Based on the ecological integration model, this study examined the factors affecting smoking in adolescents from multicultural families by dividing them into two levels: microsystem and social network factors. The data were from the Korea Youth Risk Behavior Web-Based Survey (KYRBS) from 2016 to 2020. It included 4577 respondents whose fathers, mothers, or both, were not born in Korea. The factors affecting smoking among multicultural teenagers were determined by a composite-sample multiple logistic regression analysis. Male smoking rates among multicultural adolescents were 2.49 times higher than female rates in the microsystem. When the father was “Korean” rather than a “Foreigner”, smoking was 0.55 times lower in family factors in terms of social network. In social factors of social networks, multicultural adolescents’ smoking was 12.02 times greater when they were drinking than when they were not, and 3.62 times higher when the answer to the question of whether they had experienced violence was “yes” than “no.” Based on the ecological model in this study, social factors such as drinking, and violence were highly related to smoking. Since multicultural adolescents were closely influenced by the surrounding environment, such as family, school, and social relationship, it was necessary to let parents and schoolteachers be involved in the intervention of smoking of multicultural adolescents so that they can help multicultural adolescents adjust better to school and perform better academically while decreasing risky behaviors for their health, such as drinking and, ultimately, smoking. As the influx of people from multicultural backgrounds into Korean society increases, the number of children from multicultural families will increase further in the future, considering the recent trend of middle-entry immigrant youth and foreign workers’ children . The higIn a study that examined the health risk behaviors of adolescents in multicultural families, families with Korean parents, and families with North Korean parents, adolescents from multicultural families showed higher health risk behaviors, such as smoking, drinking, drug use, and sex, than adolescents from families with Korean parents . In addiIn a study on the effect of smoking on adolescents’ health, it was reported that the quality of sleep was very low, and the group of adolescents that used both general and e-cigarettes did not get enough sleep . In addiNicotine, the main ingredient of cigarettes, is known to be highly addictive, and if people start smoking in adolescence, they often continue to smoke until they become old. In fact, this addiction is known to be very difficult to quit when people start in younger age. The younger one starts smoking, the harder it is to quit . AccordiFrom the studies of above, smoking among adolescents from multicultural families is highly related with their mental and physical risks, such as depression, stress, sleep deprivation, drinking and even using illicit drugs. Therefore, research on factors that influence behavior by identifying objective characteristics of youth from multicultural families will be used as important data to establish policies for youth from multicultural families and open them to a safer future society.Among theories related to human behavior, the ecological system theory is a theory that considers the internal and external aspects of an individual and focuses on the interaction between an individual and the various environmental systems surrounding it . The ecoIt can be inferred that it may be influenced by the family and social environment surrounding the individual. Therefore, applying the ecological integration model to explain the factors of smoking in youth from multicultural families, personal factors, social network factors, and the interactions between them can be used to explain the effects of smoking in youth from multicultural families.Based on the ecological integration model and previous studies, this study examined the factors influencing smoking in adolescents from multicultural families by dividing them into two levels: micro and social network factors. This study arranged a microsystem of factors influencing smoking in multicultural adolescents, comprising gender, grade, school achievement, sleep, stress, depression and suicidal thought as personal level variables; nationality of parents, residence type and economic status of multicultural adolescents as family factors of a social network; and drinking, drug use and violence as social factors of a social network. Based on the above, the conceptual framework of this study is presented as shown in Based on the ecological integration model, this study examined the factors affecting smoking in adolescents from multicultural families by dividing them into two levels: microsystem and social network factors. It is believed that the interaction between these levels can explain the factors that affect smoking in adolescents from multicultural families. In addition, grasping the objective characteristics of youth from multicultural families and understanding the factors affecting behavior are believed to be useful as basic data to open policy establishment for youth from multicultural families and integration into a safer future society.The study’s specific purposes were as follows: (1) to identify the microsystem, social network, and the number of smoking adolescents from multicultural families; (2) to explore the difference in smoking among adolescents from multicultural families according to the microsystem and social network; and (3) to identify the factors influencing smoking among adolescents from multicultural families.This study uses a cross-sectional research design and an ecological system theory approach to identify the factors influencing smoking among multicultural adolescents. It uses raw data from the Korea Youth Risk Behavior Web-based Survey (KYRBS) from 2016 to 2020 .The KYRBS has been conducted annually since 2005 with the aim of understanding the current status and trends of health behaviors of teenagers in Korea. An online survey was administered to anonymous volunteers across the country who were adolescents from the first year of middle school to the last year of high school. The sampling process was divided into stages for population stratification, sample allocation, and sample extraction. For sampling, we used a stratified collection extraction method, in which the first extraction unit was the school’s permanent random number and the second extraction unit was randomly selected as a class. In the KYRBS, the raw data included logical errors and outliers, and weights were calculated by the Korea Disease Control and Prevention Agency and provided as raw data weighting variables. The weights were multiplied by the weights’ posterior correction rate multiplied by the extraction rate reciprocal and response rate reciprocal, and the weights by region, gender, school type  and grade were calculated to be equal to the number of middle and high school students nationwide by year. Responses to the online survey about youth health behavior were organized using unique numbers that could not be used to determine the respondents’ identities; thus, no personal information was disclosed, and anonymity and confidentiality were guaranteed.Raw data from the Korea Youth Risk Behavior Web-based Survey (KYRBS) from 2016 to 2020 , conductThe researchers conducted the study after receiving a review exemption from Daegu Haany University with which the corresponding author was affiliated (IRB No: 2023-1-03).The study’s dependent variable was multicultural smoking adolescents, whereas the independent variables were the microsystem  and social network .The microsystem refers to the personal factors of multicultural adolescents and comprises gender, grade, school achievement, sleep, stress, depression, and suicidal thought. Gender could be answered with either “male” or “female”; grade with “middle school” or “high school”; and school achievement with “high,” “middle,” or “low”. Sleep was answered with “very sufficient,” “sufficient,” “moderate,” “insufficient,” or “not sufficient at all” to the question, “In the last 7 days, do you think the amount of sleep you have slept is sufficient to recover from fatigue?” Stress was answered with “too much,” “much,” “a little,” “not much,” or “not at all” to the question, “How much stress do you usually feel?” Depression was answered with “yes” or “no” to the question, “In the last 12 months, have you felt sad or hopeless enough to stop your everyday life for 2 weeks?” Suicidal thought was answered with “yes” or “no” to the question, “In the last 12 months, have you thought about suicide?”The social network includes family factors and social factors of multicultural adolescents. Family factors comprises the father’s and mother’s nationality, residence type, and economic status. The father’s and mother’s nationality were classified as “Foreigner” or “Korean”; residence type was classified as “with family,” “boarding/self-boarding,” “with relatives,” “dormitory,” and “child-care”; and economic status was classified as “high,” “moderate,” and “low.” Social factors included experiences in drinking, drug use, and violence of multicultural adolescents. Drinking was answered with either “yes” or “no” to the question, “Have you had more than one drink so far?” Drug use was answered with either “yes” or “no” to the question, “Have you ever habitually or deliberately taken drugs or drank butane gas or bond so far?” Violence was answered with “yes” or “no” to the question, “In the past 12 months, have you been treated at a hospital because of violence  by a friend, senior, or adult?”Smoking was answered with either “yes” or “no” to the question which was “Have you ever taken one or two drags from a cigarette?”The frequency and percentage of the microsystem and social network, and smoking of multicultural adolescents.The differences in smoking according to the microsystem and social network among multicultural adolescents by using the Rao–Scott chi-square test.The factors affecting smoking in multicultural adolescents using multiple logistic regression analysis.The data used in this study were evaluated using composite sample analysis that reflected strata, cluster, weight (W), and a finite population modifications coefficient. Data were analyzed using IBM SPSS Statistics 23. The following were analyzed:As shown in Among the family factors in the social network, the father’s nationality, when the father was Korean there smoking was 349 (56.3%) vs. when their father was foreigner smoking was 225 (36.3%). The smoking rate was highest were residence type was with family (498 (80.3%)) and when economic status was moderate (227 (36.6%)). Among the social factors in social networks, smoking was higher when they were drinking (518 (83.5%)), not using drugs (617 (99.5%)), and having no experience of violence (491 (79.2%)). p < 0.001). The explanatory power was 41.5%. The factors influencing smoking among multicultural adolescents were microsystem (gender), and family factors of social network , social factors of social network (drinking and violence).Among the microsystem, multicultural adolescents’ smoking was 2.49 times higher in males than in the female. In family factors in terms of the social network, smoking was 0.55 times lower when the father’s nationality was “Korean” compared to “foreigner”. Among the social factors in terms of the social network, multicultural adolescents’ smoking was 12.02 times higher when they were drinking than when they were not drinking, and 3.62 times higher when the answer to violence was “yes” compared “no”. These results are shown in Based on the ecological integration model, this study examined the factors affecting smoking among multicultural adolescents from the subjects of the Korea Youth Risk Behaviour Web-Based Survey (KYRBS) for five years from 2016 to 2020. The ecological model states that the environment and relationships of various dimensions surrounding an individual affect each other, which affects the development of individual behavior . In thisOf the 4577 respondents, 620 (13.5%) said they smoked, 1496 (32.7%) said they drank, and 518 (83.5%) said they smoked and drank. According to a report that studied the health behavior of 759 multicultural adolescents in 2016, 123 (19.3%) said they smoked, and 247 (48.2%) said they drank , so the In Korea, even though the sale of cigarettes and alcohol to adolescents under the age of 19 is prohibited, many adolescents smoke and drink, and multicultural adolescents are more likely to engage in health-risk activities because their social environment is more vulnerable. It was reported that adolescents from multicultural families are more likely to be exposed to the risk of smoking than drinking .It was reported that the smoking experience of multicultural adolescents was significantly higher in male students than in female students. Smoking among multicultural adolescents is often accompanied by health risk behaviors, such as drinking, which had a significant correlation between their first time smoking and drinking . It is bIn this study, social factor that affected the smoking of multicultural adolescents was violent experiences, and 233 (5.1%) of the subjects said they had experienced violence. In a report that studied the experiences of violence among multicultural adolescents, adolescents from North Korean parents, and adolescents from Korean parents, adolescents from North Korean families were 11 times more exposed to violence, and multicultural adolescents were 5 times more exposed than adolescents from Korean parents .It has been reported that experiences of violence damage among multicultural adolescents has a statically significant effect on current smoking behavior, and the higher the frequency of violence damage, the higher the likelihood of smoking behavior . As a reThe frequency of smoking and drinking among adolescents in Korea is increasing, and smoking is often accompanied by drinking; smoking and drinking in adolescence are major social problem in Korea because it affects them even in adulthood . AccordiBased on the ecological integration model, it is reported that gender in the microsystem, the father’s nationality; in the family factors of the social network, drinking and violence; and the social factors of the social network affect multicultural adolescents smoking, and they are indicating that the social environment surrounding multicultural adolescents is highly related to smoking. It was found that multicultural adolescents were closely influenced by their surrounding environment, such as family, school, and social relationships, and parents had a strong influence on their adolescent’s health behavior, so it was necessary to explore parents’ health-related characteristics .Health experts, including health teachers, suggested that smoking, which forms the identity of the youth’s peer group, should be resolved in a constructive direction, similar to music and club activities, specifically through group smoking cessation counseling. In addition, it was said that educational intervention on socio-technical factors, such as communication skills or self-assertion training, can be properly rejected in situations where smoking is encouraged or pressured . FurtherSmoking among multicultural adolescents is a dangerous act that is accompanied by drinking, which is expected to affect them even after they become adults in the future. As a result, policies, and intervention methods to prevent smoking among multicultural adolescents are urgently needed, and an integrated community intervention program that includes not only multicultural adolescents but also parents, friends, and schoolteachers from multicultural families is needed.Although Korean adults’ superficial understanding of multiculturalism has increased, multicultural acceptance is segmented, biased preferences and discrimination are intensifying, and the anti-multicultural consciousness of the younger generation is being strengthened. In addition, Koreans’ perceived sense of threat of foreigners is deepening, and multicultural education is insignificant. This suggests that Korea’s policy on multicultural acceptance is necessary for a society that lives together .In the process of youths from multicultural families being a part of our society, the more direct experiences of biculturalism, the higher the bicultural acceptance attitude and multicultural acceptance, so it is believed that awareness improvement education that can increase multicultural understanding and acceptance attitude should be conducted . It was As was previously indicated, behaviors acquired in adolescence have a lasting impact on young people’s lives and can persist far into late adulthood. Thus, it’s crucial to develop healthy habits during adolescents. The demand for psychological and mental care is rising as quickly as the number of multicultural adolescents both at home and abroad. Supporting multicultural youth results in better school adaption because of positive peer relationships and after-school programs. Additionally, it promotes parental involvement and consideration in general.Regarding the study’s limitations, the self-report and extensive raw data were both analyzed using weights. Multicultural adolescents who today have different cultures, nations, and levels of Korean language proficiency cannot, therefore, be generalized in this study. Future studies should therefore concentrate on variables that influence the smoking rate of multicultural teenagers considering variations in culture, nationality, and Korean language proficiency.Regarding this study’s limitations, this study included large-scale raw data and self-reports. Hence, this study cannot be generalized because it does not consider the timing of adolescent’s smoking start, whether they have attempted to quit smoking, or their interactions with peers.Based on the ecological integration model, this study examined the factors affecting smoking among multicultural adolescents from the subjects of the Korea Youth Risk Behaviour Web-Based Survey (KYRBS) for five years from 2016 to 2020. Among 4577 multicultural adolescents from 2016 to 2020, in terms of the microsystem, male students were 2.49 times more likely to smoke than female students, and in the family factors of the social network, if their fathers were born in Korea, they were 0.55 times less likely to smoke than those with foreign fathers and 12.02 times more likely to experience violence in social factors in terms of the social network. In addition, in this study, it was found that drinking was the highest related factor affecting smoking among multicultural adolescents.Therefore, it is important to think about educational and psychological solutions, which call for a multifaceted strategy involving parents, peers, and teachers. These interventions help multicultural adolescents adapt better to school, experience less drinking, and eventually smoke less, leading to lower rates of these risky behaviors.


Although much in the lives of members of the Caiçara small-scale fishing communities of Lázaro and Saco da Ribeira in Ubatuba, southeastern Brazil would suggest hardship, that population expresses a surprising degree of satisfaction with life. In this paper, we use a social wellbeing lens as applied through an ethnographic, mixed methods approach to reflect on this overall sense that lives rooted in small-scale fishing are well worth living despite their many challenges. We see the classic maritime anthropology theme of identity at the heart of meaning and life satisfaction. Identity provides core aspects of how people engage with their realities and anchors values that are reference points in work and social relations. With reference to the relational nuances revealed by the social wellbeing perspective, however, we show that Caiçara and small-scale fishing identities are not monolithic, but reflect gender and other social positions, and personal and familial experiences. These experiences include grappling with the complex effects of economic, social, political, and environmental changes. We conclude by arguing that fisheries policy that seeks to prioritize human wellbeing would benefit by adopting a social wellbeing perspective. Fisheries policy could thereby take into account identity, values, and relational elements of social life that give meaning and a sense of belonging to small-scale fishers, while also recognizing the cross-cutting and often contradictory variations in human experience that arise from social and economic differences. This social fabric of small-scale fishers’ lives shapes their intentions and actions and is thus a necessary complication to the practice of fisheries management that its proponents need to consider. A core assertion of the maritime anthropology literature of the 1980s and 1990s was that there is a distinctive quality to fisheries that is worthy of study and explanation Acheson , made thIn recent years, the social wellbeing approach , we apply the social wellbeing approach in this paper as a lens to showcase the complexity of attachments to fisheries and belonging to place, the tensions in social relations in the face of change, and to explore and test the limits of earlier notions that fisheries foster a distinctive identity, and even culture. We trace how complex relationships among social difference, values, and identity inform understandings and practices of living well. We affirm the importance of social wellbeing as a frame of analysis and suggest it could be a means through which to build empathetic understanding of the contextually specific qualities of small-scale fisheries among those responsible for governing the sector. These empirically grounded and practice-relevant reflections on social wellbeing complement other recent research on identity and wellbeing in Brazil and elsewhere , provides a holistic and multidimensional approach and a people-centered lens as it seeks to understand people’s objective circumstances, their subjective perceptions of these circumstances, and the relationships that shape how they perceive their quality of life . As we elaborate in the “Commonalities and contradictions in expressions of wellbeing among small-scale fishers in Ubatuba” section below, however, neither vida simples nor the two facets of identity to which we link it should be seen as monolithic. Our research reveals a range of cross-cutting tensions and contradictions among the Caiçaras of Ubatuba that reflect social and economic differences and exposure to ongoing development and change in the region. Social wellbeing provides a methodology that can effectively address these ambiguities and variations in identity.In this paper, we are particularly interested in how identity, values, and social relations inform perceptions of wellbeing in a small-scale coastal Brazilian fishing community. Identity is a core constituent of different approaches that have influenced the emergence of the social wellbeing approach, including the economics of happiness and gender studies , hook and line, hand jigs, and small trawlers. Other than trawler fishers, most fishers owned their boats and gears. Out of 15 trawling fishers, five (33%) did not own trawlers and instead worked as a hired captain or as a crew member for boat owners. Several households had more than one type of boat: canoes, skiffs, and small trawlers, and it was common for fishers to shift boats depending on the resource targeted Leite . While tMicropogonias furnieri), sea-bob shrimp (Xiphopenaeus kroyeri), sardines (Sardinella spp), pink-shrimp (Farfantepenaeus brasiliensis and F. paulensis), and blue runner (Caranx crysos), among many others. The bay also hosts several marinas and boathouses . Moreover, a sustainable-use marine protected area , with 236,047 ha, was established in 2008 encompassing almost all fishing spots used by Lázaro and Saco da Ribeira fishers. These top-down measures led to much conflict between fishers and authorities Leite . AlthougThis paper derives from a larger PhD project examining wellbeing (this manuscript), multi-level resilience , while others focused more specifically on material, subjective, or relational dimensions of living well . While many of the methods were adapted from Coulthard et al. (The study reported here adopted a mixed methods approach embedded within an overarching ethnographic approach (see details below). Within this, the social wellbeing approach was followed as a guiding body of theory, but the specific methodology was adapted from Coulthard et al.’s  handbookd et al. , the houd et al.  which ind et al. , followiFieldwork was carried out from June 2014 to July 2015. A validation visit was conducted in May 2016.Among the 44 households fishing households in the community at the time of research, 41 volunteered to participate in this research, i.e., the survey and other methods. Of the three households that did not participate, one was due to unwillingness of the household head to participate in the research, one due to sickness of a household member during the research period, and the third due to difficulties in finding a time when the participant was available.Here, we are considering fishers as those individuals who actively fish on a regular basis as a source of income. Recreational and occasional fishers were, therefore, not included. The sections below explore the five data collection methods used, providing detailed information on the type of data collected, followed by a section on data analysis. Table Wellbeing research requires the researcher to build strong rapport with participants in order to access the richness of their values and ways of life. With this principle in mind, the first author and her family resided in the community, renting a house from a respected local fisher. The fieldwork was initiated with an exclusively participant observation phase, aimed at gaining familiarity with the community members and, ultimately, the research participants. In participant observation, the researcher interacts with the people being studied in their daily lives Creswell . This inHousehold surveys can be used to produce statistics about a target population Fowler . They maWe chose the questionnaire of Hanazaki et al.  rather tThe household survey identified 48 fishers, aged 18 to 89 years old. Of the 48 fishers, 38 were adult men, five were women, and five were male youths aged between 18 and 28 years old. The five fisherwomen fished together with their husbands and also contributed to pre- and post-harvest activities . In addition, eleven women, who did not fish, were involved in fishing related activities, such as pre- and post-harvest activities and household budget management.narratives of specific challenging life-events, and life histories, to connect the lives and stories of individuals to their values and worldviews, allowing for a deeper understanding of the local fishing way of life. Life history can be considered a type of narrative, or an autobiographical narrative, yet not all narratives are life histories as they can relate to a specific event (Hatch and Wisniewski Open-ended interviews were used to explore We purposively selected 16 participants (ten men and six women) to ensure representativeness of all participant groups . We asked the question “Could you please tell me about your life as a fisher, or as wife of a fisher, and the challenges and opportunities you faced?”Based on data collected under the previous methods, semi-structured interviews Creswell  were conThe interviews were conducted with both fishermen and fisherwomen and their spouses (if the case) separately, totaling 30 participants, 12 women and 18 men. The selection criteria called for the majority (over 60%) of the fishing community households to be interviewed, while ensuring also that these interviewees spanned different age-groups, gender, type of fishery, education level, and social status found in the fishing community. All interviewees had been involved in the previous stages of the research (household survey and/or open-ended interview).The interview questions were dedicated to deeply understanding the meaning of living well for different participants, including material, subjective, and relational dimensions of wellbeing. The Global Person Generated Index (GPGI) and the relational landscape methods were applied as part of the interviews, both adapted from Coulthard et al. . The GPGThe relational landscape is our revised name for what Coulthard et al.  call theLastly, focus groups took a more prominent role in our research than suggested by Coulthard et al. . We usedAll participants from the 41 households involved in the research were invited to participate. Three focus groups were conducted, with adult men (11 participants), adult women (six participants), and youth  respectively. The meetings lasted an average of 2 h each. Focus groups were held in the community, in the house rented by the first author. Questions explored community-wide relationships and conflicts, group agency, and fishers’ participation (or lack thereof) in fisheries governance , and then coded by topics (nodes), allowing for the creation of subcategories. The topics, and therefore codes, were predefined according to the three dimensions of the social wellbeing approach . Qualitative data were analyzed through triangulation of information coming from different sources and/or methods. Some counts of frequency of mention of specific themes and rankings of priorities in the semi-structured interviews were also made, to suggest relative importance accorded by the participants. Priorities included being healthy, money, God and faith, freedom to fish, friends and neighbors, family, sons and daughters doing well, relationship with spouse, land and house ownership, and job satisfaction. Since the semi-structured interviews are based on a purposive sample, of half of the adult participants in the study, it is not appropriate to generalize these counts to the entire population.The scope of this in-depth study was necessarily confined to the time and cash budget of a doctoral study. The depth achieved was possible through previous studies, including those conducted as part of the IDRC/SSHRC funded International Chairs Initiative project, and good relationships in this community. As with all single case studies, points within the findings may or may not be generalizable to other places, in Brazil or elsewhere.The methodological diversity that we adopted in our research provided evidence to tell a distinctive wellbeing story about the Caiçaras of Ubatuba. Semi-structured interviews and participant observation suggest strong identification as Caiçara and small-scale fishers in ways that are closely aligned with key elements of the “vida simples” ideal. Moreover, results from the household survey suggest that these areas of identity provide important points of reference for how people justify their self-assessment of relatively high levels of wellbeing. The story is complicated, however, by more fine-grained subjective and social relational evidence derived through the GPGI component of the semi-structured interviews, participant observation, and the relational landscape method. It was clear that a positive association with a Caiçara small-scale fishing identity at the population level was subject to complex relational variations linked to gender, gears used, socio-economic position, and personal histories and experience. We present our findings with regard to Caiçara fisher identity in a layered approach that brings out evidence from different methods, beginning with broader findings about identity from the semi-structured interviews.Our research formally addressed Caiçara and fisher identity through questions that we asked during the semi-structured interviews. Most importantly, we asked, “What does it mean to you to be a Caiçara?” and “What does it mean to you to be a fisher or the partner of a fisher?” Table Table Our data indicates that Caiçara fishers and their families make reference to shared ideas of what constitute Caiçara fishing identity and way of life. Indeed, we found these reference points central to the conceptualization of wellbeing in Lázaro and Saco de Ribeira. Being laid back, the Caiçaras’ distinctive sense of humor, living in the present and therefore not worrying too much about the future, a strong faith in God and in the divine, the embrace of a simple and humble lifestyle, were not only cited by participants as self-descriptors, but were manifest in behaviors that the first author observed in day-to-day interactions with research participants during her fieldwork.The GPGI and relational landscape methods are aimed at eliciting individual assessments of the most important features of the lives of research participants that contribute to their subjective and relational wellbeing. Elaborations of how and why different features of life contribute to wellbeing (or illbeing) are not exclusively subjective or relational, however. Subjective, relational, and material aspects of wellbeing are interrelated. Reflections on relational dimensions of subjective experience, or the subjective or material implications of relationships, provide valuable insights into the diversity and complexity of identity. The GPGI and relational landscape results, in other words, contextualize and situate Caiçara fisher identities. Our application of these methods foregrounds the cross-cutting effect of gender identity in particular, but also brings out family and religion as complicating the subjective and relational aspects of Caiçara fisher identity. That identity is neither homogeneous nor complete unto itself.Significant distinctions surfaced when comparing levels and areas of life satisfaction by gender, as presented in Figs. Figure The category “being healthy” was identified as the most important area for participants’ wellbeing (cited by 80% of participants). Interesting, a gender analysis demonstrated that men tended to value this category more than women Fig. . Men alsWhile the “money” area demonstrated general importance according to a number of people who listed it among their top five areas of wellbeing see Fig. , in the My wife works, but the responsibility for paying our bills is mine. I appreciate her help, but that is a responsibility of the men.I work because fishing is not enough to pay the monthly bills. But my husband is too proud to admit it.Other seemingly contradictory points that emerged from the “money” area analysis were that while many participants — during semi-structured interviews — declared money as important mainly as a means of meeting their basic needs, the levels of satisfaction within the category, identified by the GPGI method, were not necessarily high in spite of basic needs being met among most households interviewed. Therefore, while general levels of life satisfaction were high (for both men and women) as demonstrated earlier in Fig. The analyses of levels of satisfaction identified through the GPGI method demonstrated that while placing greater value on “money,” men also tended to be less satisfied than women. Men declared their levels of satisfaction with “money” primarily as “OK,” and to a lesser extent “poor,” while women indicated “good” and “OK,” and only 20% of women declared it as “poor.” Here, it is important to emphasize that only participants who declared “money” as one of the five areas with the most relevance for their wellbeing were then asked to rate their levels of satisfaction with it. Therefore, almost half of participants, those who did not declare “Money” as one of the five most important areas, are not represented in the satisfaction rating analysis for this area, suggesting that many participants are content with a modest income and their way of life. In further exploring those individuals who declared their “money” satisfaction levels as “OK,” most were fishers who did not have alternative sources of income. In other words, lower levels of satisfaction with “money” were common among individuals who had fishing as their sole source of income. Again, households that did not have extended families living in the community also tended to indicate the “money” area as important for their wellbeing, and present lower levels of satisfaction with it. Therefore, there is a strong indication that individuals experiencing tougher financial circumstances were the ones relying primarily on fishing for income or those with weaker networks of support within the community.While the two first themes in Fig. five most important areas for an individual’s wellbeing, such absence does not necessarily mean it is not valued by participants. The fact that the GPGI method only allowed for the recognition of five areas must be acknowledged as a limitation for the identification of other possible important areas that do not necessarily surface in the method. This is especially relevant for the “God and faith” wellbeing area, as the “relational landscape” method and several complementary questions made to participants during the semi-structured interviews suggested a strong relationship between Caiçara male fishers and faith , being physically active and meeting the constant challenges of the sea and the catch, important subjective and relational aspects of fishing activities reported were stress reduction, positive emotions, social integration, feelings of freedom, and pride in being a fisher. All of these points emphasize that the sea acts as a source of subjective wellbeing for Caiçara fishers. The importance of religion and spirituality for participants is also reflected by the general levels of satisfaction with the “God and faith” area, where all women who cited the area declared their levels of satisfaction to be “excellent,” and all men said it was either “excellent” or “good.” Caiçaras — like the large majority of Brazilians — were mainly Catholic until the 1970s, when evangelical churches started to establish themselves in many parts of the country including coastal communities. At the time of the fieldwork (2014–2015), there were four different churches in the community, one Catholic and three evangelical.Yeah, it [religion] divided [the community] a lot. I feel it in my own skin, with my family. We used to have many festivities together, now that half of the family is evangelical, we do not get together on New Year’s Eve and many other holidays. While churches were identified as central networks of support in times of illness, loss, death, and financial hardship, as well as supporting recovery from substance abuse, the diversity of Christian belief systems was also linked to diminished community cohesion. During the women’s focus group, participants highlighted that the growth of religious diversity has had at least three distinct impacts in the community: (1) it has shrunk networks of support, to within same-church communities; (2) it has contributed significantly to the subjective wellbeing of religious individuals, including as an important support system for substance abuse recovery, both for men and youth; and (3) it has weakened relationships at the broader community level as the growing divergence in religious belief systems has had a strong impact on relationships at the community, extended family, and even household levels:The area “freedom to fish” was expressed as one of the five most relevant wellbeing areas for over a third of participants Figs.  and 7. FNowadays we fish with fear. We can’t fish here; we can’t use that net… We can’t go fishing when, where and how we want anymore. They [enforcement agents] control everything we do. I fish because I have been a fisher my whole life. If not, I would probably give up, you understand? The [government agency responsible for fisheries management] wants to extinguish us; they do not care about artisanal fishers.If they [government agency responsible for fisheries management] do not let me fish, I will “steal the fish” [fish illegally]. Not because I want to be an outlaw or a criminal, but simply because I am a fisher, and fishers fish. That is what we are [fishers], that is what we do [fishing].A way of dealing with the issue of imposed fishing restrictions commonly mentioned during interviews and informal conversations was making the decision to fish illegally, particularly in the surroundings of the Anchieta Island, a historical fishing area adjacent to the community, where fishing has been banned since 1970 due to establishment of a state park (no-take protected area):Nevertheless, there are severe consequences for fishers if caught fishing illegally, such as arrest and loss of fishing gear. Furthermore, such incidents result in the marginalization of small-scale local fishers more generally.Relations with neighbors and friends were central to women’s wellbeing. Fifty percent of female participants declared “relationships with neighbors and friends” as one of the five most important areas for their wellbeing Fig . The samFor those participants who included “friends and neighbors” as one of the five most important areas, levels of satisfaction varied. A strong trend that surfaced from this data was higher levels of satisfaction held by members of extended families who had lived in the community for many generations , and lower levels of satisfaction in fishing families that were the first generation in the community. Marriages between members of extended families living in the community were quite common and played a role in maintaining networks of support among the traditional local families. There were, at the time of the fieldwork, eight different extended families living in the community for more than three generations (in many cases for four or five). These families were mostly Caiçaras that still held land in the study area, and that passed land, boats, fishing knowledge, and skills down through the generations.If considering the three categories related to family: “family ,” “relationship with spouse,” and “sons and daughters doing well” as one broad “family” category, it then becomes the most cited area Fig.  as it ouThe central role of the family unit, either represented as immediate family members or as extended family, is fundamental for Caiçara identity and culture, in addition to its importance for wellbeing. When approaching levels of satisfaction for the three categories related to family, some interesting findings surfaced. While both men and women demonstrated high levels of satisfaction with “family” as a general area, areas related to “sons and daughters doing well,” and “relationships with spouse,” showed that men tended to present higher levels of satisfaction in both areas than women Fig. . ParticiAn explanation, based on interviews with some of the participant women, might be that mothers tended to have higher expectations for their children than men. Perhaps one reason is the perception, often held by men, of less need for formal education, and rather an emphasis on local knowledge, required for fishing activities. Some women also demonstrated greater anxiety over their children’s futures, as exemplified by women’s greater tendency to save money, while men found themselves more often in “the present moment” and not as concerned with future expenses.Finally, the men who demonstrated higher levels of satisfaction with the category “relationship with spouse” were, for the most part, according to the open-ended interviews, older fishers (60 years old or older) who have engaged in larger scale fisheries in the past , and/or wrestled with alcoholism in their younger years. For these men, being out of the family setting for long periods in their past lives as fishers, and having their wives and children patiently waiting for them back home, seemed to contribute to valuing their relationships with their wives nowadays:This woman is strong, you know? She stuck by my side through hard times. She forgave my absence, my drinking, and rudeness in the past, and I respect her for that! We were always waiting for him to come back, but I will admit to you, sometimes I couldn’t wait for him to leave for the sea again. He came home and thought he deserved to rest, he did not realize how much work it was for me to stay on land with our seven children.Nevertheless, elderly women struggled during these times; they shared memories of being insecure about when their husbands would be back home, their safety at the sea, if the income would be enough to fulfill their family needs, and furthermore having always to readapt to their presence and absence in the community:Land ownership is a very important aspect of wellbeing among Caiçara fishing households in Lázaro and Saco da Ribeira. From the 1960s onwards, Caiçaras lost thousands of hectares of land as Ubatuba gained road connections and immigrants took advantage of the lack of legal title and illiteracy of local residents to take ownership of these areas Adams . The famMoreover, as Idrobo and Johnson  found, oJob satisfaction offered another indication of the high importance placed on fishing for participants Fig. b. DespitYeah, it [fishing] is like an addiction for me, if I stay here [on land] I get anxious to go to the sea. I always want to go to the sea. It is a good thing, a good addiction, not a bad one.To fish is a profession, but it is also a pleasure, it is doing what I like. If I am frustrated, I go to the sea and all changes. I feel good at the sea, fishing. There is no other job that I would rather have.Probably not coincidentally, the only woman who cited “job satisfaction” (or in her words: “to work with what I love”) as one of the five most important areas for wellbeing was a fisherwoman. Attachment to fishing is also reflected by the high satisfaction levels in the “job satisfaction” area Fig. . TrawlerTaken in aggregate, the GPGI results provide insights into the primary aspects of Caiçara fisher life in Ubatuba that shape wellbeing. “Family” related areas and “God/faith” show high levels of satisfaction, while “money” and “freedom to fish” show lower satisfaction levels. The data pointed to men being more satisfied with the different chosen wellbeing areas, except satisfaction levels with the domain “God and faith” and “job satisfaction.” The area “job satisfaction,” however, was cited by only one (fisher) woman, who rated it as “excellent” and therefore, this number is not necessarily representative of the women in the study area.Our assessments revealed important nuances and variations within the experience of research participants regarding the influence of identity on wellbeing. Most obvious from the GPGI data is the distinction in wellbeing by gender identity. For men, fishing identity is prominent and enormously subjectively important to the point where it shapes their spirituality in ways that diverge from that of women. At the same time, however, men whose lives are most dependent on fishing for their livelihood are less satisfied than those with more diverse livelihoods and better social networks. While familial, community, and religious relational identities were important for men and women, emphasis on them was greater for women. That women’s evaluations of these aspects of their wellbeing were generally less positive than men perhaps relates to their greater responsibilities in these spheres of life. Women also have much less access to fishing as an alternative occupation than men, which restricts options beyond their land-based activities.The relational landscape method was applied to participants individually during the semi-structured interviews (18 men and 12 women). It changed the wellbeing focus from subjective to relational by asking research participants to give the relative importance of relationships with different categories of actors. In Fig. The relational landscape method revealed the importance of family (including household and extended family members) for Caiçara fishers and their partners. Moreover, data from the youth focus group confirmed that also among the younger generation, strong ties remain centered on the family unit, as siblings and cousins were commonly referred to as the closest relationships, followed by sports groups. At the “fishing community” level, fishing peers were shown to be primary relationships for fishers. Fishing together and sharing boats and gear were common customs for small-scale fishers in the study area. Fishing peers occurred frequently within households, extended families, and between members of traditional extended families in the community. However, there are cases where fishing together transcends family units, particularly for trawler fishers, who frequently rely on crew members, and therefore have a more established working regime and agreement. Relations with tourists also are important interactions at the broader community level, as many have significant dependence on tourism for their livelihoods.At the institutional level, within the community, churches demonstrate the most substantial weight for Caiçaras from Lázaro and Saco da Ribeira in terms of relational wellbeing. The local clinic and especially relationships with the clinic doctor were cited as the most important relationship between participants and local public services. The Saco da Ribeira Fisher Association, which was inactive until the end of the fieldwork, was cited by only three fishers. This status changed, however, at the time of the validation trip in May 2016 when the organization had been reignited. Follow-up research would be required to understand the association’s effects on relational wellbeing and fishers’ ability to better influence fisheries management and policy. Last, the “relational landscape” indicates an absence of engagement and collaboration between local fishers and fisheries management institutions, as all participants placed relationships with government agencies responsible for fisheries management in the far end of the institutional circle, reflecting the absence of dialog between fishers and managers in the place of study.Our findings show, in sum, a distinctive social relational landscape in Lázaro and Saco da Ribeira that accentuates tendencies in the GPGI data above. Family, religion, and fishing relationships run strongly through the ways in which people conceive of their wellbeing. As the GPGI data show, however, the intensity of these relational identities varies by particular individual circumstances and history.We organize the central findings of our study across the three social wellbeing dimensions. In Fig. In Fig. Identity is central to the literature on small-scale fisheries and one of the main justifications for research on small-scale fisheries. In this section, we reflect on implications of our research with Caiçara fishers in Ubatuba for this central premise of the small-scale fisheries literature. Social wellbeing as an analytical method complicates notions of small-scale fisher identity through careful attention to social relational context. The social wellbeing method reveals that fisher identity in Lázaro and Saco de Ribeira is cross-cut with Caiçara and other identities and is subject to varying individual capabilities, social positions, and networks. Different strands of identity fit together imperfectly and often conflict. Nonetheless, our research also shows that environmental governance based on exclusionary protected areas has directly threatened material, subjective, and relational dimensions of Caiçara identity and, thus, Caiçara wellbeing in Lázaro and Saco de Ribeira. Whether the Caiçara living in this area can confront this threat effectively depends greatly on whether their sense of shared identity can transcend the many social and identity differences that threaten to fragment it.Fishing is central to the economy and identity of the Caiçara population in Lázaro and Saco de Ribeira but fishing is not the sole referent of wellbeing for Caiçara in this place, nor does fishing mean the same thing for all members of the community. We illustrate the importance of Caiçara fisher identity in this section but also the ambiguity of the label with reference particularly to the different view on the question by men and women.The observation that men and women have different orientations to fishing identity is a long-standing theme in the fisheries literature , and institutional levels of relations with government agencies and other actors, the approach pays careful attention to subjective and relational wellbeing. These are areas normally neglected in livelihood studies, especially at more micro scales such as the individual and household levels (Weeratunge et al. In this sense, wellbeing is perceived as more than a desirable state of being; it also offers a way to understand fishers’ motivations and worldviews (Britton and Coulthard Our findings show, foremost, that the social wellbeing approach can highlight important collective tendencies in particular small-scale fisheries, but also social rifts that cut across shared identity. Awareness of these characteristics can build understanding by fisheries managers and other external actors, while also pointing to potential challenges for coordination of action and areas where work at community building can perhaps be most effective. Specifically, for the small-scale Caiçara fishers of Ubatuba, fishing clearly has more than just economic value; it is also a source of pride and satisfaction. Nevertheless, the subjective satisfactions associated with fishing have to be juxtaposed with elements of life that decrease wellbeing or reduce the capacity of fishers and their families to live a life free of fear and anxiety. In this study, conflicts with the enforcement agents of fisheries policies, threats to community cohesion, and lack of voice and participation in decision-making are all chronic areas of vulnerability that threaten wellbeing. Our social wellbeing derived observations are fundamental for the development and implementation of policies aimed at helping the small-scale fishers of Ubatuba achieve meaningful and dignified lives in a broader social environment in which they are respected.


The clinical learning environment is an essential component in health professions’ education. Data are scant on how postgraduate trainees in sub-Saharan Africa perceive their medical school learning environments, and how those perceptions contribute to their engagement during training, their emotional wellbeing, and career aspirations. This study examined perceptions of postgraduate medical trainees (residents) in a resource-limited setting, regarding their learning environment and explored perceptual contributions to their career engagement during training. The data reported contribute to understanding how clinical learning environments can be improved in low-resource settings in Uganda and elsewhere.This study was done at the Faculty of Medicine of Mbarara University of Science and Technology in Uganda. We used a descriptive cross-sectional design involving sequential mixed methods. Quantitative data were collected using the Postgraduate Hospital Educational Environment Measure (PHEEM). Qualitative data were collected using focus group discussions.Ninety of the 113 eligible residents responded (79.6%). Of these, 62 (68.9%) were males, 51 (56.7%) were third-year trainees, and the majority (40%) of the residents were aged between 30 and 34 years. Overall PHEEM scored 98.22 ± 38.09; Role Autonomy scored 34.25 ± 13.69, Teaching scored 39.7 ± 13.81, and Social Support scored 24.27 ± 10.59. Gender differences occurred in the perceptions of teaching and social support. Cronbach’s alpha coefficient was 0.94 for the overall PHEEM. Five major themes were identified from the qualitative data .Overall, this study suggests that postgraduate trainees at the institution perceived the clinical learning environment positively amidst challenges of limited resources. Trainees’ insights provided data that propose improvements on a number of domains in the learning environment. Postgraduate medical trainees’ perceptions of their learning environment (LE) relative to emotional wellbeing, engagement, and career satisfaction are important as individuals navigate through training. Learning environments are complex, comprising not just the physical and virtual spaces where learning takes place, but also the sociocultural interactions necessary for learning . ResearcBurnout in medical students can be mitigated by the learning environment , 8. DyrbData are scant on the extent of support that postgraduate medical trainees in Uganda and other resource-limited settings receive during their academic training from their supervisors. Data are also scant on how other modifiable factors such as physical infrastructure and training frameworks may be leveraged to enhance trainees’ experience of clinical care and research. A few studies from South Africa, Ethiopia, and Kenya have explored factors associated with the learning environment, including social support –14. In tOur specific aim in this study, therefore, was to examine how postgraduate medical trainees in a resource-limited setting perceive their learning environment and how those perceptions contribute to their engagement during training. This study will contribute to the data on the role of the learning environment in postgraduate medical trainees’ engagement, career aspirations, and wellbeing during training in Uganda and other resource-limited settings.We conducted a descriptive cross-sectional study using mixed methods at the Faculty of Medicine of Mbarara University of Science and Technology (MUST), a public university in Uganda, from January 12 to March 5, 2023. The Faculty of Medicine trains both undergraduate and graduate medical students. The medical curriculum for postgraduate training covers at least 3 years post-internship. Presently, postgraduate medical training is offered in all the major clinical and specialty disciplines including the Master of Medicine in Anesthesia, Community Practice/Family Medicine, Dermatology, Ear, Nose and Throat, Emergency Medicine, Internal Medicine, General Surgery, Obstetrics and Gynecology, Ophthalmology, Pediatrics and Child Health, Pathology, Plastic and Reconstructive Surgery, Psychiatry, and Radiology. A mentored research project is typically started towards the end of the second year, culminating in a dissertation which is required before graduation.Potential study participants were graduate medical trainees who had completed at least 1 year of training and consented to participate in this study. A list of potential participants and their e-mails (routinely collected as part of their academic enrolment) was obtained from the different departments and specialty units through the participants’ resident representative. The survey tool and FGD interview guide were pilot-tested on four recent clinical faculty graduates who were not part of the study to ensure clarity and intended meaning were achieved. Participants for the PHEEM survey were selected by an initial e-mail invitation that was sent to all potential participants with a link to the PHEEM tool and the informed consent form, if they decided to participate. E-mail reminders were sent out to potential participants who had not completed the survey one and 2 weeks after the initial e-mail. The FGDs were done after completing the survey.All postgraduate medical trainees were included if they had completed at least one academic semester of training, were willing to sit for an FGD of 45 minutes to 1 hour, and consented to participating in the study. Trainees who were ill, unable to provide written consent, or were doctoral (Ph.D.) students were excluded. Doctoral students were excluded because their program of study in this setting, unlike that of the clinical postgraduates in this study, is mainly oriented toward academic research, and follows a less structured independent program since they have already attained their Master’s degree qualification.The PHEEM is now the most widely used and recognized tool for assessing the clinical learning environment worldwide . It has There were 113 eligible participants identified. Due to this relatively small pool of potential participants who could be included in the study, the PHEEM survey was a census of all eligible postgraduate medical trainees in the Faculty of Medicine.Two FGDs were conducted – the first one comprised 12 members from the departments of Psychiatry, Pediatrics, Pathology, and Surgery. The second FGD comprised 10 members from the departments of Internal Medicine and Obstetrics and Gynecology. Participants for the FGDs were selected by an email invitation that was sent to all the eligible potential participants after they completed the PHEEM survey. Those who accepted to participate were contacted by the facilitator who organized the consenting, date, time, and venue for the FGDs. The FGDs were conducted among trainees who had completed the PHEEM survey to gain a deeper understanding of their perceptions of the clinical learning environment. Data saturation was achieved by the end of the second FGD so a third one was deemed unnecessary. The FGDs were conducted at the University campus in a quiet, safe, private, well-lit and comfortable room in the Faculty of Medicine. The facilitator for the FGDs was a neutral person who at the time was not involved in teaching, tutoring, or mentoring the postgraduate medical trainees.p-value less than 0.05 was considered statistically significant. Data were analysed using GraphPad Prism version 7 and Statistical Package for the Social Sciences (SPSS), version 26 .Descriptive statistics were used to describe percentages, means and their standard deviations, and interquartile ranges of the scores in the instrument used. Internal reliability of the PHEEM tool was assessed using Cronbach’s alpha coefficient. Parametric data were analyzed using one-way analysis of variance (one-way ANOVA) while non-parametric data were analyzed using Kruskal-Wallis test with Dunn-Bonferroni correction done for further pairwise comparison to determine which pairs of categories had statistically significant differences. A Thematic content analysis was used to analyse the transcribed anonymized data from the FGDs, based on the six-step framework by Braun and Clarke . TranscrOut of 113 residents invited to participate in the survey, 90 (79.6%) responded and completed the questionnaire. Of these, 62 (68.9%) were male, 51 (56.7%) were year 3 trainees, and the majority of participants were aged between 30 and 34 years. Participants represented 12 clinical departments that train specialists for a three-year period; at the time of the study only second- and third-year postgraduate trainees met the criteria for inclusion into the study, as the first-year trainees had just commenced their first semester of training. Socio-demographic data for the participants are shown in Table X2  = 6.4, p = .169; or gender and year of postgraduate training, X2  = 0.1586, p = .69.Cronbach’s alpha coefficient for the overall PHEEM tool was 0.94, for the role autonomy subscale was 0.83, for the teaching subscale was 0.93, and for the social support subscale, it was 0.74. A chi-square test of independence showed that there was no significant association between gender and age category, The mean total PHEEM score was 98.22 ± 38.09, with the three sub-scales scoring 34.25 ± 13.69 for Role Autonomy, 39.7 ± 13.81 for Teaching, and 24.27 ± 10.59 for Social Support . Significant differences also existed by funding source for three items in the perception of social support Table .Table 4Analyses of the transcribed data showed 5 major themes with a number of sub-themes as indicated in Table Many trainees aspire to certain ideals during and after training. Seeing their transition from novices to proficient practitioners of their specialties is exciting and motivates individuals along their career paths despite the uncertain journey from novice to proficient practitioner, perhaps even mastery. Participants acknowledged the importance of support, both emotional and intellectual, during training. One participant observed:“…we hold different activities within the department including case conferences and journal clubs and therefore these are done in presence of all seniors most of the time, and so they keep guiding us and teaching us…yeah, so that we improve at the next presentation.”Most of the participants valued the support given by peers and supervisors during training. One trainee in Pathology pointed out:“...[availability of supervisors] gives us a chance to always interact with them on a daily basis right from the time of lectures, to reading slides, the time of signing out cases.”One of the ways many trainees felt supported was through orientation when they started their training and during different periods of their training. Trainees valued the orientation that was provided on the educational goals, expectations, structure of the clinical services at their training stations, and opportunities available after training. One trainee observed,“…we get to learn our limits… we learn our limitations…as residents, we get to know at what point do we get to call the specialists, there are actually protocols where some of them are clearly put. A specialist needs to be called, informed about this case within this and this time.”For many residents, being able to work independently but with supervision from faculty provided an opportunity to satisfactorily engage with their supervisors during their training. Many residents appreciated the importance of the supervision of their teaching activities when they prepare to make presentations:“Seniors are there to see how you have prepared your slides, how you present your material and how you, ah, emotionally handle yourself.”Moreover, many residents highlighted the significance of their seniors and academic supervisors as role models in their academic preparation to practice.Many residents perceived that overall they were satisfactorily engaged with the learning environment and recognized that the environment provided insights into mistakes made during training. One trainee observed,“When I reflect back I see things that I, I could actually...if faced now I actually do differently, I face with confidence and I can tell what...I feel more in charge [pauses] personally as a postgraduate student.”Aspects of the learning environment that were perceived as enhancing training and practice included the availability of patients as a resource, collegial faculty, learning that was trainee-centered, and orientation on opportunities after they completed their training.Many trainees perceived their learning environment as building their competencies:“…largely the hands-on experience we have in the department, it’s quite practical in the different aspects of the study, so that’s a good thing. The second is that most, majority of the aspects in studying, uh, are sort of student-led, and I think that is a good thing as opposed to just being fed information.”Trainees appreciated the collegial environment present in their clinical training. One participant commented,“…you will find a senior on the ward, and they are also very friendly to us, they treat us like we are colleagues, and also they mentor us, yeah. They have formed mentorship groups and our mentors look out for us so much.”Participants perceived the learning environment as one that provides a suitable preparation for their future practice despite some of the challenges such as heavy workloads. One participant observed,“I have really got a chance to see many cases which I am really happy about, so despite the heavy workloads, I think it uh, that prepares me for my next uh...phase.”Participants felt strongly that in spite of the limitations of training equipment and information resources, the availability of a rich patient resource prepared them for their future practice in their specialty. A participant from Internal Medicine commented:“I think anyone who has gone through this system will probably do well out there, because uh, you know, eh, patients is also a resource (sic), and the condition they present to us is also a resource…”.Another participant from Surgery department:“…most of the conditions that we would wish to be exposed to they are readily available and we never lack the number of patients that we are interested in.”Intertwined with participants’ aspirations and ideals were perceptions of challenges relating to engagement during training and preparation for future practice, which was a major theme.The first subtheme included challenges related to training support structures. Some residents expressed dissatisfaction with interpersonal relationships between themselves and their academic faculty: One trainee commented,“…some lecturers lack proper communication skills, eh, so they push you into depression because you are stressed all the time, you can’t breathe, you are scared to enter the hospital because each day you are looking up to another day where you are going to be rebuked, and in a rather, um, immature way…yeah.”“You are either stressed by the lecturer or by the nurses, because as a resident you know this is an emergency or not. You will see a patient and think, I will review them later. But then the nurse wants you to see them at that very minute and if you don’t see them they go and report to your lecturer who is going to grill you, yet that very lecturer wants work the next morning. So...it’s quite taxing and very depressing.”Another trainee observed, A few trainees perceived the inadequacy of orientation at the start and during their training as a challenge. One trainee observed,“…unfortunately orientation is just a two-hours’ talk and that is all. Afterwards it is baptism by fire and even for the students who don’t know how things go here it is usually very difficult.The second subtheme involved trainees’ perceptions that the limitations in physical infrastructure were a challenge in their training. These limitations included limited physical space, limitations in the availability of equipment during training, and inadequate exposure to resources routinely used in their specialties.One participant observed,“I feel like if it was...all these resources were available to us more often we would get a richer experience and having, you know, that specialist training on them.”“…as a specialist in training, there are some, common, uh, investigations, that we should be able to familiarize ourselves with, I am thinking echocardiography, ECG, and these should be readily available to us, but unfortunately, they will guide me if I am wrong, we don’t get that.Another participant observed, A third subtheme involved many trainees recognizing challenges with integrating work responsibilities and learning, and considered the balance unsatisfactory. One trainee remarked,“…you find we have a lot of clinical work, most colleagues who are on certain stations can be in clinical work all day, until late evening, 6.30[p.m.] when you are…if you are lucky to break off at that time, if you are not on call. But if you are on call, you will continue your duty until tomorrow, and tomorrow will still be the same similar day. You will continue your duty. So, if this person has a lecture, he’ll miss.The last subtheme involved challenges with limitations in training frameworks and policies. Although many trainees perceived that they were familiar with their limits during training, some decried the deficiency in communication and guidance during their training. One trainee commented,“…I don’t think our roles and even the resources were made clear...uh...as for me I learnt on job, many, many things, and generally in terms of general resource, ah, provision and preparation… we are not generally guided even before the course on where to go and find information… personally struggled to get access to information…”.Some of the trainees perceived the lack of clear policies regarding their training as a challenge that impeded their training. A trainee remarked,“…it seems like the ones who are supposed to inform of our limitations also don’t know how far the residents are supposed to go, eh. Ah, for example, like you can do something…um, one senior thinks it is okay, and then the other senior thinks it is not okay. So you get confused, eh, you are torn in between…am I okay, am I supposed to do this, eh?”The goal of this study was to explore the perceptions of postgraduate medical trainees towards their clinical learning environment in a resource-limited setting, and identify how these perceptions contribute to their engagement during training. Most resource-limited settings occur in developing low- and middle-income countries, and are characterized by insufficient infrastructure (or have rudimentary infrastructure), capacity building resources (or have limited capacity), financial, human, and other resources necessary to teach, supervise and mentor trainees . In the Our finding of an overall positive clinical learning environment but with room for improvement, showed better educational environment measures than some recent studies in Ethiopia among internal medicine residents, in Sudan among pediatric residents, and among multiple resident specialties in Nigeria and Morocco with similar economic status , 23–25. The reason for gender differences in the responses to perceptions of teaching and social support in this study is unclear, given that males consistently ranked several items in the perception of teaching, and one item in the perception of social support higher than females. Considerations are needed to address the gender differences in the CLE during training, for example, providing targeted mentoring and support, and specific diversity, equity, and inclusivity (DEI) activities. To offset the gender differences seen in this study, one feasible solution could be through establishing a DEI committee that is contextually appropriate, wide-ranging, and relevant to the education needs and experiences of trainees. A blueprint for such a DEI committee can be adapted from recent studies –30. It iWe included funding source for the postgraduate trainees’ education, a characteristic not routinely described in literature, and perhaps is described here for the first time in relation to the clinical learning environment. Funding potentially impacts trainees’ welfare during daily living and through the training duration. Postgraduate trainees who fund their own training consistently rated items pertaining to catering and accommodation while on call, and access to career advice, lower than those who had scholarships from the government or other external funding.Qualitative data in this study complemented the quantitative data from the PHEEM survey. Our qualitative findings differed from a study done among Internal Medicine residents at a medical college in Addis Ababa in Ethiopia where trainees perceived the clinical learning environment as mostly negative . FissehaResidents in the study by Fisseha and colleagues perceived the resource limitations and inadequate diagnostic and therapeutic interventions as significant impediments to their training and preparation for future practice and expressed feeling unready to practice as consultants on completing their training . In our Consistent with another study in which residents perceived that their supervisors engaged them individually and provided multiple perspectives and feedback, participants in our study appreciated the regular interaction with supervisors, emotional support, and mentorship during their training . SimilarMany of the themes arising from a recent workshop on Family Medicine training in Africa, especially interactions between trainees and supervisors and feedback, were shared by trainees in our study . In partPerceptions regarding availability of resources for training were similar to that in a recent study from South Africa in which family medicine registrars (residents) reported shortages of resources such as training tools (e.g. ECG), Internet availability, and training space . In bothThis study contributes data on the international utility of the PHEEM in evaluating the clinical learning environment in low-resource settings and the qualitative findings triangulated the PHEEM data. One of the major strengths of our study was that it had postgraduate trainees from multiple specialties, which contributed a greater depth to understanding the clinical learning environment through both the PHEEM survey and the qualitative study. Another strength was the use of both quantitative and qualitative approaches, with the latter complementing the findings from the survey. Our study findings, however, are limited by its cross-sectional design, and the outcomes may not generalize to another time or place; the findings, nonetheless, provide baseline information that will be useful for future studies of this nature. Another limitation is the absence of systematic sampling. It is possible that some of those who decided to participate in the survey did so because of an unanticipated bias. Lastly, some departments had small numbers of one gender, and the perceived differences in responses may not be wholly representative of the clinical learning environment in those departments.Regardless, the conclusion from these findings is that the clinical learning environment is positive despite limited infrastructure, human, and other resources. Trainees’ insights provided data on several potential areas that could be modified or endorsed to improve the learning environment in our study context. Key elements of the CLE that will need improvement include training support, physical infrastructure, training frameworks, and supervision. Further studies are warranted on these elements and on the gender differences in the perceptions of aspects of the CLE that would enhance training.


Loneliness and exclusion from social relations (ESR) are frequently addressed as public health issues for older adults. Public discourses potentially influence how loneliness and ESR are understood in society and experienced by the individual. The aim of this study was to analyze how older adults in different parts of Sweden use the discourses and concepts available to them to describe experiences of ESR and loneliness, and how these descriptions are used to construct a self-identity.Qualitative semi-structured interviews were conducted with 30 individuals  aged 67–87 years and living in Sweden. Emphasis was, in line with perspectives of discursive psychology, on how individuals draw on discourses to make sense of experiences. The empirical material was analyzed through an inductive process where we were open to finding concepts and themes.Most participants emphasized the importance of not being lonely, considered achievable through maintaining an active lifestyle. “Othering” was taking place, where a general image of a “lonely” older adult was referred to when speaking about “others” loneliness. Those who expressed feelings of loneliness related these feelings to loss, being omitted, and other difficult life circumstances.States of ESR were discussed more comfortably than loneliness, whereas various linguistic resources were used to distance themselves from loneliness. These findings indicate the need for further studies elaborating on how older adults make sense of ESR and loneliness and what implications this has for older adults’ well-being and identity making. There is a major public attention and stereotypical portraiture of loneliness and states of exclusion from social relations (ESR) as predominately aging issues . InternaThere are, however, both conceptual and cultural challenges as loneliness and ESR are often used interchangeably , whereassubjective feeling of having fewer social relations than desired, or that of an unfulfilled intimacy from established social relations  are defined as ESR states .The call for participation consisted of information about the study, how the interviews would be conducted, and the conditions for participating. We made clear that participants would remain anonymous and had the right to withdraw from the study at any time, without giving a reason for this. Persons interested in participating in the study contacted a research administrator and were given an information sheet and an informed consent to sign. All participants contacting the research administrator met the inclusion criteria of this study and thus were included in the sample. The recruitment began in February 2021 and was completed in April of the same year, approximately 12 months after the social distancing measures for those older than 70 were strongly recommended by the Swedish government . The recM = 73.80, SD = 4.54, range = 67–87), and self-rated their health as very good or excellent (61.5%), good or fairly good (30.8%), or less than good (7.7%). From the participants, 28% reported mobility restrictions due to health issues. Most of the participants were living with their spouse (73%), some were widowed (11.5%), divorced (11.5%), and one was never married. Most of the participants had an equivalent to high school education (73%), with 11.5% having more and 15.4% having less education.In total, 30 persons participated in the study, with a nearly equal gender distribution (14 men and 16 women). The participants were of postretirement age , with the excerpts included in this article translated from Swedish into English by the authors. When analyzing the empirical material, we used the general inductive approach for qualitative data , where wThe process of coding started with first familiarizing ourselves with the material through reading and re-reading the transcribed interviews (Phase 1), noting on the overall feeling of what the participants were saying. Thereafter, we proceeded to initial coding (Phase 2), where the focus was on words, concepts, and phrases which highlighted, in line with the aim of the study, how participants made sense of ESR and loneliness, as well as how these descriptions were used to construct a self-identity. As we adopted an inductive approach, the focus in this phase was on identifying meaning units within the data and labeling and categorizing them into codes . For exaIn the final phase, Phase 3, we proceeded to what In this section, we will present the themes found after analyzing the empirical material from the 30 interviews conducted in this study. The excerpts corresponding to the excerpt’s codes are listed in The differences in how ESR and loneliness were described permeated all themes. One example of how participants made sense of ESR states was found in SE_210208_01_EE’s account  that neighbor really was, and how the process of constructing others as “lonely” may be based on certain cultural understandings of ESR and loneliness. Here, loneliness is equated with living alone, having experienced loss, and not having a spouse or family members, which resonates more closely with scholarly definitions of ESR states. However, when SE_210215_02_EE returned to her own life, she described how she was “left alone” when her husband died and that she had no relatives. Despite this description of being “left alone,” she never referred to herself as a “lonely” person or having persistent feelings of loneliness, suggesting that loneliness is more easily used to construct identities for others than for oneself.you can feel lonely in the mind even if you are not physically alone. Consequently, he distanced himself from loneliness by talking about “you” in a general sense, hence without using “I” as a pronoun that implies “the self” as an active agent in his own story. Later in the interview, SE_210202_01_EE, related feelings of loneliness to his marital life, which over 50 years of marriage had ups and downs, and it has been “hell” on several occasions. The couple never discussed the possibility of divorce, and now they are, according to him, “too old” to be upset with each other. The descriptions by SE_210202_01_EE were involving processes of othering, talking about loneliness in general terms, but simultaneously also expressing feelings of loneliness as related to his own marital challenges.Another example of othering came in the interview with SE_210202_01_EE  active. This overarching understanding permeated the articulation of perspectives on ESR states and loneliness, where being active in a broad sense was the positive and desirable goal. This dominating perspective served, in turn, to construct loneliness as persistently associated with what were understood as negative characteristics, such as fear of being alone, boredom, illness, ESR states, and loss. Thus, the participants reflected on common cultural distinctions between the “third age,” the period of activity and opportunities, and the “fourth age” as the new “real old age” associated with inactivity, frailty, illness, loneliness, and death .Although this may contribute to “the chimera of younger adults’ health in an older adults’ body” , p. 22, It is noteworthy that ESR states were discussed more comfortably in comparison with loneliness. Participants described various adversities over the life course and in later life, such as loss, difficulties during childhood, conflicts with children, diseases, spouse developing dementia, problems during working life, and living in depopulated villages. However, very few of the participants described their lives and identity in terms of loneliness. These findings raise the question of how to understand the linguistic resources used when discussing individual experiences of loneliness and ESR states in older age, and how to distinguish between them in older adults’ accounts of these experiences. We argue that these findings are in line with findings from We could not, however, know whether the participants did not want to admit to feelings of loneliness during the interviews or whether the reluctance to describe experiences of loneliness is rooted in broader societal understandings of loneliness as being surrounded by stigma . ConstitWhat appeared in the interviews was that various linguistic resources and strategies were used to downplay experiences of loneliness, by distancing oneself, talking about loneliness in general terms and depicting loneliness as a problem of “others,” whereas the accounts of ESR states were more explicit referred to the “self.” Consequently, in line with arguments by The findings of this study contribute to insights on how older people in Sweden make sense of loneliness and ESR states and how not being lonely is important in constructing their self-identity aligned with cultural understandings of active and “busy” lifestyles . We illugnad005_suppl_Supplementary_MaterialClick here for additional data file.