The number of empty-nest elderly in China is rapidly increasing. Empty-nest elderly could not receive adequate daily care, economic support and spiritual consolation from their children. Rural empty-nest elderly are facing more serious health challenges than those in urban areas.This study aimed to understand the experiences of rural empty-nest elderly in seeking medical services in China.The method of inductive content analysis was used to collect and analyze data. Data were collected by in-depth interviews. A total number of 16 participants were involved in this study. A semi-structured interview guideline, which was discussed in depth and agreed upon by all researchers, was used to encourage participants to talk about their experiences in seeking medical services.Rural empty-nest elderly is facing a great challenge in seeking medical services in China. There are some barriers for rural nest elderly to get access to healthcare services, such as low-income status, high expenditure of medical treatment and inadequate health insurance coverage. Due to the absence of the companionship of their adult children, empty-nest elderly have to rely on their neighbors and relatives to seek medical services.Rural empty-nest elderly have great difficulty in seeking medical services in China. More efforts should be made to get medical services more accessible to rural empty-nest elderly. In China, the “empty-nest elderly” are the elderly people who do not have children, or who do not live together with their children, and thus, they live alone or with their spouses , 2. WithEmpty-nest transitions pose physical and mental health challenges to the elderly people –9, whichChina Statistical Yearbook in 2018, the number of doctors and registered nurses per 1000 people in rural areas was only 1.82 and 1.80 respectively, far lower than that of 10.91 and 5.08 in urban areas . Moreover, the lack of medical devices prevent participants from getting medical care in the villiage clinic. As participant 13 stated “Due to the lack of medical devices, many illnesses cannot be diagnosed and treated in the village clinic. I have to go to the city hospital for medical treatment, but it is too far. I have to travel 20 miles to got to the city hospital”.Most of the recruited participants had suffered at least one chronic illness, and most of them had held negative feelings towards their illness. They stated that the illness made them feel psychological distress and inconvenienced.Almost all participants mentioned that their chronic illness caused them unpleasant feelings. One participant mentioned that, “It is a bad thing to suffer from illness, and no one feels good when they are sick. I feel really bad about my illness” [Participant 3]. Another participant expressed similar feelings, “The skin disease I suffered embarrasses me. When the skin disease attacks, I feel upset[Participant 1]”. In addition to the unpleasant feelings, many partcipants bore great psychological pain, just as participant 13 stated “When arthritis sets in, my leg hurts so much that I even cannot walk. I am at my wit’s end! It brings me too much psychological pain”. Participant 10 also complained, “I suffered a lot from my disease. I feel extremely uncomfortable. It brings me too much psychological pain”. Furthermore, some participants showed the feeling of being scared because some illnesses can happen suddenly and even threaten their lives without timely treatment. According to participant 3, “I have been suffering from high blood pressure. Once upon a time, I fainted in front of my house. When I woke up, my neighbors told me that they had dialed the emergency call. I was lucky enough to be saved by my neighbors. If I faint again and no one sees me, what will I do?” Participant 4 also expressed the feeling of fear, “The year before last, I had a heart attack. I was moved to hospital quickly. I lived in the hospital for half a month ... If I was not sent to the hospital in time, you won’t see me now. I’m really scared when I think of this matter.”.” Another participant also stated, “When the arthritis set in on my leg, I could barely walk. In that situation, it is difficult for me to go outdoors, let alone travelling (sighed) [participant 12]”. Besides, participants who have suffered serious injuries would have problems with basic activities of daily living. Participant 2 made it clear that, “My knee was injured in 1958. I cannot stand up when I sit for a long time. I have to move my knee first and then slowly stand up… As a result, I cannot walk long distances at all and even cannot be able to visit the village clinic when I was ill. It’s too much hassle.” Participant 7 was in a similar situation, “My leg hurt the year before last, and my bones broke. Now, I cannot work, I cannot farm, I cannot do any job…How I wish I could work (sighed)!” Hearing loss is also a serious problem faced by rural empty-nest elderly, which made them feel troubled in daily communication. Just as participant 9 said, “I am hearing impaired, and I cannot hear sound clearly unless the speaker’s voice is loud.”Participants stated that the chronic illness suffered reduced or damaged their bodily functions, which adversely affected their daily activities and made them feel inconveniced. Some particpiants complained that chronic illnesses prevented them from taking simple exercises. As participant 4 said, “I could not take part in square dancing because I suffered heart disease and high blood pressureThis theme describes the participant’s cognitive appraisal and personal understanding of their illness. This theme consists of three sub-themes, that is, dealing their illness with peace of mind, underestimating the severity of their disease and cure being no longer expected.s as a natural result of aging. As participant 6 said, “It cannot be avoided that one suffers from illness when he/she grows older…As we get older, illness finds us by itself”. Some participants in this study even show indifferent attitude to their illness. As participant 15 stated, “Illness is not the whole of my life. There are many things to be happy in my life. We should have a good mindset. When we grow old, we have to take everything in stride.”Some particpants argue that the illness suffered shoud not influence their emotions. According to participant 9 who suffers from backache and deafness, “We should deal with our illness with a natural mood, and there is no need to be upset.” Some participants regard their illnesIt has been found that participants tend to underestimate the severity of their illness. Although they knew they had an illness, they did not take it seriouly in that their activities of daily living were not negatively influenced. Participant 6 mentioned, “Although I suffer from heart disease and high blood pressure, they do not affect my daily life. I think that my health condition is generally good.” Besides, most participants suffered two or more chronic conditions and they seem to have gotten used to the diseases suffered and no longer regard them as a very serious problem. Another participant with coronary heart disease and high blood pressure needs to take medicine three times a day; however, she still thinks her illness is not serious. “The medicine I have taken could control my illness well. Thus, in my opinion, my illness is not serious. [participant 5]”. Participants exprienced a worse situation, but they still consider it not serious. As participant 3 stated,“I had fainted from high blood pressure and was taken to hospital by ambulance once a time. After that, my husband would give me a massage, when I feel uncomfortable. This could relieve the symptoms of high blood pressure. I think high blood pressure does not matter to me”.Many participants often no longer expect their illness to be completely cured. Some participants in this study suffered serious or intractable diseases. Participants with such diseases often no longer expect their illness to be completely cured. One participant noted, “Neither my heart nor my kidneys are in good health. I know that my illness is very serious and cannot be cured. [participant 7]”. Some participants suffered intractable disease, they give up the hope of the complete cure for their disease. Another participant, who had traveled to many cities to treat his intractable disease, finally gave up the hope of being cured. “It is impossible to cure my disease completely, because the sequelae of this disease has been going on for years... When the skin capillaries are blocked, it is difficult to restore it. Now I give up the hope of being cured. I just take some medicine to alleviate it [participant 1]”.Most participants reported that they looked forward to their children’s companionship in the process of visiting the doctor, while they could understand the absence of their chidren’s companionship., most of participants face great challenges in geting to the hospital when they were ill. Thus, they hope that their children could accompany them to visit the doctor. According to the views of one participant, “Two years ago, my leg had broken, which resulted in limited mobility. As a result, it’s not convenient for me to visit the doctor when I was ill. How I wish my children could accompany me to visit the doctor. However, my sons were not at home, and I had no daughter. So, I have to ask my neighbor’s son to go with me to see the doctor. [participant 10]”. In addition, some participants hope that their sons or daugthers could care for them during their hospitalization. As a participant stated, “The year before last, I had a heart attack. I was admitted to hospital for half a month. I really missed my two sons at that time, they both worked outside. How I wish they were by my side and cared for me at that time [participant 4]”. A few participants hope that their children could provide them with immediate assistance when they are in an emergency situation. Participant 3 said, “I have suffered high blood pressure. Once a time, the illness got worse and I fainted. My neighbors had dialed the emergency call. I have only one son, and he went out to work. My wife has passed away. How I wish my son could stay with me when I am in an emergency situation.”Due to their reduced mobilityAlthough many participants hoped to get the companionship of their children at a healthcare visit, they showed fully understanding of the absence of their children’s companionship. Due to the long distance between particiapnts and their children, some participants stated that their children’s absence could be understandable. Participant 4 mentioned, “I do want to live with adult children, who could take care of me. But this is not reasonable.…Their workplace is far from my home. It is not convenient for them to take care of me when I am ill”. In addition, some participants understood that their young adults are so burdened with their work that they could not have time to take care of their old parents. As a particpant stated “Yeah, I do want my children to stay with me and take care of me when I am sick. But they are so busy with their work that they can’t stay with me…I could understand (the reason for their absence) [participant 8]”. Several participants even expressed that they would not like to get their children’s accompaniment for fear of burdening them. “I do not expect my adult children to take care of me because it would add financial and time burden to them. They have not been married. They have to earn money for their marrige. [participant 6]”.This theme focused mainly on external supporters who help participants get access to healthcare services. It has been identified that participants tend to seek medical services with the help of their neighbors, relatives and village doctors.Without their children’s accompaniment and being limited mobility, many participants have to ask for their neighbors to take care of them and accompany them to seek medical services. “When I suffered from illness, my neighbors would drove me to see the doctor. Without their help, I cannot live till now. [participant 7]”. Indeed, a distant relative is not as good as a near neighbor, which could be strengthened by the 9th participant’s statement “My relatives do not live in the same village as me. Thus, I tended to ask for my neighbors to accompany me to visit the doctors when I was ill.”, some participants got support from their relatives who lived in the same village or the neighboring village in the process of seeking medical services. Their relatives helped them a lot in seeking medical services. As participant 7 said, “When I suffered from illness, my elder sister’s son would accompany me to visit the doctor. I have no children. I have to ask for help from my nephew.” Similarly, several participants stated that they had the experience of seeking medical services accompanied by their relatives who live in the same village as the participants, just as participant 13 stated “On one hand, I cannot drive. On the other hand, I am illiterate. However, the hospital is far away from my village. I live in the same village as my young brother’s son, who can drive and has received a good education. I would ask for him to accompany me to seek healthcare services when I was ill”.In additionMoreover, some participants got help from the village doctors when they were ill, as participant 15 stated “There is a clinic in my village, which I could get easy access to. The village doctor could provide medical treatment for some minor illnesses”. Moreover, the village doctors could provide home-based medical services for empty-nest elderly with minor illness. According to one participant, “I can’t walk easily as others. The village doctor would come to my home to provide medical treatment when I suffered from minor illness such as having a cold. The village doctor helped me a lot in seeking medical services [participant 5]”.In this study, we investigated the experiences of rural empty-nest elderly in seeking medical services in China. Five themes have been identified, that is, the barriers for them to seek medical services, emotional responses to their illness, the perception of their illness, their ambivalent attitudes towards the absence of their children’s accompaniment, and social support for seeking medical services.It has been identified that they are some barriers for rural empty-nest elderly to seek medical services, which is in line with the findings of previous studies. The Household Registration System (HRS) has brought about a huge income and pension inequality between the urban and rural residents , 50. FinIn addition, this study demonstrated that rural empty-nest elders hold negative emotions towards their illness. This result was consistent with findings from De Ridder et al.  and BužgIn the third theme, it has been found that many participants regarded their illness as a normal result of aging, which was in line with previous studies on older Asian people , 67. Engparental sacrifice, that is, parents tend to give up their personal needs for the sake of developmental needs of their children [parental sacrifice in China [A new phenomenon was identified in the fourth theme, that is, rural empty-nest elderly held ambivalent attitudes towards the absence of their children’ accompaniment in seeking medical services. On one hand, rural empty-nest elderly looked forward to receiving their children’s help in seeking medical services. On the other hand, many participants showed full understanding of the absence of their children’s accompaniment in medical care seeking. This may be explained by children . This stin China , 71. In in China .Three types of social support of rural empty-nest elderly have been identified in the last theme, that is, support from the neighbors, the relatives and village doctors. This could counteract the absence of their children’s accompaniment in seeking medical services. Our results also found that rural empty-nest elderly in China tended to get help from village doctors when they suffer from minor illnesses. This has not been reported in previous studies. Since the social networks of rural empty-nest elderly consists mainly of blood relatives, neighbors and village doctors, they could reach out to a very small number of people when help is needed . It is cDue to the limited access to medical services and being limited mobility, rural empty-nest elderly encounter great inconvenience when seeking medical services. In addition, our results also indicate that the absence of the accompaniment of their adult children further worsen this kind of inconvenience. Although some studies highlighted the benefits of medical visit companions , 76, it To the best of our knowledge, this is the first qualitative study to explore how Chinese empty-nest elderly in rural areas get access to medical service. Although many efforts have been made to ensure the trustworthiness of this study, there are still several limitations to this study. As with all qualitative research, the findings in this study could not be generalized. In addition, in this study, only empty-nest elderly who live in Eastern China has been investigated. Medical facilities and services in Eastern China is significantly better than that in Western China . In thisIt is clear that rural empty-nest elderly in China are facing great challenges in seeking medical services and thus more efforts should be made to get medical services more accessible to them. First and foremost, more and more general practitioners should be encouraged to work in rural areas in China, and more medical facilities with high-quality medical services should be established in the rural areas. Second, the Elder Watch Program could be put into practice in China, which calls for volunteers to keep in regular contact with rural empty-nest elderly and accompany them to visit the doctor when needed. Third, barriers for rural empty-nest elderly to seeking medical services, such as high expenditure of medical treatment and the inadequate health insurance coverage, should be addressed gradually. This involves a more complex project where the hospital business model and the health care system should be reformed.Due to the absence of the companionship of their adult children, rural empty-nest elderly have great difficulty in seeking medical services. Many empty-nest elderly have to rely on their neighbors and relatives to seek medical services. In addition, there are some barriers for rural empty-nest elderly to get access to healthcare services, such as the low-income status, high expenditure of medical treatment and the inadequate health insurance coverage. Thus, more efforts should be made to get medical services more accessible to rural empty-nest elderly in China.


Background: Children’s physical health is an important resource for a country’s future construction. However, researchers found that the physical fitness of young children around the world has declined during the two decades, from 1992 to 2012. The decline in the physique of young children has caused widespread concern around the world. Children’s main living places are families and kindergartens, so this research explores the impact of family factors on children’s body mass index (BMI) from the perspective of family attitudes, children’s sports participation, and screen time.Methods: A cross-sectional study was used to conduct a questionnaire survey of children in China. A total of 600 children were investigated, and 589 valid questionnaires were obtained. SPSS21.0 statistical analysis software was used for descriptive analysis, mean comparison, and correlation analysis of the data. AMOS 21.0 was used to construct a structural equation model and carry out path analysis.Results: (1) There are significant differences in children’s family sports attitude, sports participation, screen time, and BMI with different family structures, and parents’ education levels. (2) Family sports attitude is significantly positively correlated with parents’ education levels and children’s sports participation, and negatively correlated with children’s screen time and BMI. (3) Children’s sports participation and screen time play a chain-mediating role between family sports attitude and children’s BMI, and the role is a complete mediating role. Therefore, family sports attitudes can affect children’s physical health by affecting children’s sports participation and screen time. To promote children’s physical health, we should pay attention to the intervention of family sports attitude. (4) The mediating effects of exercise participation and screen time are similar in different family structures, so the structure of this study can be applied to different family structures.Conclusions: Children’s family sports attitude, sports participation, and screen time can affect children’s BMI. Children’s screen time and sports participation play a chain-mediating role in the influence of family sports attitudes on the path of children’s BMI. The results of this study will provide a useful reference for teachers and parents to control children’s physical health. As an important resource for the future construction of a country, their physical health is a strategic issue directly related to the future and destiny of the country , which is calculated as BMI = weight (kg)/height (m)thinness . BMI, asthinness , WHO , 49.9% of girls, participated in this study with the permission of their guardians. The instrument of this research was a questionnaire, which was designed and based on a large number of research literature; the following three parts were sorted out and formed:The content includes children’s gender, age, height, weight, and other actual basic information, and the corresponding BMI is calculated according to their height and weight.In this part, the exercise participation calculation formula used by This part includes the basic information of children’s main caregivers, occupation, education level, physical exercise frequency, and attitude toward sports. The physical exercise attitude scale contains nine items, such as Do you think your child’s physical fitness is enhanced by playing sports games. The scale was quantified by a Likert five-point scale, according to the options “disapprove, not very agree, general, somewhat agree, and strongly agree”; the scale was rated as 1–5 points, respectively. The higher the total score, the more support the parents have for children’s sports. The pretest of the scale showed that the retest reliability was high, and the overall Cronbach α coefficient was 0.87. The overall verification results of the measurement model were as follows: χ2/df = 1.84, RMSEA = 0.03, AGFI = 0.98, CFI = 0.99, TLI = 0.99, IFI = 0.99, GFI = 0.99, which shows that the questionnaire has good measurement validity and reliability.t-test and one-factor ANOVA were used to analyze the differences in demographic variables. Pearson’s cross-production correlation was used in parents’ education levels, family sports attitude, sports participation, screen time, and children’s BMI. AMOS 21.0 was used to construct the structural equation model and conduct path analysis. The mediation test process proposed by SSPS Statistics 21.0 was used for the statistical analysis. After the Shapiro–Wilk normality test, the independent sample t-test . There was no difference in the physical activity behavior between boys and girls . There was no gender difference in screen time . There was no gender difference in infant BMI . The results of analysis of variance showed that: (1) In terms of a mother’s education level, there were differences in the family sports attitude score, children’s sports participation, screen time, and children’s BMI among different mothers’ education levels. Specifically, the scores of the mother with primary school education were lower than those with high school education, while those with high school education were lower than those with a college education or above . There were also significant differences in children’s sports participation between fathers with different education levels . Children with fathers’ education levels had the highest sports participation in college or above, followed by children with fathers’ education levels in middle to high school. There was no significant difference in children’s sports participation between fathers’ education levels in middle and high school and primary school children. The screen time of children was significantly different only between primary school and college or above groups. The screen time of mothers with primary school education was significantly higher than that of college or above groups . In terms of children’s BMI, there were differences between mothers with different education levels. The BMI of children whose mothers had primary school education was significantly higher than that of those from middle school to high school, and the BMI of children whose mothers had middle school to high school education was higher than that of children whose mothers had a college education or above. (2) In terms of fathers’ education levels, there was a significant difference in sports attitude among families with different fathers’ education levels . The score of a father’s education from middle school to high school was significantly higher than that of primary school, and there was no significant difference in the score of family sports attitude when a father’s education was higher than middle school (p > 0.05). There were also differences in children’s sports participation among fathers with different education levels. Fathers’ education levels in college and above were significantly higher than those in primary school , while there was no difference between fathers’ education levels in primary school and middle school to high school (p > 0.05). In terms of screen time, there was no difference between fathers with college or above education background and those with middle school to a high school education level , while there was no difference between fathers with middle school to high school and primary school education levels (p > 0.05). In terms of BMI of children, the father’s education level from middle school to high school was significantly lower than that of primary school, and the father’s education level from university or above was also significantly lower than that of primary school . There was no difference in BMI of children between a father’s education level from middle school to high and those education levels from a college or above (p > 0.05). (3) Family structure: there were differences in family sports attitude, sports participation, and screen time among children with different family structures, but there was no significant difference in BMI. Multiple comparisons showed that the scores of family sports attitude in families with parents living together, intergenerational parenting, and three generations living in the same house were significantly higher than those in single-parent families . The results showed that the children’s sports participation of three generations in the same family, intergenerational parenting, and single-parent family was significantly higher than that of a small family . Screen static time per week in families with three generations and parents living together was higher than that in single-parent families .The results of the independent sample t-test  show thar = 0.32). There was a significant negative correlation between family sports attitude and children’s screen time (r = −0.15). There was a significant negative correlation between family sports attitude and children’s BMI (r = −0.23).Correlation analysis showed  that theThe results of linear regression showed that family sports attitude was negatively correlated with children’s BMI. Sports participation was negatively correlated with young children’s BMI. One week of static screen time was positively correlated with children’s BMI. And they all reached a significant level .r = −0.04, p > 0.05), but the negative prediction effect of family sports attitude and screen time was significant . Family sports attitude and children’s sports participation had a significant positive predictive effect . The BMI of children was predicted negatively by sports participation , while the screen time could predict BMI positively . From the significant levels and the standardized path coefficient b values in the structural model in The relationship of family sports attitude, sports participation, screen time, and children’s BMI, the mediating effect between screen time, and exercise participation were examined by Wen and Ye mediating effect test procedures . Figure Relevant studies found that different family structures in children’s lives can lead to significant differences in children’s sports participation, screen time, and BMI. This study verified whether sports participation and screen time have a stable mediating role in different family structures. Firstly, the mediating effects of children’s sports participation and screen time in nuclear and non-nuclear families were examined respectively. The results showed that the model fitting indexes of nuclear families were: χ2/df = 2.51, AGFI = 0.96, CFI = 0.99, TLI = 0.96, IFI = 0.99, RMSEA = 0.067. The model fitting indexes of non-nuclear families were: χ2/df = 1.67, AGFI = 0.96, CFI = 0.99, TLI = 0.98, IFI = 0.99, and RMSEA = 0.052. The results showed that the fitting indexes of each group were good, which could be compared with different groups of models. Then, the set equivalent model was used to compare the different groups of models, and the results showed that the model had good fitting indexes, and the fitting index difference ΔCFI and ΔTLI values were less than 0.05 (ΔCFI and NTLI were obtained by the difference of TLI and CFI between the nuclear family and the non-nuclear family) . The resThis study found no gender differences in children’s BMI, family sports attitude, weekly sports participation, and static screen time, which is consistent with the results of the Xinran Shi’s study . At the In addition, this study found that the higher the mother’s education level, the lower the children’s BMI. Qian et al. conducted a study on Chinese students aged 8–10 and found that the group whose parents have a low educational level has a low score in dietary habits and nutritional knowledge, while dietary habits are significantly correlated with BMI . Han HuiThere is a significant negative correlation between family sports attitude and children’s BMI, which is consistent with the previous research results of Gao Yan et al. A large number of studies have shown that the decisions of children’s sports participation at the beginning, middle, and end are related to the environment. Human behavior is formed by the interaction between individuals and the environment. The environmental models that affect human development include micro, medium, and macro-environmental models. Family is an important part of the microenvironment, which plays a key role in the process of children’s growth . Family s have a negative attitude toward sports participation , but the total mediating effect of sports participation and screen time was higher in non-nuclear families than in nuclear families. The results of this study will provide a useful reference for teachers and parents to control children’s physical health and the influencing factors of children’s physical health research in the future.This study identified the mediating role of sports participation and screen time. The structural equation model of the relationship between the attitude of plus family and children’s BMI was constructed and verified. And the study still has the following limitations and suggestions for future research:(1)Among the family influencing factors of children’s BMI, this study focused on examining the mediating effects of children’s sports participation and static screen time.(2)This study was a cross-sectional study. Future research can further support the conclusion of this study by using the exercise tracking method and providing direct evidence for variable causality.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Ethics Committee of Sports School of Southwest University in China. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.CP and LJ carried out the protocol and the questionnaire survey. YL recruited the survey respondents. ZT, LH, and YJ undertook the statistical analysis and graphical representation of the data. LW revised the draft. All authors participate in the completion of the study and contributed to and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Student engagement can predict successful learning outcomes and academic development. The expansion of simulation-based medical and healthcare education creates challenges for educators, as they must help students engage in a simulation-based learning environment. This research provides a reference for facilitators of simulation teaching and student learning in medical and health-related majors by providing a deep understanding of student engagement in a simulation-based learning environment.We conducted semi-structured interviews with ten medical and healthcare students to explore their learning types and characteristics in a simulation-based learning environment. Thematic analysis was used to analyse the data.The interviews were thematically analysed to identify three types of student engagement in the simulation-based learning environment: reflective engagement, performance engagement, and interactive engagement. The analysis also identified eight sub-themes: active, persistent, and focused thinking engagement; self-directed-learning thinking engagement with the purpose of problem solving; active “voice” in class; strong emotional experience and disclosure; demonstration of professional leadership; interaction with realistic learning situations; support from teammates; and collegial facilitator-student interaction.The student interview and thematic analysis methods can be used to study the richness of student engagement in simulation-based learning environments. This study finds that student engagement in a simulation-based learning environment is different from that in a traditional environment, as it places greater emphasis on performance engagement, which combines both thinking and physical engagement, as well as on interactive engagement as generated through interpersonal interactions. Therefore, we suggest expanding the learning space centring around “inquiry”, as it can help strengthen reflective communication and dialogue. It also facilitates imagination, stimulates empathy, and builds an interprofessional learning community. In this way, medical and healthcare students can learn through the two-way transmission of information and cultivate and reshape interpersonal relationships to improve engagement in a simulation-based learning environment.The online version contains supplementary material available at 10.1186/s12909-021-02858-7. Student engagement is a key topic that has become very popular and widely researched in academia. Studies have shown that student engagement can directly predict learning outcomes , criticaThe diversity of learning fields gives rise to heterogeneity within the space and manners of medical and healthcare student engagement. Some scholars have studied medical and healthcare student engagement in the clinical environment by using the Moodle system, which is based on the visual learning environment. They found that students adopted a strategic learning approach in the clinical environment by using more Internet resources to answer medical questions under time constraints, in comparison to traditional learning techniques wherein students obtain information from books . MedicalMedical and healthcare education is media- and resource-dependent in nature. It has become increasingly prevalent to integrate technology-enhanced learning (TEL) resources and promote the reform of information technology (IT)-based teaching models in higher medical and healthcare education . The mosDriven by this movement, educators have begun to focus on medical and healthcare student engagement with the IT-based learning environment. Most research focuses on the effect of using IT in the objective physical environment and the impact of teaching methods on student engagement; such methods include classroom mobile technology , online At present, quantitative research is the most common research paradigm for studying college student engagement. However, many scholars have questioned the reliability and validity of the questionnaires using quantitative research and the validity of student responses , 23. ResMedical and healthcare education has always been highly contextualised in a specific historical, ethnic, and regional development setting. The simulation-based learning environment involves various contextualised learning activities and practices that resemble real-life practice and experiences. The study of medical and healthcare student engagement in this environment needs to shift from the traditional quantitative research paradigm to a qualitative paradigm, as the latter can offer more insights into the interactive mechanisms between college students’ learning behaviour and the environment. Thus, the purpose of this study is to explore student perspectives following simulation-based learning to gain a more complete understanding of their engagement within the learning environment.The 10 participants all participated in an interprofessional education course that 48 students had taken as an optional course before the interview. The course has 10 teaching periods, each lasting 2 h. Seven periods were conducted in the discussion room, which was staffed by 1 tutor and 1 teaching assistant. Students were required to discuss cases in groups and reflect upon the professional value of their roles in the case. Students performed high-fidelity simulations in the laboratory twice accompanied by 3 tutors, one for “Neonatal respiratory distress syndrome rescue” and the other for “The rescue of cardiac and respiratory arrest patient with coronary heart disease”. Students in groups played different roles to run the case. Students made desktop deductions in the discussion room once under the guidance of 3 tutors, the theme of which was “The rescue of a large number of injured people suffering after a sudden explosion in the emergency room”. Students needed to use the hospital department plan, teaching aids, etc., to conduct an interactive discussion and engage in emergency decision-making and on-site actions instead of running the case. Every simulation study carried out in the laboratory included three steps: 1. Orientation, including an introduction to the learning objectives and the operating environment of the case. 2. Simulation, where student ran the cases. 3.Debriefing, when the facilitators gave feedback to the students and summarised their performance in the laboratory.Qualitative research commonly uses semi-structured interviews, as these enable participants to reflect on past experiences and to generate new ideas on how to promote student engagement as they engage in retrospection. This process can shed light on useful and effective learning strategies. The main interview questions include the following: (1) How does student engagement and participation unfold in a simulation-based learning environment? What are the characteristics of that engagement and participation? (2) What are the differences between student engagement in the simulation-based learning environment and learning in traditional classrooms? (3) To what extent do you think you have invested more in student engagement in a simulation-based learning environment? The concrete content is shown in Interview Guide. After obtaining consent, we conducted the interviews. When collecting data, we would engage in “epoche” and suspend our previous theoretical views, allowing participants to express their personal feelings without restriction, and we tried to help them to speak to as many real and comprehensive feelings and different experiences as possible to obtain richer themes and a more comprehensive display of the different types and characteristics of student engagement.During the interviews, the researchers conducted in-depth exploration, mainly around these open research questions, but always allowed the interviewees to fully express their thoughts without interference. Follow-up questions and investigative questions were asked if needed. Follow-up questions were used when researchers were very interested in the views the interviewee was stating and wanted to have a deeper understanding, in which case the researchers asked the interviewee to give more detailed information. Investigative questions are a technique that allows the discussion to continue while obtaining further clarification, which helped us manage the conversation with the interviewee so that it always revolved around the main research questions. We used some simple phrases, for example, “You did a good job, please continue”, to suggest the discourse depth we needed from the interviewees or to encourage them to further expand the conversation. All researchers used almost the same main questions and interview techniques for the 10 interviews, and interviewees could fully express their views about these broad questions. However, the researchers also reflected upon the interview recording after each interview with 2 students to better guide the next interview.This study used the principle of purposeful sampling, i.e., non-probability sampling, to select interviewees that would allow them to draw the maximum amount of information for the research questions in light of the research purpose . We follThis paper was informed by an approach based on thematic analysis . Data coThe characteristics of student engagement in the simulation-based learning environment were summarised into three types: reflective engagement, performance engagement and interactive engagement. Furthermore, sub-themes were identified, as described below. Table “[In traditional classrooms] Sometimes students are asked some questions but given limited time for a response. Many times, the class continues without giving enough time for student’s reflection on the questions.” [L1]“[In a simulation-based learning environment] If you don’t take time to think about it, the patient in front of you may die, and you will feel a strong sense of guilt ... if you don’t solve the problem, things won’t work out. I will try my best to do it, not to give up halfway ... unlike in a traditional classroom, when the facilitator asks a question, you just need to give a standard answer and it all ends.” [H1]One of the most significant features of cognitive performance in a simulation-based learning environment is “active reflective engagement”. Many participants in our study emphasised in the interviews that this is a kind of active thinking and active engagement. Different from the short-term thinking in traditional classes, the simulation-based learning environment requires constant and persistent thinking. Another frequently used word is “focus”. Students who were highly focused in a simulation-based learning environment were deemed to have a “strong and attractive energy field” [L1]“In traditional classrooms, sometimes the facilitator talks too fast, and you will feel a bit unwilling to listen ... In the simulation-based learning environment, there is very little possibility of being distracted, you can focus more on the facilitator, and you can take more notes.” [W2]The simulation-based learning environment also allows students to be more focused on listening to the facilitator. They feel that they must take the lesson seriously because the follow-up session contains real-life practice.“I feel more self-driven to solve the problems if they come up. I do not rely on facilitators to guide me to solve the problem. After all, I cannot just leave the problem there without doing anything … what is more important is the way of thinking. That is, how to find problems and how to find better ways to solve problems.” [H1]Students must familiarise themselves with the knowledge before entering the simulation-based learning environment. This is different from the passive learning practices in traditional classrooms, where students just follow the facilitator’s thinking, being instead a re-understanding of the original learning process and outcomes. Students are able to experience the self-directed learning process of constructing self-knowledge through observation, reflection, practice, problem discovery and resolution. Problem solving is the driving force of thinking activities, and the thinking process is reflected in the process of problem solving.“In a normal session of your major, you just passively accept theoretical knowledge. You would not evaluate doctor-patient relationship from multiple perspectives, such as the potential influence over society and a humanistic perspective. I think my way of thinking has become more active.” [Y1]Problem-solving reflective engagement is accompanied by close connections between knowledge. Because it solves real-life problems, the knowledge being connected is situated in a multidisciplinary context, and the voices of the patients are also being heard.“If you have your own thinking and vocalize it, everyone will listen more carefully to your suggestions and then put forward their own views... your own thinking is built up or challenged by others, which pushes you to do more active thinking.” [L1]The process of problem solving is usually accompanied by communication and mutual affirmation among peers. When questions and thinking are valued, students are more motivated to think actively.“I am more involved than usual in [simulation] class. In traditional classrooms, students just sit in class and dare not answer facilitators’ questions. And now [in simulation class], if your peer asks you questions, you can quickly give a response, since if no one knows the answer, the game will not continue. The facilitator usually asks questions in class. The class gets embarrassing if no one speaks ... [in simulation class] I feel the need to talk about it myself, whereas there is no such feeling in [traditional] class.” [H2]“Speaking” in the classroom is another important manifestation of reflective engagement. On the one hand, an individual has more opportunities to ask constructive questions than in the simulation environment. On the other hand, unlike the commonly seen shyness and silence among East Asians , in a siIn regard to the reasons why students want to speak up more in a simulation class, many participants think that “because of the group-discussion format, the group activities ease the classroom tension, which makes you more relaxed and can stimulate your thinking.”[Y1].Learning in a simulation-based learning environment usually requires students to play different roles, such as doctors, nurses, patients, and family members. Through these exercises, the students are expected to be familiar with the different roles to achieve the learning goals. Therefore, they often claim to be students from “a certain performing university” or “a performance major”. The description “acting elf” is often used to refer to those who are particularly good at acting.“As far as I observe, the extent of student participation is diverse. Some people more actively participate, while some individuals are indifferent to emotional performance if they don’t pay much attention to this course.” [W1]Performance means that it is necessary to channel emotions into the character and act out that character’s behaviours. The current study found that strong emotional experience and disclosure are an important manifestation of performance engagement.The emotions in the simulation-based learning environment change in accordance with the progress of problem resolution and are most often associated with the outcome of the patient. There could be “unconsciousness, excitement, tension, eagerness, expectation” when the situation of the “patient” is unknown; there could be “happy feeling, confidence, excitement and a sense of fulfilment” if the operation is successful; there could also be “regret, discomfort, guilt, inferiority, depression, depression and feeling lost, unconvinced or even condemned” when the operation fails.“That kind of atmosphere [in a simulation environment] is different. The physical environment and learning atmosphere affect my psychological state and make me more focused on being involved in the task. I do not feel like just physically being in a classroom while mentally distracted by something else.” [H1]Strong emotional engagement enables students to be physically and psychologically involved in learning activities, contributing to a state of “presence”.“In the laboratory, I don’t care too much about how long the course takes. I think even if this class overruns, I won’t be too bothered.” [H2]Many students even enter a state of “flow” when they fully immerse themselves in the tasks.Emotions and feelings are attitudinal experiences stimulated by a sense of “need” and revealed through behavioural outcomes. Although emotions and feelings are inspired by objective experiences, their nature is determined by people’s perception of the situation . During “Some people will take the responsibility of leadership voluntarily and spontaneously assign people to do certain things. I will consider that person very devoted and motivated. For those who follow the lead, I also think that they are thinking deeply and engaged entirely”. [L1]The simulation-based learning environment usually creates a realistic hospital scene. In this atmosphere, there are many actions that reflect professional leadership. These include whether one can take the initiative to take responsibility as the leader, whether one can lead the team to facilitate the learning process, or whether one actively follows the leader, quickly adjusts to the role, analyses problems, and offers responses. A deeper level of participation is reflected when those “leaders” use their knowledge and demonstrate their capabilities. As some participants said,“The more realistic the environment is, the stronger feeling I have that similar situations would happen in real life practices.” [K1]“At the time, the assessment involved a little baby [model] ... we played with him, and we felt a kind of attachment. We would say, ‘look at those babies’. There would be a kind of motherly love – a kind of feeling expressed spontaneously.” [L1]The most prominent feature of the interactive learning environment is the realistic working session, including mimicking the busy atmosphere as well as the vivid “doctor-patient” interactions in a physical hospital setup, which enable students to be fully drawn to the learning context.“For example, if you rescue the senior simulator successfully, it will give out some responses. For example, during the rescue, the student can monitor the “patient’s” pulse, blood pressure etc. ... in that simulated context, because of the role you play, you will develop a strong sense of responsibility and want to do it well.” [H2]“I will subconsciously think that I am a professional and I can do this well. Then, I will not be distracted by others, since I just need to do the operation based on what I have learnt. Building on that, I will also think about how I can better use the knowledge.” [H2]The professional responsibility of medical and healthcare students is also stimulated by the simulated environment, which fully brings medical and healthcare students into their professions.“I'm probably more engaged at that time [in the simulated learning environment] than I would be if I were alone. That is, when someone wants to interact with you, it makes me feel that this is not my own business. It is not like normal practice, which is solely operated by a single student, which easily makes one lonely and bored. Because there are interactions in a strongly collaborative atmosphere, which promotes my sense of responsibility. That is, if I do it wrong, my teammates will have to bear the consequences too, so it is not my own business.” [H3]This sense of professional responsibility also motivates students to achieve a higher level of engagement.“You exchange views with your peer... and jointly solve this problem, which leads to increasing peer support.” [K1]Peer interaction is mainly manifested in the sharing of information, mutual discussion, and skill guidance required in the process of problem solving.“What are their [my peers’] concerns? What are my concerns? What are the similarities and differences between my peers’ and my own concerns?” [H1]Unlike ordinary peer communication, in the simulation-based learning environment, peers are more conscious and conduct more in-depth communication within the profession and develop the ability to think about problems holistically.“If everyone is very cooperative and actively participates, the interactions will be smoother, it will have a more positive effect on participation. If everyone is cold and everyone does not want to talk, then this task cannot carry on.” [H3]The “companion” in the simulation-based learning environment is not simply a learning partner but a buddy who needs to complete a task that is very challenging. The mutually facilitative interaction between peers promotes active engagement. However, if the interaction is not harmonious, it will hinder further engagement. Attentiveness and responsiveness from peers will drive the next round of positive emotional experience and student engagement.“The students who participated in that course are very active and full of positivity. I enjoy interacting with them, and I am willing to speak up if I feel like it... when my classmates are thinking about the problem very seriously and trying to solve the problem, I feel that I can’t stand by but need to help out.” [K1]“Especially if your peers are very good at acting, they convince you that the entire process is very authentic and make you more engaged in solving the problems.” [H2]The impressive performance of other students in the process of peer interaction also motivates the students to be more engaged.“The facilitator also participates. The facilitator and we students feel like friends. Unlike in the classroom, where one needs to be more respectful when asking the facilitator questions, there is no distinct boundary between the facilitator and students in a simulated learning environment.” [L1]“The facilitator is more easy-going. The sense of distance and barriers are eliminated.” [Y2]The role of the facilitator in the simulation-based learning environment is more that of a guide, directing the students forward instead of just giving them answers. Furthermore, they provide students with ample space for thinking. The facilitator also takes on the role of “director”, setting up scripts and scenes, observing the actors’ performance, and giving guidance. “The facilitator, as an observer and a questioner, is not an answerer, um, is a helper, a prompter.” [H1] The facilitator-student interaction in the simulation-based learning environment is more “easy-going” and “informal” than that in the traditional classroom.“That is to say, the facilitator has high expectations for us. Thus, we must definitely treat the course seriously and put in more effort so as not to disappoint the facilitator.” [W1]The facilitator-student relationship in the simulation-based learning environment is based on a more equal footing, as there is no hierarchical relationship during knowledge transfer. Instead, the facilitator acts as a consultant. If students are given positive feedback and affirmation in a timely manner, they will be more willing to participate.This research is the first to study the feelings and experience of medical and healthcare students in a simulated learning environment from the perspective of student engagement. Based on the findings, it reclassifies the types of student engagement, forming a new student engagement type that fits the simulation-based learning environment and differs from the classic student engagement type. Our research divides student engagement into three dimensions: reflective engagement, performance engagement and interactive engagement. Compared with the dimensions of traditional learning engagement models, it fully considers performance engagement, which is a combination of thinking and physical engagement in a simulation-based learning environment, and the engagement generated by interpersonal interactions; these additions are innovative and show the characteristics of learning in a simulation-based teaching environment.This study provides insights into medical and healthcare student engagement in a simulation-based learning environment, finding that it involves reflective engagement, performance engagement, and interactive engagement. Reflective engagement is problem-oriented, with a focus on inducing active, persistent and focused thinking practices. It involves a deep, reflective and concrete processing activity. As D. H. Jonathan states, “learners learn from thinking, but not from technology” . Even inThe study also found a special form of student engagement in a simulation-based learning environment, namely, performance engagement, which is role-based emotional and behavioural engagement. It promotes empathetic experiences, facilitates interprofessional practice and encourages a stronger desire for leadership. Similar to findings in the research conducted by Ulrich et al., role play simulation allows participants to actually feel the emotions they might experience in the future and develop their professional values . EmotionInteractions within student engagement are reflected in the responses to the high-fidelity simulator, mutually supportive peer interactions and collegial facilitator-student interactions in a realistic simulated environment. The origin of learning is the real-world construction of environmental and social interaction. The application of emerging technologies such as virtual reality and augmented reality has gradually turned the simulation-based learning environment into an important learning space for medical and healthcare students . In thisMedical and healthcare student engagement in a simulation-based learning environment promotes students’ whole-hearted focus. Specifically, reflective engagement facilitates deeper levels of critical thinking and knowledge construction; interactive engagement emerges from interactive activities in the learning space; and performance engagement gives rise to role-based group activities, promoting participation and reflection. These three forms of engagement are subject to the influence of many environmental and pre-existing factors. For instance, when students engage with the roles they play, they need to constantly reflect on the role’s behaviours, feelings and thoughts while modifying their acting based on their knowledge and previous experiences. Step-by-step practices and immediate stimuli in the learning environment prompt more reflections, encouraging students to continuously conceptualise and act upon their experience; at the same time, they facilitate the interaction between the character and the external environment, thereby forming a relationship framework. Medical and healthcare students’ reflective engagement, performance engagement and interactive engagement influence each other. The use of IT highlights the multidimensional interaction between individuals, groups and the technology environment.The findings indicate two perspectives that explain the mechanisms behind student engagement: the two-way construction of individuality and space in learning and the interdependence of the learner and the learning community. Facilitators can improve their teaching in a simulation-based environment accordingly. First, in terms of the promotion of reflective engagement, expanding the learning space centring around “inquiry” helps strengthen reflective communication and dialogue and further facilitates the process of knowledge construction. Before the simulation teaching, the facilitator can use the learning situation analysis method to analyse the students’ existing knowledge base. In the orientation stage, facilitators help the students fully review the case-related knowledge, making students convert the knowledge into action when they operate the case. In the debriefing stage, facilitators guide students’ reflection, asking them to determine three to five drawbacks about themselves or their peers and provide answers. After class, facilitators assign reflective learning homework, such as asking students to complete a reflective diary to help them improve their reflective skills.In terms of promoting performance engagement, facilitators need to set the stage with a relevant and realistic scenario . First, In terms of promoting interactive engagement, the role of the facilitator should be changed from imparting knowledge to guiding and helping. For example, when the case is not operating smoothly, the facilitator should intervene in a timely manner to promote the case. In the debriefing stage, the facilitator should guide students as they think about the learning goals that should be achieved and their current learning level, as well as the gap between the two. In promoting peer interaction, the accountability method requires students to take responsibility for their roles, and the self-evaluation and peer evaluation methods allow students to provide feedback on themselves and their peers, respectively, to promote peer-to-peer interaction.The purpose of this research is to reflect on student engagement in a simulation-based learning environment from students’ perspective, offering a basis for reference by facilitators to improve their methods of instruction. However, this is also a limitation of this research, which fails to make judgements about students’ learning achievements in combination with their objective learning performance. Our follow-up research direction is to overcome this limitation. This research focuses on the learning experience and subjective feelings of students in the simulation laboratory. However, we cannot know their possible reactions in the real world, nor can we know whether the learning experience in the laboratory will affect their performance in the real world. This is also a possible future direction of our research.Student engagement in a simulation-based learning environment is different from that in the traditional classroom. The current study provides evidence for the unique nature of simulation teaching, which promotes reflective learning and immersion in a clinical environment while facilitating reflective engagement, performance engagement and interactive engagement. These three types of student engagement help them to achieve the expected learning result through the two-way construction of individuality and space in learning as well as through the interdependence between the learner and the learning community.Additional file 1.


Migrants and ethnic minorities (MEM) are known to be disadvantaged concerning risk factors for problem substance use and resources to initiate and sustain recovery . Yet, the voices of MEM are largely overlooked in recovery literature. This study explores recovery capital through 34 semi-structured interviews with a diverse sample of MEM in recovery in two ethnically diverse cities in Belgium. A Qualitative Content Analysis using recovery capital theory allowed us to identify various recovery resources on a personal, social, and community level. While physical and human recovery resources play a central role in participants’ narratives, personal recovery capital is closely intertwined with meaningful social networks  and recovery-supportive environments that maximize opportunities for building culturally sensitive recovery capital . Though MEM-specific elements such as culture, migration background, stigma, and structural inequalities play a significant role in the recovery resources of MEM, the largely “universal” nature of recovery capital became clear. The narratives disclose a distinction between “essential” and “acquired” recovery capital, as well as the duality of some recovery resources. The need for developing recovery-oriented systems of care that are culturally responsive, diminish structural inequalities, and facilitate building recovery capital that is sensitive to the needs of MEM is emphasized. A growing share of our present-day, highly diverse society consists of migrants and ethnic minorities (MEM), defined here as persons who themselves or whose (grand)parents migrated to another country in which they reside and have a minority status ,2. EpideThe new recovery paradigm , which iRecovery refers to interactions of the person and the environment over time  and is fDue to the dynamic interplay between individual conditions, social relationships, and environmental and structural factors ,19,20, rYet, knowledge of addiction recovery resources through the eyes of those who identify themselves as MEM remains limited, particularly in Europe . The aimn = 34) [In the study sample, we aimed to reflect the diversity of MEM in Flanders (Belgium)  through n = 34) .To gain an understanding of the recovery processes and resources of MEM, we set up a qualitative study design in collaboration with relevant service providers and practitioners who also functioned as gatekeepers. All procedures were approved by the ethics board of the Faculty of Psychology and Educational Sciences of Ghent University (ref. 2017/106). Oral and written informed consent was obtained from all participants before the interview started, in which confidentiality, anonymous reporting and the right to withdraw from this study at any time were discussed. During the interviews, the researcher was sensitive to the participants’ needs, regularly checking if they still felt comfortable by means of verbal and non-verbal cues. The semi-structured interview guideline (available upon request from the first author) was tested and revised during five pilot interviews. Interview questions focused on participants’ (1) patterns of substance use, (2) their recovery process, (3) barriers and facilitators for recovery, and (4) the role of having a MEM background in this process. The open-ended questions that were complemented with probing follow-up questions, encouraged participants to talk openly about their lived experiences, unfolding rich narrative data in which recovery resources (or the lack thereof) became clear . The intThe recovery resources that study participants encountered during their recovery processes were analyzed using Directed Qualitative Content Analysis (QCA), as described by Hsieh and Shannon . DirecteTo distillate recovery resources from an ecological point of view, the overarching categories in the coding frame were predefined and consisted of the three levels of recovery capital, namely personal, social, and community recovery capital ,31. UponA sample of 34 respondents (of which 4 women), aged between 18 and 60 years old (mean: 38) participated in this study. They were mostly first- and second-generation MEM, with Belgian, foreign, or dual nationalities. At the time of the interview, self-reported problem substance use ranged from abstinence to ongoing and intermittent substance use . The majority of the participants had one or multiple psychiatric diagnoses such as depression or (substance-induced) psychosis and had been in contact with specialized  substance use and/or mental health treatment in the past. Most of the participants did not have a high school diploma or international equivalent. The majority reported lifetime involvement in the criminal justice system. An overview of core participant characteristics is provided in Data analysis of the interviews uncovered various forms of personal, social, and community recovery capital that were meaningful for participants’ recovery processes. Basic needs, such as housing, financial resources, access to education and employment, and having a valid identity card that permits access to these resources, were considered crucial aspects of physical recovery capital. Many respondents, especially those who had experienced episodes of homelessness, described housing—more specifically, having a stable home where they feel safe—as a basic need that should be met to build other recovery resources and work toward recovery. (Those) Who are homeless people, who sleep on the street, that’s why they use everything. (…) That’s why he does bad things. But if somebody helped these people, I think maybe he changes his life. (…) You know why I know? Because I was on the street here.Participants described how a lack of financial resources could enhance participation in criminal activities , but also motivated them towards recovery when they became aware of the financial repercussions of their substance use. That is, financial resources were important to fulfill important needs, but also to pursue hopes and dreams for the future. The majority of the participants had low educational attainment  due to early school drop-out related to mechanisms of migration, rejection, lack of parental support, substance use, diminished motivation, and deviant behavior. This decreased their chances on the job market, while many participants mentioned employment or alternative daily activities  as meaningful recovery resources, offering them responsibility, acknowledgment, and financial resources. Several participants (both first- and second-generation migrants) described how the lack of a valid Belgian identity card impeded access to recovery resources such as employment, housing, and substance use treatment. What’s the problem? Drugs are the problem. Let’s work on that drug problem, but that doesn’t work out because you don’t have the papers.All participants discussed how problem substance use functioned as self-medication and coping mechanism for a variety of psychological and physical health issues, such as (childhood) trauma, depression, physical and emotional pain, sleeping problems, and craving. Even though substance use offered them a way to “forget their misery” temporarily, participants acknowledged that it was no satisfying long-term solution. Rather, they deemed it essential to address the root causes of their problem substance use, as well as to find “tools” and learn “skills” to deal with future challenges in an adaptive way. To deal with psychological issues, respondents indicated that they needed to build what can be called “emotional literacy”: processing traumatic experiences from the past and being able to constructively handle these emotions, often by sharing them with others . This was especially underscored by those who (used to) suppress feelings caused by taboos within their family and/or culture.You don’t feel well and then you start using to suppress your emotions. (…) I had built up walls about my past, I didn’t dare to speak about my emotions. (…) To be clean, you have to handle your problems. You have to go back to the past, where it all went wrong.As substances were often used to self-medicate, participants described receiving medication as an important contributor to their recovery, diminishing the urge to use and enhancing their quality of life. Finding the right (dose of) medication was often considered a struggle, as it could cause side effects or turn into an addiction. In that light, participants emphasized the importance of having a doctor who listens closely to their needs and past experiences with medication. Several participants indicated that the use of opiate substitution treatment (methadone or buprenorphine) facilitated their ability to function “normally” in society . However, all of them simultaneously expressed the wish to quit opiate substitution treatment, although previous attempts had sometimes resulted in relapse episodes. Better I drink methadone, I don’t use that shit (heroin), and I’m good. My body is good, I don’t think bad things in my mind. I relax. I take the medication. I’m happy. (…) Of course. I don’t want to drink the medication all my life. I want to stop, but slowly. (…) Methadone is okay, it helps you, but the methadone is the same like drugs, no? It kills you like drugs.The majority of the participants described recovery as an ongoing challenge or “battle” that requires willpower and perseverance. I have to keep gritting my teeth. The internal fight saying: no, no, no. That demands a lot of willpower.This willpower was often rooted in the feeling that change was necessary, due to increasing awareness of the negative consequences of substance use on participants’ physical and mental health, financial situation, social network, and overall quality of life. The contrast between “who they are with substance use” and “who they want to be” motivated them to make progress. This is not my life, you know my point… (…) It is no good to steal. I like to build my life, live here, have a family. I lost too much. (…) I like being again who I have been before.Over time, intrinsic motivation grew by finding meaning, joy, and satisfaction in life without problem substance use, through meaningful activities and social networks. The majority discussed how having long-term goals motivated them in their recovery process. Many participants discussed how they desired to live a “happy”, stable, mostly substance-free life with what they considered “normal” aspects of life, such as having a fulfilling job, daily activities and structure (in contrast to the “rollercoaster” life of substance use), following education, having a home, and being surrounded by people they love. However, some also highlighted the importance of experiencing positive and exciting challenges in life, as a “boring” life was considered a trigger for relapse. Several participants also discussed how experiencing personal progress and success on multiple life domains  increased their self-esteem, offering them hope for the future and strength for recovery.Participants described how acceptance of certain experiences was needed to move forward in life. For some, this meant accepting that the past cannot be changed. For others this was about accepting mental illness as a life companion. Accepting life as it is and being satisfied with small things was also mentioned in this perspective. Furthermore, acceptance was related to the presence of stigma in society. Stigma was mainly associated with having a MEM identity, but also with substance use, criminal records, and other intersectional characteristics. Building resilience to deal with stigma and other adversities was considered an important resource in their recovery process. That’s the life that I was given and it’s fucked up, but I try to make the best of it. I try to see everything positive and I know, it’s full of discrimination, racism, dishonesty, but that’s life.More than half of the participants described themselves as religious (Muslim or Christian). Their faith offered them strength to cope with emotionally difficult situations and to persevere amidst challenges. By asking God to forgive past mistakes, they could find redemption and “start over”. Furthermore, the relationship between the participants and God had a social dimension, with Him “listening” to them and being a supportive figure in their recovery process. Participants cleared their minds and found meaning and understanding by reading the Bible or Koran, praying, and going to church or the mosque. Being a devoted Muslim or Christian motivated participants to work toward change because they feared being a “sinner” in the afterlife, but they also wanted to keep the promise they made to God to be(come) “clean”.One day I told myself: now it’s enough. I’ll take the Bible, go to church, light some candles. The book of Jesus will help me. And that’s how I lost everything (referring to substance use), little by little. Somebody asks me, you want a drag? I say no, I take the book and I read. I have to get stronger. I’m a good Catholic.All participants considered abstinence or reducing their substance use as an essential, though not exclusive, part of their recovery process. Being able to reduce problem substance use could be both a result of recovery resources  and a recovery resource in itself, as it opened up opportunities for building other forms of recovery capital. The longer you are sober, the stronger you are against the craving. So, sobriety is a helping element for recovery.In some narratives, the need for “love” was strongly foregrounded. Several participants described how they had a limited social network and were highly dependent on themselves. This was related to (1) their migration background (family/friends living abroad), (2) their problem substance use , (3) stigma and shame leading to isolation, (4) intergenerational problem substance use within the family, and (5) disconnecting from people who they considered detrimental to their recovery efforts. This contributed to participants’ feeling that they had to “do it alone”, while loneliness was also called a “pitfall for substance use”. Consequently, most respondents regarded having a recovery-supportive social network as paramount.The support of others means a lot. We are so used of doing it alone, but eventually you won’t do it alone. I won’t. I couldn’t get rid of my addiction alone.Recovery-supportive social networks consisted of family, partners, friends, and peers who were described as “understanding” and “honest” people they could “count on” if they needed help or wanted someone to talk to and listen. While (fear of) loss of social networks could be a motivator for recovery, persons who unconditionally supported their recovery journey could be so too. Several participants described a recovery-supportive social network as a “clean” network that discouraged substance use and where they could be “themselves”, without having to “wear a mask”. Some participants described how they went through their recovery process together with a close friend or family member in recovery, who motivated them and made them feel like they were not alone. A number of respondents found that only peers who shared substance- and/or MEM-related experiences could truly understand what they went through. These peers could also function as role models, offering participants hopeful examples regarding recovery, religious devotion, or other life domains such as sports or family responsibilities. That friend who took me to X (substance use treatment center) yesterday. He has the same problem as me. (…) He is actually my biggest support figure. He motivates me to go to the mosque. He tells me to stop taking heroin and stuff.Participants that were parents described how their children functioned as motivators in recovery, as they offered feelings of responsibility, a future-oriented perspective, and a goal in life, even when contacts were limited due to issues around child custody.All participants described the importance of recovery-supportive environments and places, such as a church or mosque, community center, riding school, gym or psychiatric hospital. These were described as places where they could unwind, tell their story, work on their skills and talents, feel welcome, find meaning and value, and meet recovery-supportive social networks with whom they could engage in social activities. For all participants, an important feature of recovery-supportive environments was the restricted availability of substances . It is difficult to stop using drugs in Belgium, because you have it everywhere. And almost all your friends are on drugs. (…) In Turkey, we live in a village with 10,000 inhabitants and there are no dealers there. So if you want to smoke weed, for example, you have to drive 100 km by car. If you want to smoke heroin, you have to drive 150 km. That’s how I was able to stop.The narratives of the participants reveal the duality of social, cultural, and professional environments, as these environments could be considered recovery-supportive for some and as recovery-challenging for others; sometimes even at the same time. For example, while stigmatizing environments could stand in the way of recovery resources such as an understanding social network, these environments were generally characterized by limited availability and visibility of substances. Although some participants indicated that they lost all contact with their religious community due to the stigma surrounding substance use, others explained how religious community resources (such as the mosque or church) could be helpful in their recovery process, by providing them religious activities that are incompatible with substance use and offer peers, role models and meaningful goals to strive for, such as becoming a devoted Christian or Muslim. This duality was also mentioned in light of low-threshold outpatient drug services. While these offered meaningful professional support, participants also indicated that they stayed away or avoided peak hours due to the high availability of substances among fellow service users. Home environments often encompassed many physical and emotional triggers for problem substance use, but could also feel like “home” and surround them with meaningful people. Thus, while many participants deemed starting with a “clean slate” in a new environment to be essential for recovery, for others this would mean losing important forms of recovery capital. I missed everything at home. It was hard to leave everything behind, no contact with the outside world, it’s not easy. After that (admission in a therapeutic community), I was clean for a few months, but you go back to where it all started. If you put that person back in the place where he comes from, where all his user friends are, the chance for relapse is a lot bigger then when he starts over somewhere else.All participants were in contact with one or more types of professional support for help on multiple life domains. Support services that they utilized included residential or outpatient substance use and/or mental health treatment, harm reduction and social services, judicial assistance and medical care centers.According to the respondents, recovery-supportive services were characterized by (1) valuable social interactions with unbiased professional counselors, and (2) providing access to recovery capital on multiple levels . On a personal level, participants described the importance of practical  and emotional support . For specialized substance use and mental health treatment specifically, participants discussed the value of long-term and residential treatment that went beyond “fixing physical dependency” and offered opportunities to reflect on the problems underlying substance use. At the social level, recovery-supportive services provided participants meaningful social networks through peers, role models and involvement of the family. At the community level, participants indicated that treatment and support should be tailored to individual needs, which requires particular attention to language, stigma, religion and cultural background and traditions. Several participants mentioned the need for professional support to help them maintain recovery outside the “safe environment” of treatment settings.From complete safety and follow-up to no safety at all and no follow-up, it is sometimes very difficult. (…) You overestimate yourself. (…) But you do not take into account or you do not realize that it actually happened in a safe environment and that you should not compare that with reality.As more than half of the participants had been imprisoned due to substance-related criminality, they addressed the importance of offering help and treatment for substance use problems in the criminal justice system rather than merely “locking them up”. For some participants, prison lowered the threshold toward substance use and criminality, leading them to believe they “came out worse than they came in”. They explained how prison did not bring long-term solutions to their problems, due to the total lack of support and the absence of focus on the future or continuity of care after prison.I was in prison for three years. I was clean, but I never worked on myself, on my personality. You talk about your case and about what you did, but you don’t talk about what you want in life.For most respondents, however, prison was an opportunity to become abstinent and acted a stepping stone toward recovery through the decreased availability of substances , engagement in meaningful activities , and psycho-education about substance use. Furthermore, some participants argued that detention centers could lower the threshold to treatment through providing information and referral options.I was in prison for thirteen months, where I was clean. And then through  I got in contact with a center for mental health. I saw it (prison) as an opportunity to become clean, because I thought, I can’t get this shit here. (…) It was Ramadan also, so that was an extra opportunity to quit. But it was not easy, because unfortunately, it ((drugs) is offered a lot in prison.The importance of what participants defined as “their culture” was related to (self-) identification with an ethno-cultural community and the extent to which this differed from what they perceived as “Flemish culture”. Cultural recovery capital was most apparent in the narratives of participants who self-identified with a culture that was closely tied to religion. Religious values and codes of conduct  had a major impact on their recovery process, both in a positive  and negative sense . Belief, culture, maintaining my values and norms, that is an important anchor in my recovery.Stigma and discrimination were often mentioned as impeding factors for recovery from problem substance use. Stigma was related to multiple social identities  and discussed within the context of both general society and ethno-cultural (mainly religious) communities. Discrimination related to these multiple stigmas impeded opportunities for building personal, social and community recovery capital, for example through discrimination in education, on the job market, by judicial services and treatment providers. Several participants stated that they had to “prove themselves twice as hard” because of intersectional stigmas . People look at you askew. I’m brown, that’s one thing, and then I smoke too, that’s not good huh.Hence, participants expressed the importance of an inclusive society and community, offering equal opportunities to all persons and “looking beyond past mistakes”.Based on 34 in-depth interviews with persons with a migrant and ethnic minority background in recovery, this study uncovered the types of recovery capital that play a role in the recovery processes of MEM, how these support and hinder recovery, as well as how being part of a MEM group impacts recovery capital in positive and negative ways. Physical recovery capital as an essential element to initiate and sustain recovery ,34,35 miReferring to human recovery capital, participants described being able to process and cope with trauma as an important part of the recovery process . “EmotioVarious personal recovery resources were rooted in social and community recovery capital. On a social level, participants identified a loving, recovery-supportive social network as an essential aspect for recovery ,58. MeanAt the community level, we discussed the diversity and features of recovery-supportive environments, as well as the duality of some of these enabling places . IllustrMEM have been described to encounter stigma related to MEM characteristics in general , alongside stigma related to problem substance use in both mainstream society and ethno-cultural communities . While tFrom a theoretical stance, the overarching categories of personal , social and community  recovery capital ,31 were Finally, we distinguish between what we call “essential recovery capital”  and “acquired recovery capital” . For example, participants who felt like their physiological and safety needs were not fulfilled, experienced that meeting these needs was an essential first step towards recovery, while others placed more emphasis on establishing feelings of belonging and self-actualization . When “eWhile a majority of the participants originated from what is called “collectivist cultures” , many unWhile this research provides valuable insights into the recovery processes of MEM, several limitations should be acknowledged. Though various strategies were implemented to minimize bias in both sampling and data analysis procedures, the findings could have been influenced by researcher, selection and response bias ,71,72. AThe sample allowed us to uncover shared mechanisms and experiences that are related to the personal and societal categorization of MEM and that reflect the diverse population of service users in substance use treatment ,74. A coMore research is needed to uncover intersectional mechanisms at play in the long-term recovery processes of MEM, as well as how policy and practice can promote recovery . To map While some authors argue for targeted, culturally competent treatment interventions for specific groups of MEM, this approach is inadequate in addressing the complex needs of MEM . As few Recovery-oriented support should be transdisciplinary and rooted in the individual needs of MEM as human beings . HoweverIn analyzing the experiences of 34 MEM in recovery from problem substance use, we identified several forms of personal, social and community recovery capital that overlap with the general recovery literature. Yet, when zooming in on these resources, specific MEM-related experiences of loss, stigma, and socio-structural inequalities became clear. We addressed the interrelatedness of the different types of recovery capital, as well as the distinction between what the participants considered “essential” for recovery  and what recovery capital they had acquired throughout their recovery process . When supporting recovery among MEM, counselors and other support workers should bear in mind that recovery capital is universal to a large extent, but that MEM-specific aspects could also be of importance. To determine what kinds of recovery capital should be addressed, listening to the voices of MEM themselves is paramount. Finally, to ensure equal access to recovery capital, macro-structural inequalities that impede opportunities for MEM should be reduced by tackling manifest and hidden discriminatory practices at the macro-, meso- and micro-scales.