9 = “extremely strong”), whereas the amount of residue was measured on the six-point scale (0 = “None” and 5 = “very much”). Participants checked suitable texture terms using check-all-that-apply (CATA) and the mouth behaviors  that were relevant to the corresponding sample were determined. Subsequently, they answered yes/no questions about knowledge of samples, brand name, and experience. Additionally, willingness to purchase was measured by using the five-point scale (1 = “I would definitely not buy” and 5 = “I would definitely buy”).After all the evaluations were done, participants were questioned about demographics, motivation of snacking, and mouth behavior. In snacking questionnaire, participants were questioned about three main parts. First was frequency, time, and reason for snacking. The second was a liking towards 11 snacks  using the nine-point hedonic scale (1 = “dislike extremely” and 9 = “like extremely”). Lastly, they were asked to respond to questions about the motivation of snacking using the six-point scale  .In the mouth behavior questionnaire, the participants were questioned for preference of mouth behavior. They responded to the degree of preference with the six-point scale (1 = “strongly disagree” and 6 = “strongly agree”) using questions that revealed the difference in the texture of food items, and photographs representing each of the four mouth behaviors ,25,26,27Data were divided into two categories: completed without error and error occurred. Their frequency was recorded. Data that did not have any errors was considered complete data. Data having errors related to time delay, evaluation order, entry of wrong sample number, or consumer identification were recovered by tracking personal identification information (last four digits of the phone number). Missing response cases were not followed up due to time passing after consumption. After confirmation, all data, except that of participants who did not respond, were corrected and used for analysis. Demographic information was completed with further requests from participants. Therefore, the number of participants whose data was available was different depending on the samples. The number of days taken for completion of evaluation with all samples was presented as mean, minimum, median, and maximum values of the difference between the start and end date using a data unit. The frequency and percentage for evaluation time and place, knowledge of samples, mouth behavior (MB), and amount of consumption were calculated. Liking and perceived intensity scores, willingness to purchase, and adequate portion size were analyzed using analysis of variance (ANOVA) to determine significant differences among groups and samples within each group. When significance was found, the Fisher’s least significant difference (LSD) was conducted as a post-hoc test at a significance level of 0.05. Additionally, the evaluated order from the ‘No control’ group was counted as the frequency.Data from CATA was presented in terms of the frequency of selected sensory attributes and used for correspondence analysis (CA). The RV coefficient test was also performed using the results of CA to compare samples and terms between groups.® Software 9.4 . RV coefficient tests were analyzed using XLSTAT® Software package .Statistical analysis was performed using SASThe frequency of analyzable data acquired from evaluations is shown in Simple errors such as the entry of incorrect consumer numbers and the three-digit random codes were detected and data was saved. In ‘Order control’ and ‘Time and order control’ groups, some evaluations were done without following test design protocols, however, their sample number was identified with data. When the evaluation was delayed, participants were reminded and the evaluation period was extended. In addition, no response was also counted as an error. The pattern of overall error occurrence was similar to that of completeness, with ‘Order control’ and ‘Time and order control’ groups having errors nearly twice as compared to ‘No control’ groups. ‘Order control’ group accounted for most errors from preassigned orders. However, a few also occurred in the ‘Time and order control’ group despite the notification. Additionally, the completeness from ‘Order control’ was the lowest, although the degree of control was not greater than that of the ‘Time and order control’ group as the preassigned order error was counted several times per person. When preassigned order error was treated as one per participant, despite its occurrence being more than once, then the order error occurrence was the highest in the ‘Time and order control’ group, followed by ‘Order control’ and ‘No control’ groups. Other errors were mostly related to incorrect entry of numbers, such as consumer numbers or three-digit random codes.Recoverable errors referred to error data that was correctable. Even if the same consumer repeated mistakes more than twice, these were treated as an error. Participants had to enter the last four digits of their phone numbers for each evaluation, hence, their consumer numbers could be traced and errors could be rectified.The sum of missing data in each group was in the following order: ‘No control’ group followed by ‘Order control’ and ‘Time and order control’ groups. For the ‘Order control’ group, missing data for apple sauce and potato chips was higher than the total number of dropped consumers. Moreover, participants who did not complete all evaluations were also in the order of ‘No control’, ‘Order control’, and ‘Time and order control’, however, some of their data were included.Participants who did not complete the evaluation within the preset time period were considered for extended evaluation. Participants for extended evaluation from the ‘Time and order control’ group were considerably greater in number compared to the ‘No control’ and ‘Order control’ groups. For the ‘Time and order control’ group, the participants could not proceed to the next step on their own because they were informed of the testing sample within the evaluation intervals. Hence, the ‘Time and order control’ group had a lesser frequency in the no response and dropped consumers, although their number was highest in the extended evaluation.All other errors were recoverable with confirmation, except for non-response data. The response rate for all groups was high and the frequency of error differed depending on the degree of control, which could be converted into complete data using the identification information.p > 0.05). In this study, evaluation time did not influence acceptability.Information of evaluation time and place for each group is shown in All samples were mostly consumed at home, followed by the workplace. The snack consumption location for Canadians and Norwegians was home more frequently, followed by the workplace ,30. In aThe testing days were not designated, hence, ‘No control’ and ‘Order control’ participants could conduct the test in one day, whereas ‘Time and order control’ participants could take up to 10 days for completing the evaluation, considering the interval time and the date of sending a text message. Interestingly, some participants from the ‘Time and order control’ group communicated with their acquaintances in a different control group and received the survey link or QR code before their designated evaluation link was sent. However, we could not consider acquaintances in assigning participants into the same or different group. The instructions have to clearly stated that confidentiality should be maintained during and after participation, even if the participants are acquainted with each other.The results of the maximum days taken by the ‘Time and order control’ group reflected the effect of the periodic testing intervals and reminders. One consumer from the ‘No control’ group took 26 days to complete the testing. The missing data were found a few days later and completed. The maximum number of days for completion of evaluation in the ‘No control’ group was 15 days without this data. However, several participants from the ‘Time and order control’ group who received the evaluation and supplementary questionnaire on the last day did not evaluate carefully. They completed only one of the questionnaires and the remainder was completed after the reminder. Another downside of sending reminders was that some participants from the ‘No control’ and ‘Order control’ groups completed all remaining evaluations at once after receiving the reminder because they thought that they were supposed to finish the questionnaires immediately. Furthermore, some participants lost the testing samples and requested to receive more samples. Therefore, they needed more time for testing.p > 0.05) between groups in liking, perceived intensity, and amount of residue, while there were significant differences (p < 0.05) within groups.Overall, liking was rated positively ranging between neutral to like moderately, probably because all products were commercially available  and the Although spread wafer was also an unfamiliar product , its likAlthough samples were wrapped in Kraft bags, consumers in the ‘No control’ group might have opened all bags to choose their evaluation order. More than half of the participants had knowledge of samples except for apple sauce. Although the spread wafer had low product awareness and experience, its brand awareness was high. On the other hand, apple sauce was mostly evaluated last and it had the lowest brand and product and brand awareness, and experience.p > 0.05) and the samples showed significant difference within each group (p < 0.05). Similar to overall liking, spread wafer rated the highest in purchase intent, while apple sauce rated the lowest. Although apple sauce is similar to baby food, it was the only product not available in Korea, and thus was an unfamiliar product for the participants.The results of purchase intent and price that the consumers were willing to pay are shown in p < 0.05) within groups while there was no significant difference (p > 0.05) between groups. All samples were rated similarly among the three groups, except potato chips and spread wafer in the ‘No control’ group. Participants were willing to pay the highest price for jelly and the lowest for candy. The problem was that candy, cereal bar, and spread wafer were provided in a quantity of more than one, thereby confusing the consumers whether the question was for only one piece or all provided. Most samples were rated higher than the original price except for potato chip and spread wafer (Participants were asked the price that they were willing to pay in Korean won (KRW) for a provided quantity of each sample as an open-ended question and the mean values (and SD) of the responses are shown in ad wafer . For appConsumers chose all relevant mouth behavior such as cruncher, chewer, sucker, or smoosher during consumption . The higp < 0.001), ‘No control’ and ‘Time and order control’ groups , and ‘Order control’ and ‘Time and order control’ groups . Samples configuration for the groups were as follows: ‘No control’ and ‘Order control’ group , ‘No control’ and ‘Time and order control’ group , and ‘Order control’ and ‘Time and order control’ group . Samples with a difference in texture were dispersed into each quadrant and were explained by nearby texture characteristics.Correspondence analysis (CA) biplot shows the relationship between snack samples and the 51 texture attributes evaluated using the CATA method from each group . With Dip < 0.05) within groups while there was no significant difference between groups (p > 0.05). The quantity of samples provided in CLT is relatively smaller than that of HUT along with a brief exposure time [The amount of consumption evaluated by consumers is shown in ure time , hence, ure time  found thContrary to CLT, many external factors influence testing in a real setting; hence, greater efforts are required for the evaluation of several samples in HUT. After follow-up, the final number of participants with completed data was high, despite the occurrence of various errors. Most errors were related to incorrect entry of consumer numbers or three-digit random codes. Other errors included not following the preassigned order of testing or evaluation period extension. The consumer and sample numbers were both three-digit numbers. This might have confused the participants as they had to enter these numbers directly using open-ended questions, despite receiving six samples at once. Nevertheless, identification information helped in the modification of errors.Kraft bags were used for hiding packages of samples before evaluation. However, it may not have served the purpose of random sample selection in the ‘No control’ group as familiar and/or preferred products were evaluated first. Moreover, a few participants unwrapped Kraft bags as soon as they received them, thereby mixing the sample numbers. In such cases, repackaging was required until the effect of packaging was studied and consistency of the food quality was ensured by avoiding external factors such as temperature, long contact with humid air, or direct sunlight. Moreover, it is important to check if the shelf life of the product would last an extended evaluation period.Six samples were provided simultaneously by postal delivery before the start date. However, some participants from the ‘No control’ and ‘Order control’ groups conducted the test before the announcement of the start date using the QR code on the instruction manual. On the other hand, the ‘Time and order control’ group could start testing only on the day the survey link was provided. The survey link should be provided for the first sample evaluation if the start date of the evaluation is to be fixed as it eases the follow-up process.In this study, new findings were that the job profile of the participants and the time of sending messages could influence evaluation time. The term ‘home’ used in the research title in the testing information may have influenced the evaluation place. Accordingly, the QR code allowed more freedom than the link in terms of evaluation time. In addition, the access time in online evaluation did not coincide with evaluation time in the questionnaire despite its mention in the written instructions. Hence, it was important to emphasize the instruction prominently or by using a video for better understanding.Social communication was not considered in our study. Snacks are generally eaten alone, however, their acceptability and consumption can be influenced by social interaction. In our study, family members or housemates were classified in the same group. However, this factor was excluded from the analysis due to low occurrences. Furthermore, some participants who were acquaintances contacted each other regarding the testing, although they were not in the same group during the evaluation period. Thus, better instruction was needed to avoid communication among participants for reduction of errors, such as participants from the ‘Time and order control’ group receiving survey links from the ‘Order control’ group. The recommendations for HUT is summarized in the This study investigated and compared the results of three groups differing in time and order control using six samples with different textures in the home use test. It aimed to determine the amount of control/effort that would be required to handle errors that might occur while conducting HUT. Overall, the results of the evaluation were similar between the groups, regardless of the degree of control. Thus, HUT can be utilized similarly to CLT as consumer tests in terms of the number of samples. HUT allows the evaluation of samples in a real environment and can be designed to evaluate long-term usage. They can be utilized to improve the launch of new products and evaluate their success.Not much research has been conducted in a realistic environment and there is almost no report on errors that may occur while conducting HUT. However, a few of its disadvantages are its cost and high dropout rate. This study evaluated two control factors of preassigned order and evaluation time in HUT. It included the evaluation of six snack samples by participants, which is normally evaluated in one session in CLT or laboratory evaluation. If CLT or laboratory tests were included as a control compared to HUT, our findings would have been better validated. As a small number of consumer sample participated in this study, our findings may not be generalized. When conducting HUT with more consumers providing a higher number of samples than traditional HUT of one or two samples, more errors or higher dropout rate might be observed. More experiments on HUT should be performed for generalization. Furthermore, other control factors, such as sample temperature, should also be considered in the future.


A knowledge of the history of medicine enriches our thinking about contemporary medical practices. The twentieth century saw many medical advances. It also saw multiple examples of what may be called dangerous medicine. Such medicine is invasive, risky, and lacking a rigorous evidence base, but is enthusiastically embraced and celebrated by members of the medical profession and the public. Then, with the passage of time, such medicine is viewed with more scepticism. It is recognized as not being as beneficial as claimed and as causing more harm than acknowledged. It comes to be mostly seen as misguided, occasionally even criminal. In this Letter, I use a historical frame to background a discussion of the gender affirmative treatment approach for youth with gender dysphoria (GD youth), particularly focusing on masculinizing chest surgery. I ask: Is this approach a medical advance or is it a contemporary example of dangerous medicine? My hope is that the ideas expressed in this Letter will helpfully contribute to the debate about this complex and controversial area of medicine.Braslow  discusseThis brief account of Rose evokes a range of emotions. I feel horror, sadness, anger, and fear. Why do I feel these emotions? I am a human and a woman. I have had the experience of being a patient in doctors’ hands, relying on their expertise, care, and conscientiousness. It is the stuff of nightmares to be totally dependent on physicians, who, even if well-meaning, are implementing ineffective, harmful, or punitive interventions. My emotional reaction to Rose’s story is made even more complex, because I am also a psychiatrist. Therefore, part of my horror in reading this history is that I am identified with those physicians implementing such “treatments.” I ask myself: How would I have treated patients as a psychiatrist in the 1940s? Would I have done what Rose’s psychiatrist did?Another celebrated historical treatment was malaria fever therapy, which entailed deliberately inducing a malarial illness in patients suffering from general paralysis of the insane (GPI). GPI was a severe form of neurosyphilis and was a frequent cause of admission to the early twentieth century psychiatric institutions. Although risky, malaria therapy was claimed to be successful in curing some patients from this usually fatal disease. It was used from the 1920s until the 1950s, gradually being superseded by penicillin Davis, . The BriIt is a curious experience reading Shaw’s words in 2021: past, present, and future become entangled. Contemporary historians are critical of “Whiggish” histories of medicine, which stand on a moral high ground to criticize the “bad old days”  approved clinical trial–as the surgery was undertaken prior to or separate from the research.I now return to my previously posed question: How would historical medical practitioners comment on this surgical intervention? I imagine Shaw, in response to hearing about the surgical sterilization of vulnerable youth, drily commenting that the eugenic agenda of early twentieth century psychiatry and medicine might still be operative in 2021. Shaw might note that removing the term “breasts” from our language parallels early twentieth century English and American society, which was full of euphemisms to avoid distressing women. Freeman , an AmerIndeed, many of the criticisms made about the inadequate evidence base of discredited historical treatments can be leveled against chest surgery for GD youth. The studies have significant methodological limitations which mean they are at critical risk of bias and cannot show that chest surgery is causally associated with short-term improved mental health outcomes. They do not provide any information on long-term outcomes and regret rates. Limiting features include the following: small and select samples; cross-sectional assessment; uncontrolled case series or comparative studies with non-matched control groups; high drop-out rates; short-term follow-up only; unvalidated measurement scales; and a failure to account for the impact of co-interventions and the placebo effect. Those advocating for chest surgery in youth make strong claims regarding the evidence base for this surgery in adults. However, these are also limited by similar shortcomings (Cohen et al., How will masculinizing chest surgery for GD youth be viewed by future generations? The enthusiasm for it, despite the lack of a rigorous evidence base, suggests that it may be seen as another example of what Valenstein  called “What factors, aside from the lack of a rigorous evidence base, might contribute to dangerous medical practices? Can history inform us anything about what might lead physicians to over-enthusiastically and prematurely embrace risky and unproven treatments? History suggests there is most likely a complex interplay of multiple factors, and I discuss some of these in this section. In the subsequent section, I return to discuss the gender affirmative treatment approach for GD youth and highlight some themes that may suggest some parallels with this history.For physicians, “great and desperate” treatments could lead to “name and fame” and inculcate a sense of heroic doctor. For example, at the end of the nineteenth century, general paralysis of the insane confounded physicians’ therapeutic potency, leaving them just contemplating death “like men in a boat about to be swept over a fall, paralyzed with despair” Godding, . HoweverNew York Times, lobotomists were described as simply cutting out the “worry center” of the mentally ill, just as easily as they could remove an “appendix” or an “infected tooth” and bringing the patients a world “radiant with sunshine and kindness” (Harrington, An uncritical press portrayed the physicians implementing these treatments as bold medical heroes with the courage to take “desperate remedies” required to cure “desperate ills” Hurn, , p. 226.The Strange Case of Dr Jeckyll and Mr Hyde, could have been GPI personified (Swain, Physicians can be confronted by patients whose illnesses, behaviors, and physicality undermine Western ideals of masculinity, femininity, and heterosexual norms. It may be that these patients are particularly at risk of dangerous medicine. General paralysis of the insane was a disease predominantly diagnosed in men in the prime-of-life. It was intimately linked with masculinity and sexuality, and deeply confronting to early twentieth century Anglo-European ideals of manhood. Men could turn from being rational and responsible citizens to filthy, raving, and violent–Mr Hyde, from d Swain, . As the d Swain, . In the d Swain, , p. 101.d Swain, , p. 59. d Swain, , p. 79.Of note, malaria therapy was invented in 1917 in Vienna (Wagner-Jauregg, Many of the other somatic psychiatric treatments of the twentieth century were given predominantly to females. Pressman  wrote thHomosexuals’ bodies have also been a favored site for experimental twentieth century medical and surgical interventions in which treatment, social control, and punishment goals blur. Metrazol convulsive therapy, chemical castration with estrogens, surgical castration, clitoridectomy, brain operations, and aversive electrotherapy were all utilized with the aim to either convert the homoerotic desires to heterosexual ones or to obliterate desires all together Murphy, . SometimMy final historical example is the hormonal treatment of “tall girls” and “short boys.” From the 1960s through until the 1980s, large numbers of adolescents, who had no underlying medical pathology or hormonal abnormality, were prescribed hormonal treatment for their height (Cohen & Cosgrove, Masculinizing chest surgery is part of the controversial gender affirmative treatment approach to GD youth. This approach is underpinned by the view that a child or adolescent’s stated gender identity should be endorsed not questioned, and that they should be supported to undertake social transition, medical transition, masculinizing chest surgery, and, some also argue, genital surgery. Those advocating this approach consider these gender affirming treatments medically and ethically essential Baams, .Others express concern about this approach Biggs, . They noThe studies’ limitations also mean that regret and detransition rates are largely unknown. A widely cited study to support claims of less than 1% long-term regret rates is Wiepjes et al. . HoweverIn response to my historical examples, some may argue that informed consent and patient autonomy differentiates contemporary medicine from historical medicine. However, many of these historical treatments did require informed consent, either from the patient or a family member. In addition, informed consent is complex. A necessary condition for it is clinician honesty, which is not met if clinicians overstate the evidence base or act as “cheerleaders” for transition (Clayton et al., in press; Levine, This is also a controversial topic outside the medical field. Contemporary feminist academics have divided views on transgender issues and the medicalization of GD youth (Gillis et al., Some influential LGBTIQ and parent groups are vocal in their support of affirmative treatments for GD youths, but other such groups express concern. Some consider that placing the label “trans” on gender non-conforming youth is an expression of the homophobia of our society. They are concerned that the hormonal and surgical interventions maybe a repetition, albeit unwittingly, of historical treatments that aimed at converting homosexual people to fit with heterosexual norms Stock, , in her How, then, do we best read the affirmative treatment approach for GD youth? Should it be read triumphantly as cutting-edge, ethical, and evidence-based medicine continuing on its progressive march of improving human life? Or is it a manifestation of dangerous medicine, that despite best intentions will cause more harm than benefit to vulnerable youths, and over which future historians and physicians will shake their heads?Between the ages of 16 and 20, Kiera Bell identified as a man and took testosterone and underwent a double mastectomy. She then detransitioned. In a court testimony, she described her regret: “I felt like a fraud…more lost, isolated and confused than I did when I was pre-transitioned…only recently…I have started to think about having children and if that is ever a possibility, I have to live with the fact that I will not be able to breastfeed my children…I made a brash decision as a teenager…trying to find confidence and happiness…now the rest of my life will be negatively affected” (Bell,


According to a view widely held in the media and in public discourse more generally, online hating is a social problem on a global scale. However, thus far there has been little scientific literature on the subject, and, to our best knowledge, there is even no established scholarly definition of online hating and online haters in the first place. The purpose of this manuscript is to provide a new perspective on online hating by, first, distinguishing online hating from the phenomena it is often confused with, such as trolling, cyberstalking, and online hate speech, and, second, by proposing an operational definition of online hating and online haters based on ethnographic interviews and surveys of the existing scholarly literature. According to a view widely held in the media and in public discourse more generally, online hating is a social problem on a global scale. It has been claimed to be at least partly responsible for the assassination of a well-known politician ; for vaOne reason why there has been so little research dedicated specifically to online hating and online haters seems to be that online hating is often seen in academia as a mere variant of other online phenomena, most importantly trolling , cyberstHowever, the evidence we have obtained suggests that the terms “hating” and “online hating” are often used to denote a phenomenon that is distinct from what is usually called “trolling,” “hate speech,” or “cyberstalking” – and, in fact, any other online phenomenon identified in scholarly literature – and which is at the same time of considerable social significance. So this phenomenon is definitely worth scholarly attention on its own. Our evidence comes from three sources: scholarly articles, media accounts, and ethnographic interviews.We conducted systematic searches of both scholarly articles and media reports through the EBSCO Host database. We looked for scholarly articles/media reports published within the period of 2005–2021 that feature terms “online” + “haters” (33/154), “online” + “hating” (126/50), “online” + “hate” + “speech” (640/528), “online” + “trolling” (357/368), “online” + “trolls” (359/934), “cyberstalking” (406/134), and “cyberstalker” (15/14), with any duplicates being removed automatically by the system. Then we conducted a review of this material, taking into consideration additional articles and media reports on the above topics that we had known about from our previous work.N = 67) were graduate and undergraduate students at the University of Wrocław attending lectures given by one of the authors of the study. The interviews were conducted during classes, with the participants giving their responses anonymously on unsigned sheets of paper. For the sake of both time and anonymity, we abstained from asking demographic questions. However, the pool from which our sample was drawn allows us to estimate that most our participants must have been women and between 19 and 23 years old. Overall, our interviewees clearly recognized hating as a distinct phenomenon, were able to give its concrete examples, appeared to have witnessed it first-hand, and in some cases reported to have been its objects. Some of our participants admitted to having engaged in online hating in the past, expressing various attitudes toward these actions, ranging from regret to satisfaction.The ethnographic interviews were conducted specifically for the purpose of this study. The respondents to these interviews  not backed by any reasons, (b) does not appear controversial in a given environment, (b) does not have any explicit ideological content, then this is, most likely, an instance of hating.In closing, we would like to argue that despite all the methodological, difficulties, online hating definitely deserves to be studied. This is not only because of scholarly but also practical reasons. After all, one might reasonably assume that online hating causes severe social harm, and that preventing that harm will not be possible without understanding online hating as such and implementing measures that are designed specifically with that phenomenon in mind.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Research Ethics Committee at the University of Wrocław’s Institute of Psychology. The participants provided their written informed consent to participate in this study.WM, PS, MK, and MD: conceptualization. WM: investigation and methodology. WM and MK: data management and analysis. WM, PS, MK, and MD: writing and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Introduction: Substance use is common among military personnel and war veterans, especially combat veterans. Despite substantially high prevalence of cannabis use and Cannabis Use Disorder (CUD) consistently reported among veterans, little is known about psychological factors which may underlie CUD among this population.Methods: In this study, we used narrative analysis in order to interpret retrospective in-depth interviews of combat veterans (N = 12) who were released from mandatory military duty during the past 5 years and currently qualified for a diagnosis of CUD. Participants were recruited from a larger quantitative study were eligible for participation if they screened positive for a diagnosis of CUD according to the Cannabis Use Disorder Identification Test- Revised (CUDIT-R) questionnaire. CUD diagnosis was validated in-person using the cannabis section of the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5) interview protocol. All interviews were transcribed and coded using the content analysis procedure.Findings: Five main themes were extracted: (a) Traumatic events (b) Attitudes toward cannabis use (c) Combatant identity (d) The role of authority/father figures, and (e) Moral crisis. A meta-theme has been identified, “from enchantment to disillusion,” representing a gradual psychological shift from a hopeful, highly motivated stance into the current state of mental rupture and moral injury, which are unsuccessfully compensated by excessive use of cannabis.Conclusions: This study shed light on the etiology of CUD among young combat veterans, highlighting the role of supposed self-medication for trauma and sense of betrayal. Cannabis is the most commonly used drug, globally, with an estimated 192 million people, equivalent to 3.9% of the world population, who used cannabis during 2019 , with ~2Several factors have been associated with increased risk for transition to CUD. For example, higher frequency and quantity of cannabis use , co-occuIt has been suggested that combat veterans are specifically more prone to cannabis use and CUD compared to non-combat veterans . This ma‘To the best of our knowledge, little is known concerning combat veterans' narratives regarding cannabis use and CUD. In a recent study, Krediet et al.  intervieIn Israel, rates of cannabis use within the general population were traditionally lower compared to the U.S. and Europe . HoweverIn this study, we sought to explore narratives of Israeli combat veterans recently released from military duty, and who currently qualified for a CUD diagnosis. In particular, we aimed to explore the extent to which major life events prior to, during and following military service emerge as correlates of transition to CUD. An a-priori hypothesis  was thatvia social networks  and were included in the study if they served in a combat unit for at least 1 year (out of the three mandatory for men in Israel). Participants were excluded if they reported being prescribed medical marijuana during the past 6 months, due to the lack of validated measures assessing CUD in the medical context  during the past 6 months. Characteristics of study participants are presented in  context . Upon coThis instrument was used in the quantitative phase in order to screen for participants who qualified for a DSM-5 diagnosis of CUD, and were thus eligible for participation in the qualitative phase. The CUDIT-R is an eight-item self-report measure assessing problematic cannabis use during the past 6 months . Items were rated on a five-point Likert scale ranging between “0” (never) to “4.” The sum score was automatically computed and a cut-off point of 6 was used to initially screen for a DSM-5 diagnosis of CUD . The CUDA structured face-to-face diagnostic interview developed by the NIAAA and designed for lay interviewers. Among other issues, the AUDADIS-5 addresses DSM-5 substance use disorders. For the current study, the cannabis section of the AUDADIS-5 was used , which hInterviews followed a timeline procedure , focusinvia phone by one of the researchers or a research assistant. Time and place for the face-to-face interviews were set, and participants were requested to attend the interview while not under cannabis intoxication. Interviews were held primarily at the authors' offices, with duration ranging between 60 and 90 min. Prior to initiation of the interview, the AUDADIS-5 was administered in order to validate a probable diagnosis of DSM-5 CUD . Two participants did not meet CUD diagnostic criteria according to the AUDADIS-5, and were therefore not included in the data analysis. Upon completion of the interview, participants were given 150 NIS  and who gave their consent for participation in the quantitative study, were approached All eligible interviews were audio recorded and transcribed while omitting personal details which could allow identification. Transcribed interviews were analyzed using the content analysis procedure , initialData analysis has yielded the following themes, which will then be presented in detail below: (a) Traumatic events (b) Attitudes toward cannabis use (c) Combatant identity (d) The role of authority/father figures, and (e) Moral crisis . In lineA main, a-priori theme that emerged had to do with traumatic events and their effect on patterns of cannabis use. The majority of participants in our study were drafted into their service during Operation Protective Edge, which took place in Gaza strip in 2014, and was characterized by a relatively high number of IDF casualties. Its effects were repeatedly reflected in participants' narratives. For example, Tom recalled:Only a minute ago we hung out together, he was my friend… and then a moment later he's dead. And there was this guy who went to high school with me, and he's missing in action. And these three guys from my unit, great fellows, we used to spend a lot of time together, they're also killed. It's a deadly period, the worst that could possibly be, it's the first time that people I know go away and never return. It's a time when I understood that death is eternal.”“All participants related to cannabis as a means for coping with life's adversities and traumatic events from their military service. The word “disconnection” repeatedly appeared when addressing the effects of cannabis use, echoing cannabis' role as a dissociative defense mechanism which allows participants to maintain such disconnection from traumatic memories and avoid mental pain.Cannabis makes me calm. I love this sort of disconnection. It allows me to sit down at the end of the day and say: ‘I'm switched-off, I've forgotten everything that happened today.' If I don't smoke [cannabis] my thoughts run wild. When I smoke I just turn it off.” (Jonathan)…“Why do I smoke? Because I want to take some time off from my life. To get away and lay down on a cloud of laughter, forget all my worries and hardships” (Sharon)“Some of the participants specifically addressed cannabis use as a means for medicating trauma-related experiences. The most common was sleep disturbances, while others addressed the compensatory effect of cannabis:For a long time I could not sleep. It was hard for me and I tried all sorts of solutions. Cannabis made it better. It's not only more effective than other medications, but it also really works… I can finally sleep properly. For time to time there are tough nights, but it became a part of my life in a way that I don't think I'll ever want to quit” …“[Cannabis] allows me to cope with the losses I have suffered” (David)…“I told myself: I made it through this war [Operation Protective Edge], nothing happened to me. I didn't die, I'm not wounded, I deserve to do whatever I want” (Guy)“As the interviews progressed, participants expressed an ambivalent stance toward cannabis. On the one hand, they addressed the regulatory function as a means for comprehending traumatic memories without being emotionally shaken. On the other hand, participants mentioned tolerance, psychological dependence and loss of control as common phenomena associated with cannabis use, and at times even fear of its negative long-term effects. Participants also mentioned that in some cases cannabis may increase their experience of negative emotions, such as anxiety, post-traumatic stress symptoms and anhedonia. In addition, a feeling that was portrayed is one of false wellness which emerges after prolonged cannabis use.I'm starting to feel bad about the weed. When you're weak you start to see its downsides. If we would have talked six months ago, I would say it's the best.” (Michael)…“In a way I blame the cannabis. It gave me more anxiety, more worries, more demons, many things that I never had before. It brings me down a little. I know I blame it all on a plant, but I really think it has a big part in this”.“It makes you feel good in a false way, because at some point your body gets adjusted to the feeling. I feel I want to try and quit, I feel it turns my motivation down, the will, the passion. I don't like it when that happens. It turns my life off.” (Avishai)“Participants reflected on the high expectations that preceded their recruitment to combat units. Some emphasized the fulfillment of a national ethos, while for some becoming a combatant followed a family heritage and destination:At the beginning it was so exciting. My heritage. What my father kept talking about his entire life. His comrades and the strong bonds they have, this is something I wanted for myself.” (Jonathan)…“Everyone would praise us, telling us how important we are to the country, telling us we're heroes, and all sorts of other clichés” (Sharon).“However, the majority of participants experienced a deep sense of disappointment following their military service, accompanied by feelings of distrust. Some participants talked about the discrepancy between their anticipation for an exciting and meaningful service, amplified by a national glorification of the Israeli combatant myth, and facing the monotonous, sometimes boring, military routine. Even while taking part in combat missions, a gap emerged between high expectations for flawless warfare and the disorganized, at times chaotic conduct of their combat unit:it gets tough when you realize you're not going to fight on a daily basis. I wanted to do more, but this routine of walking around doing nothing kind of brought me down” (Jonathan)…“So many mistakes have been made when it came to people's lives. I have a friend who died from a mortar bomb while sitting in a rally point. He only had two seconds to seek cover in some concrete cylinder that no one can really squeeze himself into. This just isn't right” .“It appears as though a part of the anticipation toward military combat service had to do with the image of command. Several participants related to the commander as a parental figure whose responsibility over his subordinates was absolute. Notably, this followed participants' personal biography, as some grew up with a dominant father figure, while others reported being deprived of a close relationship with a father figure:He's [the commander] in charge of 20 soldiers. It's a matter of life and death, so he has to be their father. He's in charge of everything and if he's dysfunctional, he has to have a good reason for that” (Tom). “I wanted to be posted exactly where my father was, go to the same places as he did, as a paratrooper” (Jonathan).“These expectations toward their commander were often faced with a disillusioning reality in which commanders failed to be flawless, and at times were perceived as unfair, irresponsible and ego-driven:There are several troop leaders who have lost their humanity and trampled me along the way. Let's just say that during Operation Protective Edge, the most negative psychological experiences I had are related to the way I was treated by commanders, not to what I have seen in action”(Guy)… “The commander yelled ‘casualties!', so being a paramedic I took my stretcher and ran like crazy to see who's injured. I was certain there's someone dying out there, but it turned out to be a drill, a way to see how we respond. What a cruel trick to pull” (David).“During the interviews, participants often recalled morally injurious events from their military service. These events seem to create a prolonged tormenting conflict between participants' internalized moral values and the immoral deeds they were bound to perform as soldiers. In some cases, immoral conduct emerged from the paradoxical nature of the battlefield, while in other cases participants were ordered to perform immoral acts. At times, moral injury has occurred while in action, and in some cases it emerged later on after their release from duty. For many of the participants, these “faulty events” remain an unsettled business, accompanied with shame and guilt, which still echo in their daily life, self-perception and their desire to self-medicate:I felt like I lost my identity while on duty. I used to look at myself in mirrors of the houses we seized in Gaza, and I got sick of seeing my face camouflaged, hearing little girls cry. I was like a mission contractor during these years, and it left its mark, I've lost my innocence back there” (Tom)… “90% of the time using such brutality was uncalled for. Punching someone just to keep him silent. For six months I would go out at night, see some farmer and chase him down with two assault dogs, only because he was allegedly filming and spying on us. But I don't believe it. This is what they [commanders] would tell me to do and I had to do it, but it felt faulty to me most of the time” (Avishai)…”“In this study we explored narratives of Israeli veterans who were recently released from military duty and are currently qualified for a diagnosis of CUD. Major themes that emerged were related to trauma and moral crisis associated primarily with military-related events, as well as an ambivalent stance toward cannabis use, combatant identity and authority/father figures. A meta-theme that has emerged, encompassing these themes, is participants' gradual transition from enchantment to disillusion, resulting in a current cannabis-related pathology accompanied by an ambivalent representation of their military service.In our study, trauma has emerged as a primary theme, and one that is highly concurrent with cannabis use. Previous findings have indicated that post-traumatic stress response and PTSD are very common among combat veterans and are highly comorbid with cannabis use and CUD . High coDespite its beneficial short-term effects on negative emotions, coping-oriented motives for cannabis use may in fact be harmful in the long-run. For example, coping motives for cannabis use have been associated with an increased risk for CUD onset , 36. It In addition to the risk of developing CUD, participants emphasized the paradoxical nature of cannabis use in medicating post-traumatic stress symptoms. Despite accumulating evidence of the beneficial effect of cannabis use on sleep disturbances associated with PTSD , 44, canAdditional themes that emerged had to do with participants' disillusionment from a personal and national ethos related to the military, as well as a moral crisis associated with combat-related events. Several authors have emphasized the role of a sense of betrayal in the formation of moral injury among combatants and ex-combatants. In these cases, a deep sense of distrust may develop toward commanders and/or leaders, who are perceived as betraying 'what is right' in high stakes situations . A senseFrom a psychodynamic perspective, trauma may emerge from significant others' failure to provide a psychologically adequate environment for the development of a coherent and cohesive sense of self-esteem . SubstanThis study has several limitations that should be considered. First, the qualitative nature of the study doesn't allow for exploring statistical and causal association between variables, as well as for the generalization of the findings beyond the study participants . Second,Despite these limitations, the increase in the global prevalence of cannabis use and CUD, both within the general population and among veterans, as well as the emerging changes in cannabis' legal status, call for integrative research into the psychosocial predictors of CUD. Further exploration of veterans' narratives regarding cannabis use and CUD is needed in order to trace the etiology of CUD within this population. Themes that emerged from our study can be used for further quantitative investigation of underlying risk factors for CUD. The role of personal and national disillusionment, moral injury and the role of authority in predicting CUD among combat veterans should be explored in future large-scale longitudinal studies, thus allowing for better prevention, assessment, and treatment for those who develop pathological patterns of cannabis use.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Dr. Ephraim Grossman, Department of Education, Ariel University, Ariel, Israel. The patients/participants provided their written informed consent to participate in this study.MS and DF: acquisition of data, analysis and interpretation of data, drafting the article, and final approval of the version to be submitted. SS-G: conception and design, analysis and interpretation of data, revising the manuscript critically for important intellectual content, and final approval of the version to be submitted. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.