Meta-dehumanisation and self-dehumanisation have been identified as potentially relevant phenomena for developing a deeper understanding of distress related to voice-hearing, particularly those experiencing voices as part of psychosis. Chadwick has previously argued that those with psychosis, including those who hear distressing voices, typically feel “dehumanised and set apart by their experiences of psychosis and trauma.” The present study explores the subjective experience of self-dehumanisation in people who experience distressing voices, which was selected as a useful starting point to inform future research focused on understanding dehumanisation in people with psychosis.Qualitative data was obtained through twenty semi-structured interviews with self-identifying voice hearers and analysed using reflexive thematic analysis. This followed the recursive six phase procedure of Braun and Clarke, and this was conducted from a critical realist, contextualist position.Reflexive thematic analysis of participant’s experiences produced a core theme, Dehumanisation as the End of Experiential Continua, and six subthemes: Extent of Distressing Sensory Fragmentation; Sense of Belonging with Other Humans; Integrity of Self as a Private, Coherent Entity; Sense of Worth as a Human Being; Strength of Personal Agency; and Trust in Own Credibility and Reliability. Two further themes, The Push and Pull of Dehumanising Forces and Reclaiming Life through Humanising Forces, were identified. Findings were presented to a panel of five experts by experience, all with lived experience of psychosis and service-use; all five strongly endorsed the themes as fitting with and expressing their own experiences of self-dehumanisation.Reflexive thematic analysis of voice hearers’ accounts identified self-dehumanisation as the endpoint where six experiential continua coalesce. Experiential movement along these continua was affected by a range of interpersonal, intrapersonal, and societal forces over time, including dehumanising attitudes of others and voice malevolence and omnipotence. Future research might examine if and how psychological therapies aimed at those experiencing distressing voices, such as people experiencing psychosis may address feelings of self-dehumanisation. Of all people diagnosed with schizophrenia-spectrum disorders, 60–80% experience auditory hallucinations . In WestThus, specifically exploring the experience of dehumanisation in people who hear distressing voices may be a useful springboard for future research exploring the experience of dehumanisation in people with psychosis and schizophrenia-spectrum disorders, as it is possible that the relationship such individuals have with their voices is dehumanising , in addiThe present study was aimed at understanding what constitutes the experience of feeling dehumanised in people who hear distressing voices and what factors influence the development and mitigation of this experience, with a view to opening the pathway to future research which may explore the role of dehumanisation in people who hear voices within the context of psychosis. It aimed to provide a foundation of understanding the phenomenon of dehumanisation in a broad sample of participants experiencing distressing voices.How do voice-hearers describe the subjective experience of feeling dehumanised and, conversely, the experience of feeling humanised?This research uses reflexive thematic analysis of qualitative data gathered through individual semi-structured interviews. The interview schedule was developed and revised through discussion between the authors. It was piloted with and reviewed by a person with lived experience of voice-hearing as part of psychosis. The semi-structured interview questions were modified in accordance with the feedback given by the person with lived experience.The research has been quality assessed against Braun and Clarke’s tool for evaluating reflexive thematic analysis . The ontParticipants were recruited using convenience sampling from Hearing Voices Network groups, the research advertising platform MQ Participate, and Twitter. Convenience sampling outside of NHS settings and minimally restrictive inclusion criteria were used to recruit a heterogeneous sample.The inclusion criterion for this study was: currently self-identifying as experiencing at least one distressing voice. The exclusion criteria for this study were: being below the age of 18 at the time of recruitment and being unable to speak English. The criterion related to language was in place due to a shared understanding of language and meaning being important for reflexive thematic analysis. No criterion was in place regarding diagnosis and data were not gathered regarding whether any diagnosis had been received. The target analysis sample was 15–20 participants. A larger sample size was selected as the information power of the sample was expected to be lower due to low sample specificity, a cross-case analysis method, and broad research questions , while tAll participants were given an electronic copy of the information sheet and had the opportunity to ask questions prior to participating. Informed written consent was obtained for all participants via an online system, Qualtrics.Interviews were conducted remotely and audio-recorded, eighteen via video call and two via telephone, based on participants’ preference. Interviews were conducted and transcribed by the primary researcher (BO’B-V). The wording of the interview schedule, information sheet, and consent form were reviewed with a Person with Personal Experience of voice-hearing as part of psychosis to improve accessibility and sensitivity and minimise any potential distress due to the emotive and sensitive nature of the research topic. Data collection took place May–September 2021.This study was given ethical approval by the University of Bath Psychology Research Ethics Committee . The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and the British Psychological Society (BPS). All participants were provided with the information sheet, given an opportunity to ask questions, gave written consent, and consented verbally at the start of their interview.Braun and Clarke’s  six-stepThe analysis was conducted using NVivo Version 12 (2020). The themes developed were analytical rather than descriptive and each theme and subtheme was comprised of both inductive and deductive codes.The primary researcher familiarised with the transcripts through multiple readings, annotating, and two iterations of coding. Initial themes and subthemes were developed and mapped through discussions between BO’B-V and PC about the clustering of codes.Following this, BO’B-V reviewed the clustering of codes under themes for a second time, merged two subthemes, and revised the theme names. BO’B-V moved recursively backwards and forwards between the interviews, extracts, codes, subthemes, and themes to check the evidence for the themes and subthemes, their boundaries and coherence.Theme definitions were written for each theme and subtheme to outline their central organising concept and boundaries. Finally, theme names were refined, extracts were selected and woven into the narrative of the results.BO’B-V had some experience of working with voice-hearers clinically in inpatient and community settings and had previously completed historical research into the recovery movement for those with psychosis. TJ had some experience working with voice-hearers in an inpatient setting and conducts research on the experience of dehumanisation in psychosis. PC had extensive experience of working with psychotic voice-hearers clinically and through research. All researchers felt curiosity and concern about the subjective experience of dehumanisation in voice-hearers.Final theme checking was completed by BO’B-V to verify the validity of themes against the content of interviews. Throughout the analysis, BO’B-V kept a reflexive log which recorded positions, assumptions, and influences throughout the research process.BO’B-V sought to enhance analytic generalisability by developing a theoretically oriented analysis , identifTo check the analysis and assess external validation within a clinical psychosis population, themes and subthemes from the present study were presented to an Expert by Experience panel of five people with lived experience of distressing psychosis who had previously accessed mental health services. The group was asked to provide their perspective on whether the themes fully captured and described their experiences of dehumanisation.both voice Malevolence and Omnipotence plus 16 or more on Resistance . Eight participants identified as Black British, four as White British, two as Mixed (White and Black) British, one as Mixed (Black British and Chinese), two as Asian Indian, two as Asian Other, and one as White Other, European. Eleven participants were 18–24, four were 25–29, one was 30–34, one was 40–44, one was 50–55, one was 60–65, and one was 70+. Nineteen participants disclosed how long they had heard voices for and completed the BAVQr. Participants reported having heard voices on average for 11 years, with a range of 1–70 years. At the time of study participation, median BAVQr scores were Malevolence (8), Benevolence (7), Omnipotence (9), Resistance (18), and Engagement (7). 47% of participants scored 10 or more on either Omnipotence or Malevolence, and 37% of participants scored 10 or more on s, e.g., ).The average length of an interview was 37 min (range 17–82 min). One participant was recruited via the Hearing Voices Network, four participants were recruited via Twitter, and fifteen via MQ Participate. A further fourteen potential participants expressed interest but did not respond to invitation to schedule an interview.Six different kinds of experiential changes were identified as constituting feeling dehumanised for voice-hearers. These changes represented the loss of some essentially human quality or capability. Feeling humanised involved these changes reversing. A range of societal, interpersonal, and intrapersonal forces were shared by participants as either moving them towards feeling dehumanised or moving them away from this. See Voice-hearers’ descriptions of feeling dehumanised indicated six key psychological processes (sub-themes): that is, distressing sensory fragmentation, lower self-worth, lower sense of belonging with others, less sense of themselves as private and coherent, weaker personal agency, and loss of trust in themselves and their credibility. There was substantial intra-and inter-personal variation within each, and hence these six subthemes were conceptualised as being like continua.A central unifying core theme emerged, that of Dehumanisation as the End of Experiential Continua. Thus, whilst for different participants, different combinations of the six sub-themes were more important than others, in moments of self-dehumanisation, participants experienced a facet of each continuum, like rivulets coalescing into one stream. And there was a strong and consistent sense that dehumanisation was the end of each continuum, the end of the line so to speak.Two further themes were developed which related to humanising and dehumanising forces – that is, forces which moved people along continua either towards or away from feeling dehumanised.Participants expressed that voice-hearing often felt inexplicable and terrifying at first and that this contributed to feeling, at worst, not human for having “lost it” (P12). The experience of voice hearing was often perceived as alien initially, and for some continued to feel alien to the self and difficult to reconcile, as P1 said, “these are alien voices that I’m hearing, they are not my own voice […] they do seem to know what’s going on in my mind, but they are still alien to me.”Some participants reported extreme distress with strong sensory qualities, with one participant describing voice-hearing as like a “traumatising attack” (P17), and another describing the intensity as “like pouring out of my skin […] it’s like burning alive” (P8). Others reported that, during their recovery, they managed to start experiencing their voices as a harmless event in the mind rather than as having “some sort of god-like quality to them so they sort of felt kind of all powerful and difficult to resist,” which related to starting to feel human again:I can now say to the men, you know, I don’t believe you or, you know, if they’re making a threat, I can say, “ah, that’s just an empty threat, you can’t follow through on that (P4)Voice-hearers reported feeling alone with the experience of voices, alongside feeling rejected from valued social groups or from society. The feeling of not being acceptable to other people contributed to a sense of defeat and thoughts about removing the self from humanity, or already being in some way removed:When you try to fit into the society and to your friends and you try your level best to be the one person they used to know before the voices came […] and it doesn’t matter the efforts you make the people they’re just like “no, no, no, we cannot accept you here” […] it makes you feel like you’re not a person anymore, like you belong to the wild and they belong to the earth, and you are in the wild, you are just one, you are just you, you’re not a person, you’re no one else (P12)One participant (P20) reflected that he perceived himself as belonging towards the bottom of the hierarchy of beings and felt he could never move up this hierarchy regardless of what he did: “I’ve just come to the understanding that I’m just less of a person because of it, I’m the subset of the subset of people.” He noted the importance of his intersection here of hearing voices and being from a minority ethnic group, which he felt compounded his position.Others believed that their struggle to match the behaviour and achievements of others deprived them of belonging with other humans:[I] view myself like less of a person because I can’t make decisions like a normal person, I can’t carry on with my life, I can’t do the same as other people, I feel like undignified, I feel like I’m not fit to be alive (P19)Voice-hearing impacted on participants sense of the integrity of their self and identity, with this initially feeling destroyed or diminished for some. Those with more malevolent or incongruent voices experienced them as more destructive towards their sense of self. This loss of a sense of a coherent, integrated self contributed to feelings of being less of a person or not quite human, as P4 reported, “the thing I always emphasise about these kinds of experiences is how initially they completely destroy your sense of self,” and as described by P14, “I cannot do what I feel like, like dancing, it has eliminated me from dancing which was my which was my hobby and my passion […] it has really diminished my personality […] really affected my character and my reputation.”Some described feeling that their mind was no longer a private place and felt a strong sense that their voices could abuse access to their mind, or impact on activities which were integral to their sense of self, as indicated by P19, “they just heard my decisions, what I want to do, and they do contrary.”Many participants described feeling a loss of self-worth due to their experience of voice-hearing and associated impacts, as P15 expressed, “most of the time the voices dehumanise me I feel like I’m not enough.” P20 highlighted a similar feeling:I’m not gonna leave the scrap heap because I know I can’t really, if I think about it my reality is the scrap heap, but I will be at the top of the scrap heap rather than towards the bottom […] for me it was very much I’m already not human, as it is, I’m just this thing (P20)Some reported feeling exhausted and defeated by the constant fight to prove their own worth, with the eldest person in the study (P1) reporting that this fight had continued for decades by saying, “I always have to challenge myself to believe that I am really a worthwhile person. […] I have to sort of deploy arguments like that to prove that I’m not a worthless person, as the voices keep insisting.”Others noted feeling inadequate as a human being compared to other people and feeling less capable than others, and some perceived their voices and other people as in agreement about the kind of criticism they deserved:The men would be swearing at me telling me that I was rubbish in various flowery language sometimes commanding me to kill myself so […] yeah almost kind of taking on board and believing what they were saying about me you know internalising all of that (P4)Voice-hearers shared feeling a loss of control or influence over their lives and an impact of hearing voices on how strong they perceived their personal agency to be:I didn’t want to do this, they took a part of me […] why do you have to act like that lunatic if you say you are not? When you’re trying to defend yourself, you yourself just say yourself like “okay I think I’m a lunatic now, because I haven’t controlled it” (P10)Experiencing voices taking over their actions and choices or reducing their ability to perform valued behaviours and activities contributed to this reduced sense of agency. P1 reported needing to exert high levels of focus to stop himself performing behaviours his voices wanted him to do, for example, “I concentrate hard as I’m able to do and force myself not to do it […] I lose a bit on the swimming front, because I never swim out of my depth.”Experiencing fighting the voices as ineffective further weakened people’s sense of their own agency. Many noted impacts on their functioning in valued areas of their lives and some felt unable to meet their own expectations as well as those of the voices, as P9 said, “You have tried everything every possibility not that you cannot, you cannot achieve it you feel like demoralised you feel low […] you feel less of a human.”Voice-hearers cited losing trust in their own credibility, believability, and decision-making capabilities, through the influence of voices, the control voices have over their actions, and through the “psychosis ring” (P20) other people place around what they say and do. This contributed to a feeling of not being human, for instance, for P8, “the guilt, the frustration, the assessing my life, and they just um I just perceive myself as the worst, worst creature in the planet really.”One participant described failing to catch a rat leading to this kind of doubt in their mind:Because there wasn’t anything […] nothing came in the front room, it’s like my brother says to me, “Well, you know, it’s because of your illness” and I’m kind of going, “Is it or is it not?” And it’s like I’m trying to figure it out […] now what I say has a psychosis ring around it (P20)Facets of this include not feeling free to allow their minds to be unoccupied , losing a sense of being able to rely on themselves acting authentically , and experiencing voices as out of control (P17): “at first, I did not really appreciate myself, I felt maybe like I’d lost it, um, I am losing my mind […] then I did not feel like a human being.”Participants reported a wide range of forces moving them up and down these experiential continua. Particularly, dehumanising attitudes held by other people, which incorporated both animalistic and mechanistic dehumanisation, as well as being seen by people as uncanny, bizarre, or dangerous, had a powerful effect on how dehumanised voice-hearers felt in their interactions with other people, as illustrated by P4 when he said, “in the early phases I felt people were treating me as less than human […] somebody who was slightly irrational, a bit bizarre.” These attitudes connected to ostracism and stigma. For example, with regards to interactions with friends, P14 expressed, “they make me feel like I’m odd one out and I’m not a human […] in short, they dehumanise me,” and P15 highlighted, “I told my friend about my experience with the voices I hear and all she could tell me was that I was going crazy no such things existed and you see how a close friend can share something so delicate with and she turns out to tell you that it’s not possible […] so I tend to feel bad.”There appeared to be a process whereby meta-dehumanisation became self-dehumanisation. Meta-dehumanisation was by voices, by other people, or both, as described by P15, “one criticises me, some encourage me […] but mostly they dehumanise me, they discourage me badly,” and P18, “I think the voices they are the same as the people, you know, and the society, I hate it.”Many reported that verbal abuse, relentless pressure, and the omnipotence and malevolence of voices contributed to their feeling of being dehumanised:Three evil men basically erm they kind of so they torment me sort of deride me […] the persecutory type of experiences and I think initially they almost had a sort of a god-like quality to them […] kind of all powerful and difficult to resist (P4)Some reported experiencing a felt sense that voices deliberately and maliciously sought to compound trauma in their life, adding an additional layer to abuse, as indicated by P1, “the bad voices sort of capitalised on that and made my life even more of a misery.”Participants also experienced several situations in which they observed society largely perceiving them as unwelcome or beyond hope, as well as situations where purported protectors perpetuated prejudice:You tell people in the outside world that you’ve got mental health issues, that’s one thing. That’s one level of stigma. If you further admit that, by the way, I hear voices as well, then you get a lot of opprobrium directed at you […] people say that you must be a bad person, you’re dangerous […] we can’t trust what you say (P1)Voice-hearers reported a range of forces which helped them to feel human again or retain their belief in their humanness in the first instance. These included consistent acceptance by others, which helped with feeling a sense of belonging and safety with other people, as P17 experienced with his family, “they understand how it is for me and they are always there and accepting my problem and maybe they give me so much love and understanding.”Reclaiming personal agency and control over life through effective coping, engagement with meaningful activities, helping others earlier in their recovery from distressing voices, helped with progressively feeling human again for participants such as P1, “I’m living with myself as I am, and learning to cope with the voices, and perhaps more importantly teaching other people how to cope with the voices.”Those who felt human had managed to develop a tolerance towards social rejection, a sense of being on their own side, or a perception of the voice-hearing experience as special and uniquely human, which was how P5 conceptualised it, “the fact that I can hear voices and my friends and maybe close relatives cannot hear […] I think it’s unique, but I have not had anything extraordinary that has made me feel inhuman, I just feel normal.”Changes in voices or the perception of voices, such that they had diminished authority or were perceived as an event in the mind, was helpful in strengthening a sense of agency and regaining trust in self, as well as integrating the sensory experience of voices and gaining distance from the experience, as indicated by P10, “that was the big thing, like after I accept this thing, like you are able to control this, like you make yourself the controller” and by P4:Re-assert some authority myself over them […] that kind of power dynamic is the key thing that’s evolved over time but initially I was absolutely terrified by these experiences […] I felt very unsafe both from myself and from my family (P4)Recognition that abusive voices were immoral in their behaviour and recognition that voices might be trauma manifesting itself were powerful ways in which people began to make sense of the voice-hearing experience and respond to it in a more self-compassionate way. Similarly, engagement in safe group contexts helped with increasing belonging, as was the case for P4, “the more then that I was able to leave the house to feel safe again […] that sort of reintroduction to society meant that I was more kind of socially acceptable.”Voices which were perceived as empowering, guiding, benevolent, were also identified as humanising forces, as P6 noted, “it was lack of trust, lack of support, people not being there, people who are pushy […] I think I had this kind of support from the voice.”Those who held onto a sense of their humanness had stuck close to others who accepted and supported them with the challenges of hearing voices, as P10 emphasised, “they have been with me throughout uh it’s without them I do not know if I would be where I am like they were I say number one who came let me say to my rescue.”Immersion in benign nature was helpful in enabling participants to feel human again and reducing the level of threat they experienced, as shared by P8, “being in safe place and nature […] time to be as safe as I could be […] that’s how I’m dealing with it.”Belief and trust in a part of the self that was vital, permanently present in the background, and able to provide hope in coping with voices, was also important for participants in feeling human again, as shown by a metaphor P1 was taught by a psychologist, “I decided I would believe there is a little spark, a little light that never goes out, metaphorically speaking, inside you,” and by P12:Not giving up on myself, even if others they gave up on me, and trying my level best to, even if they’re challenging, I kind of come up with a new challenge that it’s hard for them to overpower me on that, I think I have an upper hand now and I have an advantage over them (P12)Themes and sub-themes were presented to a panel of Experts by Experience, who all had experience of distressing psychosis and linked experience of using mental health services. The group agreed with all the themes as presented, and shared personal experiences of dehumanisation pertaining to each. Subthemes of “Strength of Personal Agency” and “Sense of Belonging with Other Humans” resonated particularly strongly, as did experiences of meta-dehumanisation perpetrated by healthcare workers and members of society. The group emphasised the humanising capacity of peer support, connection with other people who understood their experience, and acceptance. It was felt that no new themes or subthemes should be added.The present study is the first to develop a conceptual framework grounded in subjective experience of self-dehumanisation in people hearing distressing voices. Central to this framework are six essentially human experiential continua which coalesce at the point of self-dehumanisation – that is, sensory fragmentation, belonging with other humans, self as a private and coherent entity, worth as a human being, personal agency, and trust in one’s own credibility and reliability. The six continua align with and extend the literature on voice-hearing drawn from those with and without psychosis diagnoses.Losing trust in one’s own sensory and perceptual experience and credibility was identified as one such experiential continua. This echoes research showing how voice-hearers are often perceived as “unreliable narrators” and start to doubt their own credibility . LikewisSome participants described feeling propelled towards the end of the continuum by voices, and difficult interactions and experiences, whereas for others it felt like a gradual erosion of one or more of the six essentially human experiential dimensions. Voice omnipotence, malevolence, and omniscience  were fouFirst proposed by Strauss , the conThe sample in the present study is not psychosis specific. Rather, the intention was to recruit a diverse sample of voice hearers from across the voice-hearing continuum, and it is therefore important not to assume that the presence of voices automatically implies the presence of psychosis. Moreover, it is important for voice hearers themselves that the experience is not automatically pathologized as a symptom of, or sign of vulnerability to, psychosis or schizophrenia. However, there is evidence that the findings in the present study on self-dehumanisation have relevance to the experience of voice-hearing across the continuum, including those hearing voices with psychosis. All participants described voice-related distress, in line with the inclusion criterion: and voice-omnipotence, malevolence and resistance were strongly reported by many participants, in many instances at high levels. Although at no point in the study was service-use asked about, we know at least four of the sample had used mental health services linked to voices . It is impossible to know how many others had also done so. All five experts by experience on the service user consultation panel had experienced service-use for psychosis, and all five endorsed the core theme and sub-themes, adding illustrative examples from their own lives. Nonetheless, further research with psychosis-specific samples is needed to establish the degree to which experiences of self-dehumanisation characterize the extreme end of the psychosis continuum.A strength of this study was that participants exhibited a wide range of ages and ethnicities and an almost even balance of binary genders. This may enhance the transferability of the findings to other contexts. In keeping with a critical, realist contextual stance, the present research accepts as real the voice hearers’ lived experience. However, the sample was obtained by convenience and limited to those self-identifying as hearing distressing voices. It is important to emphasise once again that no diagnostic assessment was undertaken, the sample was not psychosis-specific, nor was the range of symptoms of psychosis assessed. Participants described a range of current levels of distress and disturbance, with some seeming to be further along in their recovery journey. Crucially, all 20 participants could relate to and describe experiences of self-dehumanisation. Future studies would benefit from sampling participants with a diagnosis of psychosis and a range of positive and negative symptoms to assess generalisability of the current findings. A final strength of the present research was the external validation of results. Checking the findings with an independent panel of experts by experience demonstrates that the findings have relevance beyond the initial study population and reinforces the argument for the relevance of the findings to people with psychosis.Dehumanisation is emerging as an important new trans-diagnostic concept in understanding mental health problems. Future research and practice can explore the relevance of the phenomenology of self-dehumanisation in voice-hearers to other clinical groups. In relation to psychosis, research can examine how self-dehumanisation relates to social isolation, depression, and suicidality, as well as other symptoms within psychotic experience. The six essentially human continua might also inform development of much-needed measures of self-dehumanisation to support research and practice in mental health.The concept of self-dehumanisation also adds a potentially important nuance to our wider understanding of self-compassion , an impoSelf-dehumanisation may have important implications for the ongoing evolution of psychological therapies for distressing voices in psychosis. One of the defining attributes of clinical cognitive and mindfulness-based approaches to psychosis has been an ever-greater emphasis on the concept of the self. It has long been recognised that psychotic symptoms such as voices and paranoia are linked to low self-esteem e.g., , 44) and and44)) Specifically, mindfulness for psychosis has been described as a humanising therapeutic process  and the Finally, in relation to group therapies for psychosis, it has been argued that non-specific therapeutic group factors play an important role . In the There can surely be no more profound a psychological threat than to lose a sense of being a person, of being human. For the voice hearers in the present study, experiences of self-dehumanisation were identified as the end of the line, an experience where six essentially human continua coalesce. The phenomenology of self-dehumanisation in voice hearers may add to our understanding of what lies at the far, clinical end of the continuum of psychotic phenomena, and provide a platform for further evolution of psychological therapies for psychosis.The original contributions presented in the study are included in the article/This study involving humans was approved by University of Bath Psychology Research Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. The ethics committee requirement for written informed consent from participants was met.BO’B-V and PC conceptualized, designed, and wrote up the study. BO’B-V completed the interviews, transcription and led on analysis. TJ completed the review of themes with an Expert by Experience panel. All authors contributed to the article and approved the submitted version.


This cross-sectional study aimed to investigate the association between psychosocial school factors and life satisfaction, symptoms of depression and psychosomatic health complaints among first grade secondary school students in Serbia. We analysed data from the 2018 Health Behaviour in School-aged Children (HBSC) study in the Republic of Serbia. Analyzed psychosocial school factors included satisfaction with school, schoolwork pressure, teacher support, classmate support and being bullied at school. Life satisfaction was assessed by the 11-step Cantril’s ladder (cutoff >5). Symptoms of depression were measured by the Center for Epidemiologic Studies Depression Scale (CESD-10) and psychosomatic health complaints by using the HBSC symptom checklist. Univariable and multivariable binary logistic regression was used to determine independent predictors of students’ life satisfaction, symptoms of depression and psychosomatic health complaints in the school environment, while also considering their socio-demographic characteristics and perceived family and friend support. The study included 1605 students (average age 15.26 ±0.44 years), of whom 50.3% were females. Results from the binary logistic regression analyses showed that life satisfaction was positively related to school satisfaction and classmate support, and negatively to being bullied at school. Symptoms of depression were positively associated with schoolwork pressure and being bullied at school, and negatively with teacher and classmate support. All analyzed factors of the school environment were significantly related to psychosomatic health complaints, whereby schoolwork pressure and being bullied at school were positively associated, while teacher and classmate support and satisfaction with school were negatively associated. Given the established association of psychosocial school factors with mental health, there is a need for targeted measures both at school and community level with the aim of improving social support in the school environment, reducing schoolwork burden and preventing bullying at school, potentially resulting in the overall improvement of mental health of the first grade secondary school students. Schools represent an environment in which students spend a significant part of their time during childhood and adolescence. A supportive school environment can contribute to the development of healthy lifestyles and good mental health of students .The definition of mental health has changed over time from negative aspects, through positive, to an integrative concept, where it is described as a continuum that moves from mental problems to well-being, or is viewed from multiple dimensions . Namely,Life satisfaction represents an important aspect of subjective well-being, one of the most important components in modern models of mental health . It is dDepression is one of the most common mental health disorders in adolescence with an estimated prevalence of 4–5% in middle and late adolescence . In the Estimated prevalence of psychosomatic health complaints in children and adolescents ranges between 10% and 25% . ClinicaResults from former research studies vary regarding the importance and influence of different factors in the school environment on mental health. For instance, some studies report that classmate support is significantly associated with psychosomatic health complaints , 21, whiIn the national context, there is a lack of epidemiological data on adolescents’ mental health and wellbeing and currently there are no national prevalence estimates of adolescents’ mental health problems. Furthermore, studies regarding mental health on a representative sample of this population are missing. A recent study indicates that less than 31% of Serbian youth aged 15–29 has within-the-normal-range stress level, 69% has anxiety and 52% has symptoms of moderate or severe depression . MoreoveThis cross-sectional study presents a secondary analysis of data obtained from the Health Behavior in School-aged Children (HBSC) Study in Serbia in 2018. The national survey was carried out using the International protocol of the HBSC study, in line with the WHO methodology described in more detail elsewhere , 29. AccAfter sampling, selected schools were contacted first by mail informing them about the survey and asking their consent to participate in the survey. Replacements schools were included in case that school refused to participate, however replacement schools were selected so that they would resemble schools in original sample . In recruitment stage, after initial mail, schools were contacted by phone. Recruitment was done during March 2018. Data collection was done between April 16th and June 7th 2018 in selected schools during one school class.The Ethical review board of the Institute of Public Health of Serbia consented to the implementation of the HBSC study in Serbia. A self-administered questionnaire was used with the parents’ (guardians’) consent that was collected by school Students completed questionnaire during one school class. Participation in the study was voluntary for the students, meaning that even though parents consented for their child to participate in the study, the adolescents could refuse to participate at the day of the survey. All students were free to end their participation in the survey at any time.Participation in survey was anonymous and no personal information was collected. The completed questionnaires were put in closed envelopes. Authors had no access to information that could identify individual participants during or after data collection. The Ethical review board of the Institute of Public Health of Serbia also consented to perform this particular study .In the HBSC study in Serbia in 2018, students enrolled in the fifth and seventh grade of the primary school and students in the first grade of secondary schools (according to school system in the Republic of Serbia) in selected schools and selected classes were provided information about the survey including anonymity and voluntary participation. Students with parental (or guardian) consent of selected classes who accepted to participate in the survey were eligible survey participants. There were 192 initially selected and 101 participating schools. Out of 384 classes, 200 participated. Out of 7680 students, 4028 participated. Refusals were either due to not having parental (or guardian) consent or due to absence because of illness on the day of survey.In this study, we performed a secondary data analysis of the HBSC study in Serbia and target population in this particular study included only first grade secondary school students, since we were especially interested in the importance of psychosocial factors after the transition from primary to secondary school. Being a student of the first grade in secondary school was the only inclusion criterion and there were no exclusion criteria.Survey instrument was standardized, self-administered questionnaire that included mandatory and optional questions. Students filled in the questionnaire during one school class. The questionnaire was anonymous.The questions used for this analysis included demographic and socio-economic characteristics of the respondents, self-assessed health status, questions related to school, family, friends and peer violence/abuse.School type was differentiated based on whether the student attended grammar school or secondary vocational school.Four statistical regions were identified: Belgrade, Vojvodina, Šumadija and Western Serbia, Southern and Eastern Serbia.Socio-economic status was determined based on the Family Affluence Scale (FAS III), a composite indicator which is used to measure objective socio-economic status within the HBSC study . It is dSchool satisfaction was estimated based on the question: “How do you like school at present” with answer options ranging from 1 –“I like it a lot” (highest level of school satisfaction) to 4 - “I don’t like it at all” (lowest level of school satisfaction). This variable was dichotomized so that the answers “I like it very much” and “I like it a bit” denote school satisfaction and the answers “I don’t like it very much” and “I don’t like it at all” denote school dissatisfaction.Schoolwork pressure was determined by the question “How pressured do you feel by the schoolwork you have to do?” Answer options range from 1 –Not at all (lowest level of schoolwork pressure) to 4-A lot (highest level of schoolwork pressure). Answers were grouped so that a student was considered to be pressured by schoolwork if the answer was “Yes, a lot” and “Yes, very much”, as opposed to “Yes, a little” and “Not at all”.Classmate support was determined based on answers from a 5-point Likert scale of agreement (from “strongly disagree” to “strongly agree”) with the following statements: “Students in my class like to be together”, “Most students in my class are friendly and want to help”, “Other students accept me as I am”. A sum-score was generated from the responses to the above three items ranging from 3 to 15. The final score was classified as high or low classmate support based on a cut-off value of ≥2.5 .Teacher support was determined based on answers from a 5-point Likert scale of agreement (from “strongly disagree” to “strongly agree”) with the following statements: “I feel that the teachers accept me as I am”, “I feel that the teachers (professors) take care of me as a person”, “I have great confidence in my teachers”. The same scoring system was applied as for classmate support .Being bullied at school (bullying victimization) was estimated by the question “How often have you been bullied at school in the past couple of months” with the possible answers “I have not been bullied at school in the past couple of months”, “It has happened once or twice”, “2 or 3 times a month”, “About once a week” and “Several times a week”. Responses were grouped and dichotomized as “not bullied” (if answered I have not been bullied) and “bullied” .Life satisfaction was determined based on Cantrill’s scale: “Here is a picture of a ladder. The top of the ladder “10” is the best possible life for you and the bottom “0” is the worst possible life for you. In general, where on the ladder do you feel you stand at the moment?”, where respondents indicated their life satisfaction on a scale from zero to 19. Cut-off value of ≥6 was used for categorization of respondents with high and low life satisfaction .Center for Epidemiologic Studies Depression Scale (CESD-10) [The presence of depressive symptoms was evaluated by using Short depression scale of the CESD-10) , which cPsychosomatic health complaints were determined using the HBSC symptom checklist, which includes the frequency of the following complaints in the last six months: headache, stomachache, backache, feeling low, irritability or bad temper, feeling nervous, difficulties in getting to sleep, feeling dizzy. Possible answers were: “About every day”, “More than once a week”, “About every week”, “About every month”, “Rarely or never”. Students who had two or more symptoms (complaints) at the same time at least once a week were classified as having psychosomatic health complaints .Perceived family and friend support was evaluated based on two subscales constructed of the Multidimensional Scale of Perceived Social Support (MSPSS). Items on family support measure the perceived availability of emotional support and help within the family and respondents stated agreement with the statements on a 7-point Likert scale, ranging from “very strongly disagree” to “very strongly agree”. The statements were as follows: “My family really tries to help me”, “I get the emotional help and support I need from my family”, “I can talk about my problems with my family”, “My family is willing to help me make decisions”. First the sum of responses was calculated, then its mean value. A cut-off score value of ≥5.5 points , 34 was Perceived friend support was assessed the same as perceived family support by using a 7- point Likert response scale. The statements were: “My friends really try to help me”, “I can count on my friends when things go wrong”, “I have friends with whom I can share my joys and sorrows”, “I can talk about my problems with my friends”. A cut-off score of 5.5 points  was consMissing data for one or more statements for assessing classmate and teacher support, and friend and family support was considered as a missing value. Furthermore, missing data for one or more of the eight listed health complaints was considered as a missing value. Regarding the symptoms of depression, observations with two or more missing responses were not included in the analysis, while in the case of one missing response, that response was replaced by the mean value .Categorical variables were presented as numbers and percentages, while continuous variables were presented as means and standard deviations. Chi square test and the two tailed t test were used to test the difference in life satisfaction, the frequency of psychosomatic health complaints and depressive symptoms in relation to the observed factors of the school environment, demographic and socio-economic factors. Also, the chi-square test was used to test the difference in psychosocial factors in relation to the type of school. In addition, univariable and multivariable binary logistic regression was used to determine the association of psychosocial factors of the school environment with life satisfaction, depressive symptoms, and psychosomatic complaints. The outcome variables were: life satisfaction (high/low), psychosomatic health complaints (yes/no) and depressive symptoms (yes/no). Apart from psychosocial school factors, we also included demographic and socio-economic characteristics of the study participants, as well as perceived family and friend support into regression analyses due to their previously reported significance in the literature. Variance inflation factor—VIF value of 5 was used as a criterion for examining collinearity of independent variables. Independent variables that were significant at the p value of <0.1 in the univariable analysis were included in the models using the enter and backward methods. A p value of <0.05 was used as the minimum level of significance throughout the analysis. Statistical analysis was performed using the IBM SPSS Statistics, Version 20.0 .In this study, 1605 students were included (average age 15.26 ±0.44 years), of whom 50.3% were females .Approximately the same number of students expressed high satisfaction with school and high schoolwork pressure  . Less thThere was a statistically significant difference in satisfaction with school, schoolwork pressure, teacher support and friend support among students who attended grammar school and secondary vocational school . Namely,The level of life satisfaction was significantly higher among male students and in students with higher socio-economic status . Also, tOn the other hand, symptoms of depression were significantly more common in girls, and there was also a statistically significant difference in the presence of symptoms of depression in relation to the region, all analyzed psychosocial factors of the school environment, support from family and friends .When it comes to the presence of psychosomatic health complaints, there was a statistically significant difference in relation to sex, region, type of school and all analyzed psychosocial factors of the school environment, as well as family support. Namely, girls and students from Belgrade schools and grammar schools reported psychosomatic health complaints significantly more often. They were also more common in students with low school satisfaction, high schoolwork pressure, low support from teachers and classmates, students who were bullied, and those who had low family support .In this paper, we examined the association between psychosocial school factors and mental health of the first grade secondary school students in Serbia. We found that certain school psychosocial school factors are associated with life satisfaction, depressive symptoms and psychosomatic health complaints, adjusted for demographic, socio- economic and social support variables outside the school environment.In our study, life satisfaction was positively related to satisfaction with school and classmate support, and negatively to being bullied at school. This finding is mostly in line with previous research. Wahlström et al. also identified classmate support as an independent predictor of high life satisfaction in the population of Swedish adolescents, but also the support of teachers and high perceived school demands, which did not stand out as significant in our study in the multivariable analysis, although they were previously significant in the univariable analysis . HoweverIn our study independent predictors of the presence of depressive symptoms were all observed psychosocial factors of the school environment, except for school satisfaction. In addition, the strongest predictors were schoolwork pressure and being bullied at school. This is consistent with a study among Norwegian adolescents, where stress related to school and bullying were also the most significant factors associated with symptoms of depression and anxiety . Other sIn this paper, all analyzed factors of the school environment were significantly related to psychosomatic health complaints, whereby schoolwork pressure and bullying at school were positively related, while teacher and classmate support and satisfaction with school were negatively related. These results are in line with the previous literature. Namely, it is described that the psychosocial work environment at school is associated with psychological and somatic complaints , 38. ForThe results of this study confirm the complexity of the relationship between psychosocial factors of the school environment with positive and negative aspects of mental health. Overall, most psychosocial factors of the school environment were significantly associated with both positive (life satisfaction) and negative aspects of mental health . At the same time, the support of classmates and being bullied at school were significant independent predictors for all three observed parameters of mental health.We consider these findings valuable to prepare evidence based health promoting intervention programmes aimed at improving mental health and wellbeing of Serbian adolescents. The newly adopted national Youth strategy for the period 2023–2030 foresees measures of support to programmes that contribute to mental health of young people . The impOur study had certain limitations: cross-sectional study design that prevents conclusions about the causality between the psychosocial school factors and mental health; not taking into account other factors that could be related to impaired mental health and wellbeing of students, such as objective health status of students and the presence of chronic diseases, or their academic success, or other possible stressors such as negative/ traumatic life events, family conflict etc. According to our knowledge, this is the first study in Serbia that systematically examines the relationship between psychosocial factors of the school environment and mental health of students on a nationally representative sample. It allows comparison with other countries from the HBSC network using the same methodology and study protocol.Further studies should focus on the interactions of psychosocial school factors and also include other important factors in order to determine the magnitude of the contribution of factors of school environment. Also, in further research, the population of senior high school students could be included in order to observe the dynamics between psychosocial factors of the school environment and mental health during schooling. It would be of great importance to examine whether and how new teaching models, such as online teaching, have influenced this dynamic.The results of our research indicate that the psychosocial school factors were associated with mental health, specifically life satisfaction, symptoms of depression and psychosomatic health complaints among first grade secondary school students in Serbia.Life satisfaction was positively related to satisfaction with school and classmate support, and negatively related to bullying at school.Symptoms of depression were significantly related to all psychosocial factors of the school environment except satisfaction with school. There was a positive association of depressive symptoms with schoolwork pressure and being bullied at school, and a negative association with teacher and classmate support.All analyzed factors of the school environment were significantly related to psychosomatic health complaints, whereby schoolwork pressure and being bullied at school were positively related, and the support of teachers and students and satisfaction with school were negatively related.Bearing in mind the high prevalence of impaired mental health in the population of the first grade secondary school students and their significant association with the psychosocial school factors, as well as the fact that these factors are modifiable, it is necessary to apply appropriate measures at the school and community level with the aim of improving social support in the school environment, reducing the level of schoolwork burden and preventing abuse at school. In the future, this would potentially contribute to improvement of mental health of first grade students.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S1 Checklist(DOCX)Click here for additional data file.


To be able to design telerehabilitation programs targeting the needs and preferences of end-users, patients’ in-depth perspectives are needed. To date, such studies are lacking and, therefore, the aim of the present study was to describe patients’ perceptions of performing exercise-based cardiac telerehabilitation after a myocardial infarction (MI). Individual semi-structured interviews were performed with 15 patients  after an MI who had participated in exercise-based cardiac telerehabilitation for three months. The interviews were transcribed verbatim and analyzed with inductive content analysis. An overall theme was defined as “Cardiac telerehabilitation—a new alternative for exercising that is easily accessible and up to date”. Four categories, including “The important role of a physical therapist with expert knowledge”, “Prerequisites playing an important role in the willingness to participate”, “Making exercise accessible and adjustable” and “Inspiring future exercise”, and 15 subcategories were identified. Understanding the patient’s perspective is an important key to further improving and successfully implementing exercise-based cardiac telerehabilitation, as an alternative or adjunct to traditional, centre-based programs. The findings can serve to improve patient–physiotherapist interactions and to inform important aspects related to exercise, technology and a sense of security from an exercise-based cardiac telerehabilitation program. Cardiac rehabilitation (CR), following a myocardial infarction (MI), is an evidence-based comprehensive intervention aiming to achieve clinical stabilization, cardiovascular risk reduction, disability reduction, psychosocial and vocational support and lifestyle behavioural change, including patients’ adherence and self-management . Centre-Despite strong evidence-based benefits, centre-based EBCR remains underused in patients after an MI in Sweden and elsewhere ,6. BarriTo facilitate the further development and implementation of exercise-based cardiac telerehabilitation programs into real-world practice, increasing knowledge of patients’ perceptions is important . To dateThis is a qualitative study with individual semi-structured interviews, analysed using inductive content analysis .Inclusion criteria: a diagnosis of MI and age ≤ 80 years at Sahlgrenska University Hospital (SU) Sahlgrenska and Östra, Southern Älvsborg Hospital Borås (SÄS) and Skaraborg Hospital Skövde (SKAS). Exclusion criteria: incomplete revascularization, significant valve disease, severe arrhythmia, heart failure , difficulty speaking the Swedish language, no internet connection or access to a device.This study was part of a larger research program, also involving a quantitative evaluation of exercise-based cardiac telerehabilitation delivered in real-time, group-based videoconferencing meetings under the direct supervision of a physiotherapist. The physiotherapist used a PC with videoconferencing equipment and patients used their own devices, such as a PC or tablet. Before entering EBCR, patients performed a pre-exercise assessment, including tests of physical capacity, in accordance with routine EBCR in Sweden . All theAfter a warm-up period, the aerobic exercises were performed in 45 sec intervals with a high intensity level corresponding to 14–17 on a Borg rating of perceived exertion scale (RPE) with 15 s periods at moderate intensityRPE 12–13) between intervals for a total duration of 25 min. The muscular resistance exercises were performed in 12 reps × two sets and consisted of four exercises with an elastic band and six exercises for the core and arms performed on a mat. The exercise program ended with a cool-down period and exercises for flexibility.Before and after each session, patients were given the opportunity to talk individually to the physiotherapist. The interviews were performed when the patient had finished the program.Eligible patients were informed about the study by a physiotherapist working at the cardiac intensive care unit or on the first CR visit. Patients who agreed to participate gave their written consent prior to the start of the study. Of 23 patients who had completed the cardiac telerehabilitation program, 15 patients were purposively selected to participate in the interviews. The purposive selection was made to obtain as much variation, including gender, age and different hospitals, as possible. The sample size in a qualitative study depends on the quality and richness of the data and it is not possible to propose a specific number of interviews ,17. In tThe interviews were performed by the last author (MB), who has previous experience in both interviewing and EBCR. The interviews were conducted digitally or in a private room at the hospital, as preferred by the patient. All the interviews started with the question “Can you tell me about your perceptions of participating in exercise-based cardiac telerehabilitation?”. The interviews had a semi-structured focus and were based on an interview guide . Follow-The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Regional Ethical Review Board in Gothenburg (registration no: 790-18).The results were analysed using qualitative content analysis according to Graneheim and Lundman . QualitaThe analysis followed The COnsolidated criteria for REporting Qualitative research (COREQ) guidelines . First, A first analysis, from reading the interviews in their entirety and dividing the text into meaning units, condensed meaning units and creation of codes, was performed by the first author (UN). A second analysis, including the same steps, was performed in the first five interviews by MB and the results were compared. UN and MB then worked together to define preliminary subcategories and categories, which were then discussed in an iterative process with a third physiotherapist (BÖ) until a consensus was reached. Both UN and MB are physiotherapists and have a pre-understanding of the subject through clinical experience with the patient group and by performing the exercise-based cardiac telerehabilitation program during the study. BÖ has no pre-understanding of the concept of telerehabilitation or the patient group but had experience with the method of qualitative content analysis.Among the 15 included patients (3 women and 12 men), 1 patient was from SKAS, 8 patients from SU Sahlgrenska, 4 patients from SU Östra and 2 patients from SÄS. Their median age was 69 (min 51 and max 79) years.The overall theme that emerged from the analysis was: “Cardiac telerehabilitation—a new alternative for exercising that is easily accessible and up to date”. In general, patients perceived that exercise-based cardiac telerehabilitation, with real-time exercise sessions supervised by a physiotherapist, was a modern form of exercising that felt safe and was easy to perform in a time-efficient way.An overview of the 4 main categories and 15 subcategories and the overall theme is presented in Patients stated that the physiotherapist played an important role in their participation in exercise-based cardiac telerehabilitation. They said that the workout felt safe, that they received clear instructions and had the opportunity to ask questions and receive advice. Moreover, the patients perceived that the physiotherapist increased their motivation to exercise with a positive and encouraging attitude.It’s a sense of security, that someone who actually has in-depth expertise and knows what I need to exercise in terms of fitness and strength, both how much and what is best for me, because I’m not fully aware of that.” (7)“Patients stated that exercising in real-time with a physiotherapist during the exercise-based cardiac telerehabilitation sessions gave them a sense of security in case an adverse event were to occur. Another aspect of security was that the physiotherapist knew their address in case of a serious adverse event during the exercise session. Patients felt that it was important that the physiotherapist had disease-specific expertise and knew how to prescribe safe exercises.I think more about safety, during exercise, I unlocked the door at home, because I did not know how my body would react.” (8)“The patients also thought about their own safety while performing home-based exercises after the MI.I think it’s necessary to have a physiotherapist who motivates you by your side for a long time. It’s a bit of encouragement, I think it’s very important.” (13)“Patients perceived that the physiotherapist was professional, encouraging, positive and motivating during the exercise-based cardiac telerehabilitation sessions, which gave them the extra push they needed, to maintain a higher intensity and not give up.Yes, she [the physiotherapist] was very clear, she knows what she is doing and talked and explained why we did what we did, so that was great.” (5)“One important aspect while exercising via telerehabilitation was that the instructions from the physiotherapist were clear and uncomplicated and easy to follow.We have two different physiotherapists and they have slightly different styles and it is also good that they have different balance exercises, it’s good to have different versions.” (1)“If there is a new instructor who performs another exercise or does it another way, then I have to check again and then I can’t keep up.” (3)“Some patients said that it was not a problem that different physiotherapists conducted the exercise sessions, while others felt that it was a bit more difficult to follow the new physiotherapist digitally if the exercises were not performed in exactly the same way.Yes, you can ask questions afterwards, if someone asks a more personal question, then the physiotherapist says, ‘Yes, we can talk about that afterwards’ and it also feels very good to be able to do that.” (1)“The opportunity to ask questions and receive support from the physiotherapist was regarded as an important part of the exercise-based cardiac telerehabilitation program. Some patients said that it was not always easy to ask questions digitally, as compared to a real-life session.When I have to exercise myself, it becomes so much more inefficient. The breaks between the intervals are far too long and, although I can see the exercise instructions and read the text, it becomes stagnant.” (6)“Receiving feedback and advice from the physiotherapist about exercise was also described as a valuable aspect. Patients felt that it was not always easy to exercise on their own without support from the physiotherapist, as this often resulted in a more ineffective workout.Previous exercise habits and computer experience played a significant role in the patient’s willingness to participate in exercise-based cardiac telerehabilitation.I thought it worked out very positively, smoothly and easily. I have always been a little fascinated by new thinking and new stuff, so, when I got the question about the study, I said yes and I had a positive input to this, so to speak, but I also think it has met the expectations I had.” (7)“Patients said that they generally had a positive perception of exercising. Their expectations of the exercise-based cardiac telerehabilitation program were high, but they were usually met.I am an old man when it comes to electronics and computers and everything like that. I don’t really agree with all this modern technology, there was resistance, but the physiotherapist managed to convince me to try.” (6)“Obtaining information about exercise-based cardiac telerehabilitation at the first in-person meeting with the physiotherapist was an important and motivating aspect for patients who felt hesitation about participating.Every time I make an extra effort, there is always a slight worry that has not existed before.” (3)“A perceived fear of movement in relation to exercising could be expressed by patients after their MI. Patients were more observant of bodily symptoms and they feared a recurrent MI, especially during exercises at a higher intensity.I was never afraid of having another heart attack, rather the opposite, it may have been a push in the back that you can now actually start a little aerobic exercise.” (9)“Others felt no uncertainty or distress in relation to exercising and had no fears or perceived any obstacles to performing exercise-based cardiac telerehabilitation.I have performed many of these exercises previously, so I recognized a lot of it. So, for me, there was nothing strange.” (14)“Patients with previous experience of exercise were able to recognize several exercises in the telerehabilitation program, which was perceived as a facilitating factor.I use a computer a lot at work, so the technical part wasn’t an obstacle for me, but I can imagine that many people will think it is.” (1)“Some patients said that they used computers at work or during their leisure time. Those who did not have sufficient computer skills turned to relatives for help. Patients said that they understood that a lack of computer knowledge might be an obstacle to participating in exercise-based cardiac telerehabilitation.Patients said that it was essential that exercise-based cardiac telerehabilitation was easily accessible to save time. Individualized exercise and user-friendly technology were also factors of relevance to patients.It easily takes two, two and a half hours if you don’t do the exercise at home and therefore I think this is great, because it cuts the timeframe.” (7)“Patients said that the availability of home-based exercise was a great advantage, without the need for transport to the hospital and finding a parking space.The advantage of this is that you don’t need any equipment, more than an elastic band, so, wherever you go, you can just bring an elastic band and your pants and a sweater.” (4)“The fact that the exercises could be carried out in a small area without any equipment, except for elastic bands, was valued by the patients.If you have already booked exercise at a certain time, it’s much easier to just do it, than if I have to think, when should I exercise?” (3)“Some patients valued a scheduled time for the exercise sessions, while others could perceive negative aspects about having a predetermined time, as it was difficult to be absent from work.You feel like you’re a group, even though I don’t know exactly what everyone looks like, you know that there are others out there doing the same thing as me. That’s quite fun, I think.” (9)“Some patients stated that, even though they performed home-based exercise, they felt like the exercise program was carried out together as a group. Exercising with peers was important to play down the dramatic feeling of exercising after an MI.I did not experience it as a group really, it was like between me and the person who led it, so to speak. I knew there were others participating, but I didn’t really care about that, except that I sometimes saw them.” (14)“Other patients felt that the exercise sessions were more like a private session between themselves and the physiotherapist. They wanted to focus on their own performance and did not bother about the other patients.Yes, it went well, I think. Since these are the exercises that everyone does the same amount of and she [the physiotherapist] says that, if you can’t go all the way, then adapt like this and so on.” (4)“Patients perceived that the exercises felt personalized, based on their own ability and previous experiences, despite being performed in a group.For my generation and those who are older, I think you perhaps need to be a little more hands-on and show how it works on a computer.” (1)”The technology was generally seen as user friendly. Some patients said that user acceptance was possibly a generational issue.It has worked very well, it was just a question of getting started and then, when you figured out how to use the settings, it was very simple, no problems. I got the link and just clicked on it and got started.” (5)“Patients could experience some initial frustration with video and sound settings and not understanding the digital terminology, but they quickly learned how to manoeuvre the technology and they then found it user friendly.The first time, you should perhaps allocate a small section of 15 min where you show how it works, this is how you ‘pin’ and here is the sound.” (7)“Some patients wished that they had received more information and instructions about the technology before starting the exercise program, to learn about settings and avoid technical problems.It has been very good, I think, and in a form that suits me very well.” (5)“Patients stated that they perceived exercise-based cardiac telerehabilitation as a new, well-conducted concept and a fun and different way of exercising. It was also simple and easy to carry out.The exercises you can do are a bit limited, of course, so you must be a little clever. But I think it has worked well. I can definitely imagine doing more exercises via telerehabilitation.” (3)“Even though the limited space of home-based exercise was seen as a potential limitation for implementation, the overall patient perception was that the program had a wide variety of exercises that included the whole body.Patients said that they observed positive effects of the exercise-based cardiac telerehabilitation program which motivated them to continue exercising.So, all of a sudden, I discovered that I like exercising, so I now find that I am just getting better and better and both my wife and my children can see that I have improved.” (15)“The patients described a positive feeling and increased strength and fitness fairly quickly. They noticed that they were able to perform the exercises more and more effectively as the exercise period progressed. Even their family members were able to see the positive effects of exercising.Yes, I would like to continue, but my exercise period is over, I understand. But then it is good that I have already established a routine to continue on my own.” (13)“After having finished the exercise-based cardiac telerehabilitation program, patients expressed the feeling of being motivated and having enough knowledge to be able to continue with regular exercise, even though some patients would have liked to continue with cardiac rehabilitation.Some tips on what exercises I can do on my own, when you can’t go to the gym, I need that. As well as what kind of aerobic exercise I can do myself, either at home or outside or wherever.” (9)“Others felt that continued exercise could be a challenge and they wanted further advice from the physiotherapist.This study contributes to an increased understanding of patients’ perceptions of performing exercise-based cardiac telerehabilitation after an MI. The overarching theme indicated that exercise-based cardiac telerehabilitation is a modern form of exercising that is easily accessible, time efficient, up to date and easy to perform.The information about exercise-based cardiac telerehabilitation provided by physiotherapists at the CR centre was described as important for participation, especially by patients who were insecure about digital healthcare. This finding is in line with a study by Frederix et al.  showing 2max as centre-based EBCR [According to guidelines, EBCR programs should be individually prescribed, based on the initial evaluation of physical capacity to achieve the optimal effect . One impsed EBCR .In line with previous studies ,22, patiIn a previous study, patients stated that social support, in terms of peers sharing experiences, was a significant prerequisite for attending centre-based EBCR programs . The impPatients in the present study stated that the accessibility of telerehabilitation was a motivating factor, which is supported by previous studies ,12. ScheIn the end, the successful incorporation of exercise-based cardiac telerehabilitation into clinical practice is dependent on patients accepting the intervention. External variables such as ease of system use, learnability and technology self-efficacy may influence acceptability . In geneIn terms of credibility, participants need to understand the event under study and the fact that it represents a diversity of demographics, viewpoints and experiences ,18,28. EAnother aspect of credibility is that data analysis was planned a priori . InvestiIn summary, to meet the needs of more patients, new evidence-based best practice models for EBCR must be evaluated and implemented. To succeed, it is important to keep patients at the centre of the development of digital care models, to achieve a patient-centred healthcare system and to guarantee results that are practical, interpretable and comprehensive. The present study adds several aspects that are important to consider when setting up an exercise-based cardiac telerehabilitation program. The interaction with an expert physiotherapist played an important role for patients, and thus models without real-time feedback may be less successful. Patients appreciated the possibility of being able to choose settings in the telerehabilitation platform to either obtain a strong sense of group dynamics and interaction with peers or to focus on their own exercise. Regardless of this choice, it is important for physiotherapists to give clear instructions and adapt the exercise program to individual patients. Based on the fact that patients also felt safe and motivated during exercise sessions and managed to handle the technology after an initial learning period, telerehabilitation can be considered a promising model.However, although a growing amount of research is being conducted on the evaluation of new digital delivery models, it is important that this rapid digital evaluation should not replace traditional care but rather supplement it. Hybrid models of EBCR, including components from both centre- and home-based EBCR, are being increasingly suggested . In the This study showed that patients perceived exercise-based telerehabilitation as a modern and easily accessible way of exercising after an MI. Patients valued the supervision and support from physiotherapists with expert knowledge in EBCR which provided a sense of security during exercising. Understanding the patient’s perspective is an important key to further improving and successfully implementing exercise-based cardiac telerehabilitation, as an alternative or adjunct to traditional, centre-based EBCR. The findings may serve to improve patient–physiotherapist interactions, as well as inform important aspects related to exercise, technology and a sense of security to inform the design, development and evaluation of future exercise-based cardiac telerehabilitation programs, with the overall aim of increasing patient-centred care and accessibility.


How do we include animals in sociology? Although sociology’s initial avoidance of the nonhuman world may have been necessary to the field’s development, recent scholarship – within mainstream sociology, environmental sociology and animal-centred research – is helping expand the field’s horizons. With a focus on variety, this article reviews four key paths that researchers are taking to include animals in their research: (1) studying interspecies relations, (2) theorizing animals as an oppressed group, (3) investigating the social and ecological impacts of animal agriculture and (4) analysing social-ecological networks. This review shows how applying – and innovating – existing social theories and research methods allows researchers to include animals in their analyses and will be relevant to a variety of scholars, including mainstream and environmental sociologists, animal-focused researchers and social network analysts, to name a few. We begin with a brief review of environmental sociology and its attempts to challenge the mainstream human-focused paradigm. From there, we traverse four major and intersecting pathsSilent Spring and the Apollo missions’ first images of Earth, a new ecological consciousness took hold. Quite rapidly, beliefs in the inseparability of society from nature, and the need for profound structural change, became the spirit of the time. This was also true for sociologists looking to broaden the field’s gaze and create an environmental sociology that takes society’s relationship with the environment as its bedrock. Chief to its foundation was the New Ecological Paradigm (NEP) presented by Soon after the growth of the modern environmental movement in the 1960s , the fieCentral to HEP is the prominence of human culture that, given its dynamism, is believed to help humans overcome natural limits of the environment . NEP, onWhile NEP challenged the dominant sociological paradigm, this was not an attack on sociological theories. It was, instead, a call for contemporary sociologists to broaden their focus and include society’s relationship with the nonhuman world. Indeed, resurrections of the discipline’s founding theorists reveal their careful attention to society’s relationship with the environment. Marx spoke of the modern human’s alienation from nature, as well as industrial society’s disrupted social-ecological ‘metabolism’ . Weber eMore recently, however, some have challenged environmental sociology’s NEP as insufficient in its inclusion of nature. human–animal relationships and their implications for human society. For most of human history, humans have freely interacted with other animals in various contexts, including relations of friendship, companionship, and hunting for survival. From the beginning of the Neolithic era, however, human–nonhuman relationships became more controlled and instrumental with the shift from hunter-gatherer societies to the domestication of animals. Whereas subsistence hunters would seek to maintain proper and respectful relations with animals and nature,[S]tarting about 10,000 years ago, the human relationship with wild animals was transformed. Domestication changed this relationship into one of dominance and control as humans took on the role of master. Animals – no longer wild – became classified as property, and were considered items to be owned and exchanged. Today, domesticated animals can be bred, controlled, abused, or killed as the owner desires. : 67–68The first research path focuses on Furthermore, as more animals were being used for animal agriculture, they began to disappear from public view. With growing industrialization in the 18th and 19th centuries, nonhuman animals were increasingly kept in warehouses and stockyards where, in Fordist assembly-line fashion, they were gathered, killed and turned into meat. While, in some cases, spectators could observe this process , furtherWhen Species Meet, and ‘domination’, both ‘mothering’ and eventual ‘trafficking’ of those they breed  from agency – which is informed by context. ‘On this view of agency’, they argue, ‘non-human animals are agential beings’ who are incorporated into social relations ‘on the basis of difference and inequality’ . To properly account for nonhuman agency, realized agency  could be mistaken for a lack of potential agency, obscuring efforts to exercise agency that fall outside clear acts of resistance , Nibert attributes the rise in gender inequality to the development of organized hunting and animal domestication, which lead to unequal divisions of labour, the devaluation of women’s labour and male control of surplus wealth. This surplus wealth  necessitated the creation of a ‘warrior class’ and ‘priestly class’ to defend and manage this wealth More recently, social scientists have extended Marx’s concept of alienation to include nonhuman animals. As According to Others have extended Marx’s later work on the emergent rifts between society and nature, given animal agricultural production . Foster Contrary to Marxian analyses of the environment, modernization theories focus on social and technological innovations that may help bring humans back in balance with the nonhuman world. Ecological Modernization , for exasocial-ecological networks – with its structural focus on human–nonhuman interactions – offers a unique way to include nonhuman animals  and a set of relationships [ties] connecting pairs of these actors’ .For sociologists taking a social networks perspective, the new area of mals see . Brieflymals see : 1. Spec actors’ , 2019. IIn their introductory discussion of social-ecological networks, While research on social-ecological networks often aggregates individual animals into species  exploring interspecies relations, (2) studying animals as an oppressed group, (3) investigating the impacts of the animal agriculture industry and (4) analysing human–nonhuman interactions as social-ecological networks. Of course, this should not be taken as an exhaustive review of the literature. Instead, this article is meant to illustrate some of the key ways in which social scientists are bringing nonhumans into their research. By spotlighting existing theoretical , conceptual (e.g. nonhuman agency) and methodological  innovations, this article aims to inspire researchers to innovate and extend additional theories, concepts and methods to further integrate animals into sociological research. Ultimately, tackling the discipline’s nonhuman exclusion – and including animals in sociological research – reflects a growing understanding of human society’s interdependence with the nonhuman world. It also reflects a commitment to a more comprehensive sociology that acknowledges human society’s significant relationships with its fellow nonhuman co-inhabitants.


International evidence shows variation in organ donation and transplantation (ODT) based upon a range of patient characteristics. What is less well understood is the impact of patient “ethnicity/race/immigration background,” as these terms are defined and intended differently across countries. We also know that these characteristics do not operate in isolation but intersect with a range of factors. In this paper, we propose a framework that seeks to clarify the definition of the key terms “ethnicity/race/migrant” and to review how these communities are operationalized across European studies about inequities in ODT. Further, patients and the public wish to see Equality Diversity Inclusion (EDI) approaches in their everyday lives, not just in relation to ODT. We propose a ‘care pathway/whole-systems’ approach to ODT encompassing culturally competent public health interventions for a) the prevention and management of chronic diseases, b) improvements in public engagement for the promotion of the culture of ODT and enhancements in end-of-life care, through to c) enhanced likelihood of successful transplant among migrant/ethnic minority communities. Our framework recognizes that if we truly wish to take an EDI approach to ODT, we need to adopt a more social, human and holistic approach to examining questions around patient ethnicity. There is a plethora of evidence in most countries across the world showing variation in organ donation and transplantation (ODT) based upon a range of patient characteristics. These include—but are not limited to—age, gender, ethnicity, income, educational level, cultural beliefs, and religiosity –3. As hiPilot studies which have sought to examine these aspects in relation to ODT have shown that “ethnicity” and/or “race” and/or “immigration background” do not operate in isolation but intersect with a range of other socioeconomic factors at the individual level, and with other factors at the interpersonal and societal level , 14. TheTo fill these gaps, this study aims to clarify the definition of the key terms “ethnicity,” “race,” and “migrant” and to review how these communities are operationalized in studies addressing inequities in ODT in Europe. Second, it puts forward a proposal for a “care pathway/whole-systems” approach to ODT encompassing culturally competent public health interventions for a) the prevention and management of chronic diseases, b) improvements in public engagement for the promotion of the culture of ODT and enhancements in end-of-life care, through to c) enhanced likelihood of successful transplant among migrant/ethnic minority communities.The terms “ethnicity,” “race” and “migrant” are often considered synonymous; however, they are not interchangeable. For instance, although they are interconnected, there are substantial specific features related to each that require consideration . “EthnicStudies have noted that lack of consideration of within-group variations like cultures, language(s), religious affiliation, number of generations spent in the host country, time elapsed since immigration for first-generation migrants, socioeconomic status, and specific Human Leukocyte Antigen (HLA) types may lead to failure of considering the features with the potential to provide valuable insights into the heterogeneity of different ethnic minority groups and enable the development of more targeted interventions accordingly , 25, 39.The European Public Health Association acknowledges the controversial definition and categorization of “ethnic minorities” in Europe. However, it stresses that, regardless of how these populations are defined and categorized, the features related to “ethnicity” are frequently rather independent of ‘immigrant status’ . BesidesThe World Health Organization suggests that 80% of non-communicable diseases including premature heart disease, stroke and diabetes may be prevented by intervening on risk factors  through behavior change interventions . HoweverFor example, in the United Kingdom (which has a longer-standing immigration history relative to other European countries), kidney dysfunction is a problem that disproportionately affects Black, Asian and Minority Ethnic individuals (BAME). Although BAME people represent only 11% of the UK population, they accounted for 24% of patients dependent on renal replacement therapy in 2017. BAME people are more likely to develop chronic kidney disease than white people, and those who have chronic kidney disease experience faster decline in kidney function than white people. There is some emerging evidence from the UK Biobank that HLA alleles may have an impact upon kidney function . UnderstAdditionally, some important factors to consider is how mortality rates for patients undergoing dialysis differ by ethnicity. A study from the United States (US) exploring this aspect found substantial differences by ethnicity across the 50 states. After matched analyses for comparable age and risk factors, mortality risk no longer differed for Whites or Blacks but remained much greater for territory-dwelling Hispanics and Asians . It shoupost mortem organ donors in relation to the number of patients on the WL for transplantation is seen in many countries, although there are differences [Shortage of ferences . When taferences . As illuferences . For insferences , 52. Howferences . On the ferences . ProlongSecond, when looking at the organ donor register, for example, in the UK, more people identifying as white are present on the donor register than all other ethnic groups . ReasonsThird, when donation is requested to a donor family the consent rate among ethnic minorities  is lower than in whites . As the As a result, there is a need for end-of-life care which meets the needs of this group of patients. Providing end-of-life care to patients from different cultures is a challenge for services as there can be barriers to communication in the form of language, delegated decision-making within families, and reluctance to discuss about death –59. It iThere are substantial variations in kidney transplant incidence, prevalence, availability, accessibility, and quality worldwide, with the lowest rates evident in low- and lower-middle income countries. Understanding these inequities will inform efforts to increase awareness and the adoption of practices that will ensure that high-quality kidney transplant care is provided around the world .Despite increasing interest in equitable healthcare, inequities in access to solid organ transplantation, especially among “ethnic/racial/migrant” minority patients are documented. In the UK, non-white ethnic minorities—mainly of Indian, Pakistani and Caribbean descent—comprise 11% of the population, 7% of organ donors, 35% of people awaiting a kidney transplant, and 21% of people who died on the WL. Norway has an increasingly diverse population. Many non-white migrant and ethnic minority groups, largely of Somali, Pakistani, Syrian, Iraqi and Eritrean descent, share many of the same risk factors for end stage kidney disease (ESKD), though currently protected by a younger age demographic. Little is known about ethnicity and organ donation in Norway because ethnicity data is not routinely collected, and where this is done only country of birth is recorded. Blood and tissue types differ between ethnic groups but are more often shared by close family members and people of the same ethnicity. Ideally, donors should be as diverse as the recipient population ..A review of inequities in access to heart, lung, liver, pancreas and kidney transplantation based on the social determinants of health  in the US found that racial and ethnic minorities, women, and patients in lower socioeconomic status groups are less likely to be referred, evaluated, and registered on the transplant WL. Yet, the quality of the data describing these inequities was variable across the transplant literature and overwhelmingly focused on kidney transplantation , similarn = 171; Caucasians = 118/BAME = 53) from 2006 to 2020 (median follow-up = 80 months). Pancreas graft and patient survival were equivalent in both groups. BAME recipients had a higher prevalence of type-2 diabetes mellitus pretransplant , and waited for a similar time to transplantation once waitlisted, although pre-emptive simultaneous pancreas–kidney transplantation rate was higher for Caucasian recipients . Despite equivalent rejections and steroid usage, BAME recipients gained more weight , but had similar HbA1c (functioning grafts) at 3-, 12-, 36-, and 60-months post-transplant [Beyond kidney transplantation, most studies on ethnicity-based outcomes in pancreas transplantation are from the United States, where healthcare delivery is predominantly insurance-based. There is no equivalent data from the United Kingdom, where the healthcare system is publicly funded. A recent article published in 2022 reported the first single center experience on ethnicity-based outcomes of pancreas transplantation from the United Kingdom. A retrospective analysis was performed of all patients who received pancreas transplantation  implemented at multiple levels of the healthcare system will be necessary to reduce inequities in early transplant steps [Collection of national surveillance data on early transplant steps, as well as routinely captured data on upstream social determinants of health—including the measurement of patients’ perceived discrimination  rather tnt steps .Further, although living donor kidney transplantation (LDKT) is the best renal replacement therapy for patients with ESKD providing survival advantages over dialysis and deceased donor kidney transplant, studies report diminished uptake of LDKT among migrant and ethnic minority populations –26, 31. From 2013 to 2018, custom datasets from the United States Renal Data System and the United Network for Organ Sharing were merged to calculate the Kidney Transplant Equity Index (KTEI), defined as the number of minority patients transplanted at a center relative to the prevalence of minority patients with ESKD in each center’s health service area. Markers of socioeconomic status and recipient outcomes were compared between high and low KTEI centers. The KTEI is the first metric to quantify minority access to kidney transplant incorporating the prelisting ESKD prevalence individualized to transplant centers. KTEIs uncover significant national variation in transplant practices and identify highly equitable centers. This novel metric should be used to disseminate best practices for ESKD patients from ethnic minority groups and with inferior socioeconomic status .Most countries are seeing life expectancy increase; however, this is not the case for all ethnic groups. As populations grow older, the demographics will change. For example, in the United Kingdom, most ethnic minorities comprise a younger demographic than the white British population. Yet, by 2051, this pattern will change with “Other White,” “Chinese,” “Other Asian,” “Indian,” “Other,” and “White Irish” alongside “White British” all being the ethnic groups with the highest representation aged 50 and over . By the Data show that transplant inequities persist for migrant and ethnic minority communities across the world, including the countries where these populations benefit from universal healthcare coverage in the European area . A systeThe main limitation of this work lies in the inconsistency of how migrant and ethnic minority populations are defined in European studies, which may result in a biased analysis. However, one of the goals of our study was precisely to examine how individuals from these communities are categorized in relation to ODT in Europe. Therefore, what seems to be a major limitation of the study is rather a strength in its ability to point out the need for clarification of terms and definitions to be addressed and harmonized across Europe, as noted by earlier European reviews on migrants’ health . FurtherThis study has also several strengths, lying primarily in its ability to highlight the multiple gaps in research of inequities in ODT among migrant and ethnic minority populations in Europe. Further, it succeeds to stress on the need for engagement of a more coordinated European framework to enable harmonization of definitions across Europe. This may lead to improved consistency of data collection to allow better data reporting, interpretation and cross-country comparisons. Finally, while not denying cross-country variations, it points out the need for a shared, coordinated approach to these vulnerable communities.The prevention and elimination of inequities related to patient characteristics is currently emergent in ODT in Europe. What requires clarification is the impact of patient “ethnicity” and/or “race” and/or “immigration background” on inequities in ODT, as these terms are defined and intended differently across countries. We contend that both the features related to “ethnicity” and “immigrant status”—and the intersection with the multiple factors associated to each–should be considered to identify the modifiable factors for targeted interventions to improve equity in the ODT process for these populations. However, evidence shows that, in the European context, these populations are categorized in a heterogeneous fashion and that most, except few studies are retrospective , and focused on kidney transplantation. Because inequities are documented among migrant and ethnic minority populations in the entire ODT process, a “care pathway/whole-systems” approach to ODT encompassing culturally competent public health interventions is needed for improved a) prevention and management of chronic diseases, b) public engagement for the promotion of the culture of ODT and enhanced end-of-life care, through to c) enhanced likelihood of successful transplant among migrant/ethnic minority communities. Our framework recognizes that if we truly wish to take an EDI approach to organ donation and transplantation—we need to adopt a more social, human and holistic approach to examining questions around patient ethnicity.