Wikipedia’s significant gender bias is widely acknowledged. In this paper we analyze the Spanish Wikipedia with the aim of estimating the percentage of women editors and measuring their engagement and editing practices with respect to their men counterparts. To identify the gender of Wikipedia registered users, we analyzed both the information contained in their user profile and the information provided by users about themselves on their personal user pages. Using our own coding procedure, it is possible to identify a greater number of women than by relying only on the gender reported in their user profile. Combining both methods, our results show that the percentage of women is small, a meagre 11.6% of all analyzed editors, though there is still a significant percentage of users whose gender cannot be determined by either method. Men outnumber women in all Wikipedia namespaces in a ratio that is always equal to or greater than 3:1. This fact can be partially explained by the lesser persistence of women editors, who tend to leave Wikipedia much more quickly. There is, however, a small group of veteran women editors who, in some cases, surpass men editors in terms of their editing practices and participation in different Wikipedia namespaces. Wikipedia is without a doubt one of the largest human collaborative efforts ever undertaken. With the aim of becoming “the sum of all knowledge”, as stated in Wikipedia’s vision , it was The importance of Wikipedia as the main source of information for most internet users is unquestionable. The site generates more than half a billion page views every day. Many people search for answers to so-called ‘popular culture’ questions: celebrities, music, films, TV series, sports, and so on. However, Wikipedia has also been acknowledged as the most important source of scientific and technical information for most citizens, including students at all levels of education. Wikipedia is currently the most important channel for the public communication of scientific knowledge, and scientists and scholars are increasingly aware of this fact , 5. In hDespite its alleged neutrality, which is in fact embedded in its second basic pillar , WikipedUsuario (a masculine word in Spanish for user) is displayed by default on the personal page; where a user explicitly identifies herself as a woman, Usuaria (feminine) is shown instead. However, as Massa and Zelenkauskaite  lawyer”) to identify the user as a woman. Additionally, in the presence of infoboxes (Wikipedia fixed-format tables) related to gender, we used them as a clear expression of the user’s gender.If the user explicitly provided information about his or her gender, we used this information to classify the user. Taking advantage of the grammatical gender encoded in the Spanish language, we used expressions such as If the user provided their real name, it was also possible to determine his or her gender, given that most names in Spanish are indicative of gender and can easily be classified as a man or a woman. In case of doubt , we did not apply this rule. On the other hand, given that women are less likely to reveal their gender through their chosen username , we did Estoy interesada en… (“I am interested in…”), since interesada is the feminine form of the participle “interested” in Spanish.If the user provided no explicit information about their gender, but this could be inferred from the use of grammatical gender in their self-descriptions, we used this information to identify them as a woman or a man user. For instance, we determined that a user was a woman if she wrote Finally, if the above was not sufficient to determine gender, we classified the user as a user of unknown gender. For the sake of clarity, we refer to these users as “unknown”.To ensure coding reliability, two researchers each independently coded two packages of user profiles, which contained 55 profiles per package. Given the cardinal nature of the users’ gender variable , we computed Krippendorff’s alpha  to deterMAN is the gender computed by our manual content coding and CAPI is the gender extracted through the MediaWiki API. Then:To determine differences in editing practices, we used gender as the grouping variable, which takes three possible values: man, woman or unknown. Gender was determined by combining the gender specified in user’s profile (extracted through MediaWiki API ) with thMAN = CAPI then class = CMANIf CMAN = Unknown, and CAPI! = Unknown, then class = CAPIIf CMAN! = Unknown, and CAPI = Unknown, then class = CMANIf COtherwise, raise an error as both procedures do not agree.Editing practices and engagement were characterized according to the following attributes: participation (both strength and variety), lifespan, and content preferences , 33, 37.Participation in different Wikipedia namespaces is a measure of their level and type of engagement . WikipedRegarding the lifespan of participation, we measured the number of days between the first and last edition, the number of active days , the percentage of edits per active day, and the number of days since last edition. This latter information will be used as a measure of editors’ disengagement .Content preferences were measured as the number of edits in special categories and groups of pages that we consider relevant to our purposes. We followed the procedure described by Lam et al.  using a First, we used a Chi-squared test to measure differences in proportions among groups  with the aim of determining which method  is more effective to identify the gender of editors. Then, in order to determine if there are statistically significant differences in editing practices among the three groups , we used a non-parametric Kruskal-Wallis H test, followed by Cohen’s d effect size, and complementary non-parametric post-hoc Dunn’s test with the Benjamini-Hochberg correction , as we hOur first result emerged from our manual coding procedure in answer to our first research question (RQ1a). We were able to code 4,746 of 5,651 personal pages, after excluding empty, removed, and locked user pages. Of these 4,746 personal pages, 2,029 were attributed to men (42.8%), 295 were women (6.2%), and 2,422 could not be attributed and therefore remained “unknown” (51.0%). We recalculated the sampling weights in Taking into account these corrected weights, and assuming a maximum error of 1.5%, our first estimation of the editors’ gender (according to our coding procedure) allows us to conclude that, among the editors of the Spanish Wikipedia, 6.1% are identified as women and 41.1% are identified as men, while the gender of the remaining 52.8% is unknown. If we take into account only user profiles attributable to women and men, those identified as women will represent 12.9% of the total number of editors. This figure is close to results obtained by comparable studies of the English Wikipedia, which have estimated the proportion of men editors at between 84 and 91% , 12, 18.As we have discussed previously, editors can specify their gender in their account’s preference settings. The gender setting is public information that can be extracted by means of MediaWiki API . We usedAccording to There are 2,792 users identified as men , comprising 58.8% of the total number of editors.There are 353 users identified as women , comprising 7.4%.The other 1,601 users remain labeled as “unknown” (33.8%).Once again, if we take into account only editors identified as women or men, women comprise 11.2% of the total number of editors. Finally, if we take into account the stratified sampling weights after normalization for generalization purposes, there is a slight increase in this figure, from 11.2% to 11.6%. From here on, we use this subset containing 4,746 editors coded as women, men, and unknown to analyze their differences.According to these results, we can answer RQ1c: Are there differences between editors when it comes to how they disclose their gender on Wikipedia? Use of Wikipedia’s gender setting–available via the MediaWiki API–is comparable among men and women, but women are less likely to disclose personal information in their personal profiles. On the other hand, users with an unknown gender through coding are also less likely to use the setting to disclose their gender, thus reinforcing the idea that some users might be reluctant to reveal their gender.In this section we analyze the differences between men, women, and unknown user profiles with respect to their editing practices. First, we compare their participation in the different Wikipedia namespaces.Excluding the number of edits to their personal page, users who are identified as men show higher figures than those identified as women, regardless of the Wikipedia namespace in which they participate. However, if we consider only the editors belonging to the most active stratum, all these differences become irrelevant except for the case of the namespace named Wikipedia, where users identified as women clearly outperform those identified as men. On the other hand, users identified as women have a higher percentage of edits in non-content pages. For those users identified as women in the most active stratum, this percentage is not statistically significant. Unsurprisingly, unidentified users focus more on content than on discussion and administration pages.In this case, users identified as men show more diverse interests than those identified as women, as they create and edit a larger number of different pages. Users identified as women, for their part, prefer to focus on a smaller number of pages. Nevertheless, this is not true for the most active editors, where users identified as women are more active with respect to creating and editing different pages and all gender differences vanish or are even reversed.Thus, RQ2a and RQ2b can now be answered. With respect to RQ2a (“Are there differences between men and women in terms of the intensity of their engagement as editors?”), the answer is yes, users identified as men are much more active than those identified as women, and they create and edit more different pages. However, this is not true for the most active editors, where all gender differences disappear or are even reversed. With respect to RQ2b (“Do men and women participate in a comparable way in the different Wikipedia namespaces?”), the answer is no, since there are significant differences across all Wikipedia namespaces (where users identified as men constantly outperform those identified as women). Once again, however, this is not true for the most active editors, who show no significant gender differences, except for the Wikipedia namespace (aimed at content about Wikipedia itself), where users identified as women are much more active than those identified as men.In both cases, these differences could be partially explained by the fact that women withdraw from editing Wikipedia sooner than men. In general, users identified as women are editing for shorter periods than those identified as men, though during these periods they edit more regularly and more intensely. However, this is not true for the most active editors, who show no gender differences, except in the number of edits per active day, where users identified as women clearly outperform those identified as men. Nevertheless, the most dramatic gender difference observed in This provides us with the answer to RQ2c (“Do men and women continue editing for similar periods of time?”). Evidently, users identified as women withdraw from editing Wikipedia much sooner than those identified as men, except for those in the group of most active editors. The dropout percentage is almost five times larger for users identified as women, an enormous and significant difference. In the case of the most active editors, dropout is significantly reduced, however, and there are no significant gender differences, though the dropout percentage remains higher for users identified as women.It is also possible to analyze whether men and women editors focus on different content areas. This table reveals some interesting facts about content pages, although it is important to remember that we have not analyzed all Wikipedia content pages, but only those that belong to only one of the five top-level categories. First, users identified as women appear to be slightly less interested in editing pages related to Science and Nature (6.5% and 7.3%) than those identified as men. Worthy of mention is the fact that Science includes Technology, typically a male-dominated territory . NeverthTo extend our exploration of gender differences in content editing, we also analyzed individual pages where the proportion of women contributors is greater than expected. Given the immense number of pages to explore, we selected the most popular pages (in terms of participation). Accordingly, we selected only those content pages and their associated discussion pages with at least 50 editors, yielding a total of 1,403 pages. For each of these pages we then computed a Chi-squared goodness-of-fit test to compare the proportion of women editors with the expected probability of being a woman, excluding the unknown class.Feminismo), where they have relatively more presence and edit more than users identified as men . Notice that in most pages, editors identified as women have, in average, more edits than editors identified as men. On the other hand, we found 54 pages where the percentage of editors identified as women was significantly smaller than expected (p < 0.05), among which there were seven pages that had never been edited by any woman. Four of these are related to soccer; the other three are “C” (the programming language), “Finland” (the country), and “José María Aznar” (the Spanish right-wing politician), which are apparently unrelated.As shown in Thus, we are able to provide an answer to RQ3a . With respect to the presence of men and women across the most popular Wikipedia content pages , men editors appear to be present everywhere, though their average number of edits is quite variable between pages. Editors identified as women, on the other hand, appear to focus on a reduced set of pages, mainly because they make fewer edits.a priori two interesting groups of pages, the first of which is composed of pages belonging to two WikiProjects, namely, “Women” and “Feminism”. The second group is composed of pages that contain “woman”, “women”, “gender”, “femin*”, and other gender-related words (or word fragments) in their title, yielding a total of 69 pages. In both cases, we included edits to content pages and their corresponding discussion namespaces. These results could be attributed to personal preferences and the overwhelming presence of men editors rather than to a gender issue, except on a few pages that specifically address gender issues. When looking at the 10 articles with the highest rate of editors identified as women , we founAs expected, users identified as women were clearly more interested in editing these groups of pages, as a large percentage of them did so (with respect to the group they belong to), with a larger number of edits than users identified as men or unknown. This is especially true for WikiProjects related to gender issues, indicating that these seem to be a good way to attract women to Wikipedia. In answer to RQ3b (“Are there pages or groups of pages where women are clearly underrepresented or overrepresented?”), there are many pages on which women are clearly underrepresented, as most pages have a lower than expected percentage of editors identified as women; in some anecdotal cases, the percentage is even zero. This is especially true for pages with fewer than 50 editors. On the other hand, pages explicitly related to gender issues appear to attract a large percentage of editors identified as women, though those identified as men still outnumber or “surround” those identified as women in a ratio of 3:1 or higher.Using the data about editors and their editing practices, we tried to measure the degree of separability between men and women, as points in an n-dimensional space characterized by the measured variables. As an exploratory analysis, we just wanted to determine whether the typical participation and engagement measures  are enouMost users identified as men (90.2%) would be correctly classified using this procedure, while most users identified as women (79.6%) would not. Therefore, building classifiers that could help to discriminate between men and women by considering their editing practices is faced with two important issues. The first of these is the well-known gender bias that causes an unbalanced data set . Secondly, the low degree of separability among women which makes all the typical balancing techniques useless, especially those based on oversampling the less populated class .Finally, if we attempt to classify the 1,601 unknown editors according to their nearest editor , we find that only 198 (12.4%) of those editors would be classified as women, a figure only slightly higher than the overall 11.6% found previously. In answer to RQ4 (“Can we discriminate between men and women according to their editing practices?”), we can just point out that editor’s gender cannot be determined according to their editing practices, as women are completely “surrounded” by men.Our analysis provides a detailed view of the editing gender gap in the Spanish Wikipedia by focusing not only on the number of men and women editors, but also on the number and type of their editing practices. Before addressing the implications of our results, we must discuss some of their limitations. First, we analyzed a dump, which is a static picture of Wikipedia at a specific moment in time. All the results described in the previous section, therefore, must be properly contextualized to that moment in particular. Second, we established a minimum of 50 edits as a threshold for analyzing editor activity, which is a typical setting for this kind of analysis . HoweverThe traditional method used to attribute editor gender using MediaWiki API enables the identification of a less than satisfactory 3.8% of women editors and 35.0% of men, while an overwhelming 61.2% remain unknown. As we have discussed, editors appear not to disclose their gender through the Wikipedia user profile . In factAs in previous studies , 12, we With respect to the kinds of pages contributed to, our results show that women have higher percentages of edits on non-content pages than men, and less than them on content pages . Since most non-content pages are aimed at interacting with other editors–particularly talk pages, where editors discuss shortcomings and possible improvements to Wikipedia articles–our findings seem to coincide with Lam et al.’s  assertioWe also analyzed whether men and women editors have similar interests, using the top-level Wikipedia categories to group pages into disjoint sets, finding that women appear to be slightly less interested in editing pages about Science and Nature, but these top-level categories are too general and inaccurate, as already discussed. Our results are somewhat consistent with the findings of Lam et al. , but notRegarding specific content pages, men editors always outnumber women in a ratio of 3:1 or higher. In fact, there is a long list of Wikipedia articles to which women contribute significantly less or even not at all. We were only able to find two groups of pages where women seem to be more active than men, which were two WikiProject pages (“Women” and “Feminism”) and another group of pages related to gender issues. These pages were edited by a tiny fraction of editors, however. Accordingly, women seem to be more interested than men in contributing to WikiProject pages focused on closing gender gaps.However, when we concentrate our attention on the most active editors, gender differences among women and men editors vanish or are even reversed, with women more active than men in some cases. However, women editors are a clear minority. Women who become established Wikipedia editors achieve higher number of edits over time, yet our results also point to a clear difference between women and men in terms of Wikipedia engagement. Women withdraw from editing Wikipedia sooner than men, especially during the first weeks. Therefore, there is a lower retention rate among women than men, a finding consistent with Lam et al. . AlthougOur study is one of very few to provide a detailed analysis of the gender gap in the Spanish Wikipedia while adding to knowledge of Wikipedia in other languages. In contrast to other ways of estimating this gender bias, we have mainly analyzed the information disclosed by editors about themselves in their user profiles. Unsurprisingly, our research confirms the well-known fact that women editors, a mere 11.6% of all editors whose gender was identifiable, are hardly present as contributing editors. In tackling this issue, we have combined two methods of gender determination. The first of these relies on the user’s self-presented gender disclosure on their Wikipedia user profile, a method only used by 38.8% of the editors considered in our analysis. The second is a coding process that allows us to attribute gender according to information disclosed on editors’ personal pages. Our coding process helped us to identify the user’s gender in 49.0% of cases. As we have shown, this is particularly relevant for women editors, who appear less likely to disclose their gender using Wikipedia’s gender setting.Generally speaking, women are not only a minority among Wikipedia’s editors, but their editing practices also appear to be less intense compared to men. In fact, Wikipedia is an immense space in which women may feel outnumbered by men , even on gender-issue oriented WikiProject pages. This fact may incline women not to disclose their gender via the Wikipedia gender setting or self-presentation on their user page. However, we also found that women who achieve a certain level of edits over a long period become as active as men on Spanish Wikipedia, or even more so in terms of their editing practices. Perhaps, in addition to well-established initiatives such as edit-a-thons and WikiProjects designed to attract more women to Wikipedia, it would also be useful to make the involvement of this highly active group of women editors more visible. Increasing awareness of women’s successful experiences could be a good starting point to encourage other women to continue editing, and thus promote the long-term engagement of women on Wikipedia.Based on the quantitative findings of this study, future research on this topic should focus on the reasons why women withdraw from editing in Wikipedia, a topic which is still largely unexplored. Further qualitative studies could provide a more fine-grained, in-depth understanding of the current gender gap in Wikipedia by, for instance, exploring the views of women on a framework for gender equality in this collaborative environment, or by describing their experiences as content generators in a highly male-dominated environment. Deeper analysis of the role of edit-a-thons is also needed for understanding the self-inclusion strategies that can enable more women to adopt and maintain a habit as regular editors over time.


Maintaining a healthy work–life balance is important for both males and females. Nevertheless, gender segregation still exists in labor markets in South Korea. Therefore, this study aimed to investigate differences in occupational characteristics, job quality indices, and work-life balance between male and female employees. This study was a secondary analysis of the data collected through the fifth Korean Working Conditions Survey in South Korea. Generalized ordinal logistic regression analysis was carried out to investigate the associations between job quality indices and work–life balance of employees by gender. The job quality indices were different according to gender. Male employees were mainly affected by working time quality and work intensity, while female employees were affected by both these factors and by the physical environment. Therefore, strategies differentiated by gender are necessary to improve work–life balance. In particular, more careful attention should be paid to female workers’ physical environment. Healthy work–life balance refers to a state where work activities and home or non-work-related social activities coexist in harmony . The facMaintaining a work–life balance is an important factor for the well-being of both individual workers and their families. Although working hours are decreasing globally, the average annual working time in Korea is 2124 h; among the Organization of Economic Cooperation and Development (OECD) member countries, only Mexico has longer hours, at 2228 h . The aveThe gender gap in work–life balance and job satisfaction has long been an issue, and various studies have been conducted on it ,9,10,11.The labor markets of most welfare developed countries are highly segregated by gender ,16. TherIn cases where work–life balance is not present, individuals may experience a deterioration in their physical and mental health, as well as problems such as decreased quality of life, job satisfaction, and organizational commitment, and companies may experience increased turnover ,29. TherThis is a descriptive cross-sectional study to compare job quality indices that affect the work–life balance of employees by gender with secondary data analysis using raw data from the fifth Korean Working Conditions Survey (KWCS) (2017) conducted by the Korea Occupational Safety and Health Agency. Included in this study were 37,336 (74.4%) employees selected from the 50,205 workers in the fifth KWCS. The selection criteria were: older than 15 years old, and worked for pay for more than one week prior to the time of the survey. Those who were self-employed, business owners, employees, unpaid family workers, and others were considered workers. The variables used in this study were selected by referring to the sixth Euro Working Condition Survey (EWCS) . The surOccupational characteristics included age, occupational groups, sectors, number of workers in the workplace, and average monthly income. Sectoral analysis of fifth KWCS was carried out based on the Korean Standard Industrial Classification (KSIC). In this study, the 21 KSIC sectors were reorganized into ten categories based on the sixth EWCS .Job quality indices were divided into six areas: physical environment, work intensity, working time quality, social environment, skills and discretion, and prospects. The physical environment included the potential risks to workers’ physical well-being, environmental risks such as vibration and noise, biological and chemical risks such as chemical contact, and ergonomic risks related to posture, which were measured with a total of 15 questions. Work intensity included quantitative demands such as the speed of work, time pressure and strict deadlines, factors affecting the performance evaluations, and emotional needs, which were measured with 12 questions. Working time quality measured working hours and the length of recovery periods between working days, atypical working hours such as weekend work, night work, and shift work, and the flexibility of working hours in relation to the worker’s discretion to determine working hours and free time to meet business needs. These were measured with a total of 19 questions. The social environment measured the positive and negative experiences that can occur in the workplace with 15 questions about experiences of bullying, violence in the workplace, and support from colleagues or superiors.The area of skills and discretion measured cognitive skills such as task complexity, discretion to decide the order and method of work, and organizational participation and training. These were composed of 15 questions.Prospects refers to workers’ perception of employment status, type of contract, and prospects for career advancement to measure continuity in the job. A total of seven questions were used to measure prospects. The questions were scored with Likert scales or were dichotomous questions. The responses were converted into scores ranging from 0 to 100 points, and the mean index scores were calculated to compare the detailed questions in each area. In this case, the responses were converted into scores so that high scores indicated positive responses. Work–life balance was evaluated with a total of six questions. The positive aspect (good fit between working time and non-working time) was measured with the question “Is your working time suitable for you to lead your family life or social life?” using a 4-point Likert scale ranging from “Very appropriate” to “Not appropriate at all”. The negative aspects (the conflicts between work and family) was measured with a total of five statements: “I worry about work even when I’m not working”, “I’m too tired to do housework after work”, “I don’t have enough time to spend with my family members due to my work”, “I don’t have enough time to work because of what happened at home”, and “I feel that I cannot spend time on work because of my responsibility to my family members”. Respondents were asked to rank their agreement with the statements using a 5-point Likert scale ranging from “always” to “not at all”. The samples from the fifth KWCS were designed with a secondary probability proportion stratified cluster sample survey, and standardized weights were applied to the samples when the data were analyzed to more accurately estimate the population. The data were analyzed using the IBM SPSS/WIN 25.0 program.2 tests or t-tests were conducted to identify differences in the occupational characteristics, the job quality indices, and the work–life balance by gender. A generalized ordinal logistic regression analysis, a statistical analysis method for ordinal dependent variables [Descriptive statistics and Xariables , was perThe occupational characteristics of male and female employees are shown All job quality indices showed statistically significant differences between male and female respondents. In the areas of “physical environment”, “work intensity” (for which the score was inverse transformed), and “working time quality”, females showed significantly higher scores than males. In the areas of “social environment”, “skills and discretion”, and “prospects”, males showed significantly higher scores than females. The characteristic of the work environment that showed the largest difference between male and female respondents was “skills and discretion”, for which the score of males was about six points higher than that of females . The differences in “work–life balance” between males and females are shown in Turning to the negative work–life balance items, the “skills and discretion” area was shown to increase worry about work in both males and females. The lower work intensity scores (or higher reverse transformed scores) had the effect of reducing worry about work. For the items “I’m too tired to do housework after work” and “I don’t have enough time to spend with my family members due to my work”, “skills and discretion” had no significant effect on males but had significant positive effects on females. Among the predictors of the effect the job has on time with family members, “working time quality” had the largest effects on both males and females. For the items, “I don’t have enough time to work because of what happened at home” and “I feel that I cannot spend time on work because of my responsibility to my family members”, “skills and discretion” was shown to be a positive predictor in both males and females. Among the predictors of concentration problems due to family issues, the characteristic that had the largest effect was “work intensity” for males, but “physical environment” for females. This study was conducted to investigate differences in occupational characteristics, job quality indices, and work–life balance between male and female employees using data from the fifth KWCS. It seeks to understand the associations between job quality indices and work–life balance by gender.Although the participation of females in the workplace is increasing in South Korea, the occupational characteristics of male and female workers were significantly different in all areas, including age, occupational groups, sectors, number of employees in the workplace, and monthly income. This is consistent with the fact that gender segregation in the labor market is becoming more apparent as females’ paid work increases, as reported in the results of the sixth EWCS . This stJob quality indices also showed significant differences between males and females. Females had higher scores than males in physical environment, work intensity (reversed), and working time quality. Males had significantly higher scores than females in social environment, skills and discretion, and prospects. In the results of this study, the ratios of craft workers and agricultural workers were higher among males, and those of service and sales workers were higher among females. In addition, the ratio of employees in the transport sector was higher among males, but the ratio of employees in health sector was higher among females. Therefore, the difference in job quality indices between males and females may be due to the differences in occupational groups and sectors between males and females.Overall, finding a good fit between working time and non-working time among the job quality indices was higher among females. When occupational characteristics were controlled, the factor that had the largest effect on a goodness of fit between working time and the non-working time was working time quality for both males and females. The working time quality index takes into account the number of working hours, atypical working time, working time arrangements, and flexibility. According to the results of previous studies, both work–life balance and job satisfaction decreased with longer working hours . AlthougMost of the job quality indices that positively affected the positive work–life balance items for work–life balance also negatively affected the negative work–life balance items. However, skills and discretion increased both the positive and negative aspects of work–life balance. In particular, skill and discretion were factors that had the most significant positive effect on “worrying about work for work–life balance” for females, although it had no effect on males. It also had a positive effect on the “tired after work” and “job affects family time” items among females. The score for skill and discretion was higher among males than among females. This result, which indicates that skills and discretion have larger effects on work–life balance for females despite the foregoing, was unexpected. In studies conducted outside of South Korea, females reported less decision making authority at work, and their psychological demand level developed more unfavorably than did males”, which resulted in an increased job strain gap between males and females . PreviouThe factors of job quality indices that have an effect on work–life balance were investigated by gender. According to the results, males were mainly affected by working time quality and work intensity, while females were greatly affected by the physical environment in addition to these two factors. For females in particular, the physical environment was the factor that had the largest effect on the item “family affects job time”. The physical environment consists of ambient risks, biological and chemical risks, and ergonomic risks. According to a previous study, about 50% of female workers experienced a high prevalence of musculoskeletal symptoms in their lower backs . AlthougThis study has several limitations. First, the criteria for selecting survey participants was simply people in South Korea who worked for incomes in the past week and who were at least 15 years of age. This means that the survey included self-employed people, business owners, employees, unpaid family workers, and other workers. Therefore, although standardized weights were applied, the possibility that the results of this study contain biases related to sampling cannot be excluded. Second, although this study investigated differences in occupational characteristics, job quality indices, and work–life balance between male and female employees, differences in job quality indices and work–life balance between male and female employees cannot be simply interpreted as arising from gender differences because occupational characteristics were also different between male and female employees.The present situation of jobs and job quality indices is different between male and female employees in South Korea. The factor that had the largest effect on work–life balance was working time quality. Therefore, improving working time quality rather than simply reducing working hours is considered important. In addition, there were differences between males and females in work and family conflict according to job quality indices. Although working time quality and work intensity affected work–life balance for both males and females, females were also affected by the physical environment of their workplace. Therefore, to improve work–life balance, strategies differentiated by gender are necessary. In particular, more careful attention should be paid to the physical environment of female workers.


It is important for people with Type 2 Diabetes Mellitus (T2DM) to eat healthily. However, implementing dietary advice in everyday life is difficult, because eating is not a distinguishable action, but a chain of activities, embedded in social practices and influenced by previous life experiences. This research aims to understand why and how eating practices are developed over the life-course by investigating influential life experiences – turning points – and coping strategies for eating practices of people with T2DM.The Salutogenic Model of Health guided the study’s objective, study design and analysis. Seventeen interviews were performed and analysed based on the principles of interpretative phenomenological analysis. Narrative inquiry and the creation of timelines and food boxes were used as tools to facilitate reflection on turning points and eating practices.Turning points for unhealthier eating were experiences that strongly disturbed the participants’ emotional stability. These experiences included psychosocial trauma, physical health disorders, job loss, and smoking cessation. Turning points for healthier eating were experiences that significantly changed participants views on life and made participants reflective about the effects of current eating practices on future health and life goals. These turning points included confrontation with ill-health, becoming a parent, psychosocial therapy, and getting married. Notably, turning points for healthier eating seemed only to happen when life was relatively stress-free. All participants experienced turning points for healthier eating, yet, not all participants succeeded in improving their diets. Two coping styles were distinguished: active and passive coping. Active coping individuals were able to act in line with their personal intentions, whereas passive coping individuals could not. Differences between active and passive coping styles seemed to be explained by differences in available resources important for adapting and maintaining a healthy diet.Disadvantaged childhood and later life adversities together with the inability to manage the mental stress explained the development unhealthier eating practices. All participants experienced turning points for healthier eating that caused eating to become a priority in their life. Yet, the fact that not all were able to eat as they intended, advocates for nutritional guidance for people with T2DM, with a greater emphasis on reflexivity, psycho-social well-being and social support. Poor dietary habits are responsible for more deaths than any other risk factor globally, including smoking . NationaReasons for the complexity experienced may be in regard to gaps in knowledge of biomedical understandings of healthy eating and daily practices. Indeed, research has suggested that lay individuals and health professionals often speak different languages when discussing health and diet –24. HealIn addition, eating practices can also drastically and suddenly change after experiencing a turning point , 28. Turspecific situations of tension  With that experience, I had such an emotional knock, I was like this [pointing her index fingers together]. I lost so much weight then. And I really couldn’t eat or drink. Nothing. [...] My boys went to my mother [...], because I didn’t cook. I didn’t feel like it at all.Tygo: I am an emotional eater, if I feel bad, I eat everything I can get my hands on.Participants found it difficult to regain stability over their emotional states in the context of everyday life. This manifested itself, in some instances through the participant not paying attention to what was eaten, sometimes by the participant eating very little (e.g. Carla), but mostly by participants eating excessively (e.g. Tygo). In case of the latter, excessive eating was used to progress and regain command of their (negative) emotions .Karin: I actually think that after my husband died, I started eating a lot due to grief. I would describe this as, responding through snacking. Then the weight piled on. Now that I think about it. Before that, it was different. When you have a partner, you don’t sneakily snack. At least, I didn’t.. but when you are alone [...] and you experience grief, you don’t know what you have to do to cope with it. He always came home at 3 o’clock  [...] Well, now, I do have a cookie or something with may tea, but I used to have a nice chat with him. Now I have to drink my tea or coffee alone, you know. It is actually that I started to eat to cope with the grief.Saskia: That’s when I started injections, after he [husband] died. The anxiety, the stress, are cooped up inside me.For example, losing a loved one, especially when it involved a spouse, caused loneliness, which led to less interest in cooking, and sadness, which led to emotional eating .The onset of certain physical health problems caused stress, which led to unhealthy eating, because it confounded daily life through feelings of social isolation , impediment of living an active healthy lifestyle, and chronic suffering from pain . Excessive eating was also used to cope with the stress caused by smoking cessation. Commonly, the participants experienced a lack of social support while dealing with the emotional aftermath of turning points for unhealthy eating.‘calmer waters’ in terms of life circumstances  and mental well-being .Diane: Yes. I have recouped after hitting ‘rock bottom’. I do notice that I manage my life more than before. That being healthy, and that quitting smoking also came up as an issue. I just succeeded with that in one go.Turning points that induced healthy eating were experiences that significantly changed participants views on life and made participants reflective about the effects of current unhealthy eating practices on future health and goals. These turning points included confrontation with ill-health, becoming a parent, psychosocial therapy, and getting married. It is important to emphasise that these turning points generally happened in late-adulthood when most participants were in comparatively Secondly, it is important to note that turning points for healthy eating did not always have an infinite effect on eating practices. For example, Robert and Saskia managed to achieve significant weight loss (30–45 kg), but unfortunately regained much of it later due to other health complications .Henk: Not being entirely in control. Your body always craved food. And then it ended and now, I have it reasonably under control.Interviewer: Yes, and how did you succeed?Henk: Through shock. At 83 k, I realised that it was going wrong. And then other things came to light.A confrontation with ill-health was the most frequently identified turning point, which also caused the most drastic and long-lasting dietary improvements. In some cases, the reason was external, because it came from health professionals , or from family/friends . In other cases, the reason was internal, because participants themselves noticed alarming cues: Claudia decided to start cooking more frequently after just feeling unwell, Henk started dieting after being shocked at his high weight, Theo decided to limit his alcohol intake after realising it was getting out of control, and Mieke took better care of herself after being shocked by the death of her mother. Participants improved their diets either on their own, or with help of a dietician, by following a lifestyle program, or by undergoing bariatric surgery.slightly, Diane, Saskia and Carla stressed that parenting has improved their eating practices drastically. Unlike the other participants with children, Diane, Saskia and Carla experienced parental abandonment and child neglect in their own childhoods. Their parents were emotionally unavailable, and due to either financial- or health reasons, were unable to provide food and enjoy foods together with their children. Being parents themselves gave their life a new sense of purpose that strongly motivated them to do things better. This included providing healthy meals, and enjoying meals together with their kids, but also taking better care of their own diets and weight, because they wished to stay as healthy as possible for as long as possible.Diane: That first year, before I had children [I didn’t cook]. That time I associate with really living for fun. I was drunk almost every day [laughing]. Yes, that was quite something.. yes, wild! [...] I also sometimes used to say that she [my daughter] saved my life.Interviewer: How did you go about [Eating more healthily]?Diane: Oh I just did. I knew clearly how it shouldn’t be, but I didn’t know exactly how it should be. And yes. Making the most of it […], but that is with everything. Also, with raising the children. I was not raised properly. That’s way I needed assistance with raising them.. that’s also how it is with cooking. However, I enjoyed having breakfast together in the morning [...] I thought that was always very important.Secondly, becoming a parent was identified as turning point by Diane, Saskia and Carla. Although most participants had children and generally they indicated that this only changed eating practices Annie: I have experienced it as a very wonderful experience. Due to the fact that you are sitting with a group of people, around 10, 12 people, who actually know very well what you are going through, because you are almost all going through the same thing, and that makes it easier to live with. You don’t have to explain anything. [...] I still have contact with a few people from there. [...] You are, of course, receiving therapy at that time, and at some point, you start to see things differently. And then you have slowly elevated your perspective [...] this comes from how they support you in looking at things differently. You realise that the outlook is simply different. [...] And I have to say, I have benefitted a lot from it.Thirdly, psychosocial group therapy was identified as a turning point by Diane and Annie. After suffering from depression, psychosocial therapy changed their outlook on life and equipped them with tools to take better care of their mental well-being. They emphasised that the most helpful aspect of their therapy was sharing their stories with others and feeling understood. Once their mental health was improved, there was more room to take better care of their diets as well.Saskia: Before getting married [...] I had also lost a lot of weight. [...] I wanted to fit into my wedding dress [...], but that motivation maybe lasted a week after that. After getting married, it was gone again [...] That now seems simply unwise: [...] to make sure you were slim as possible just to fit into your wedding dress.Finally, Saskia identified the prospect of getting married as a ‘small’ turning point. Her wedding motivated her to lose weight as quickly as possible. Looking thin was important for her, because she had felt always ashamed of her weight and appearance, as she had been overweight as a child.why a specific experience had such impact on a specific individual’s eating practices at that specific time. The personal connotations explain why turning points varied in terms of impact and duration of the effect on eating practices. For example, from the nine turning points that Saskia mentioned, getting married improved her diet only for a short period of time, while the traumatic experience of being raped as a child still has a permanent impact on her eating behaviour. She identified this as the cause for developing emotional eating habits. In addition, the personal meaning (or situatedness) explains why similar experiences can have different effects on eating practices. For example, the reason why losing a job was such a significant turning point for Annie, but did not affect eating practices of some others, is that Annie perceived losing her job as the main cause for the termination of her relationship.Annie: I was born in 1957 and until 1995 everything went smoothly. I never actually once thought that there was anything that could have an influence my eating. Well in 1995, I lost my job after 20 years and my relationship with my partner also fell apart. In response, I started to eat a lot [...] My partner and I also worked together. We used to see each other every day at work. And when that stopped, there were a lot of things that we didn’t talk about anymore. Most of it was connected with work and then at some point.. [...] I stopped seeing him every day, you know? Then it just becomes very different, yes.Although parallels and commonalities are described among the different types of turning points, it should be stressed that consideration of the personal connotations to the individual of the turning point, together with contextual- and the temporal aspects is needed to fully understand at that time. For example, Mark identified the health warning from his GP as a turning point. Yet, coincidentally, watching a TV show on reversing T2DM with lifestyle reinforced the effect of this turning point, and being retired facilitated the implementation of the dietary advice into practice.Furthermore, turning points are highly contextual, and, therefore, should be interpreted in the light of the everyday life circumstances temporal influence of past experiences on present eating practices is needed for a meaningful interpretation as this serves as an overall ‘background’ for the turning points. Particularly, the undeniable influence of the childhood experiences on later food norms, cooking skills and eating practices. Both food-related and more general growing-up experiences influenced eating practices in later life. Typically, the participants grew up in large families under relatively financially deprived circumstances. A few had a happy childhood, but most had a disadvantaged childhood, in which they had to work hard and felt invisible to their parents. Some even experienced severe child neglect or abuse. Living in large families implicated that all food always had to be shared. Seemingly, being in charge of what, when, and how much to eat became important for making food choices in their later lives, and may explain why participants indulged themselves with snacks once they started to live on their own. Not being in charge of food choices and feeling unacknowledged may explain for some experienced resistance towards dieting: the ‘rules from the dietician’ limited (again) their freedom of choice.Freek: A dietitian could tell me how much weight I would need to lose and this and that, but kind of authoritarian pressure doesn’t work for me.Dennis: They [health professionals] don’t think along with you, but more in the line of: “Let me tell you what’s going to happen”, and that does not work for me; I’d just tell them to piss off.Finally, the strong Freek: [My mother made] all the old-fashioned traditional Dutch dishes; stamppot, kale with sausage, carrots, sauces, etc. We also slaughtered our own pigs and cattle ourselves, so there was plenty of everything. We had the potatoes ourselves, you had the fruit ourselves; all year round. [...] We only had to buy butter, a pack of sugar, and some flour. [...] In winter, apples were picked and peeled, and they were sent to the stone factory. There, they were dried and you could eat them on a winter’s day. [...] Everything was used. [...] And then you also knew what you ate. Do you remember what you eat now? It’s all stuff from abroad. People now don’t know anything about half the food they eat.Furthermore, most participants were accustomed to eating fresh and self-produced foods during their childhoods (processed foods were relatively scarce and expensive at that time in the Netherlands). They learned and were taught food-related skills by helping their parents with harvesting, preparing, and persevering foods. Eating fresh products and cooking similar dishes to what their parents cooked was considered ‘proper’ and healthy food.n = 8/11) had an active coping style.Almost all participants experienced an ill-health confrontation turning point that led to reflectiveness on eating practices. However, how this affected actual eating practices in the present varied strongly among the participants: not all were able to eat in line with their new intentions. Broadly, two coping styles for healthy eating were distinguished: active and passive coping. In active coping, two subtypes are described: healthy coping and happy coping. The nuances within, and reasons for these coping styles are discussed in the next two paragraphs. Notably, of the participants with high SoC (> 35), most  this already led to weight loss and/or lower T2DM medication use, whereas others  started with healthier eating only recently. All demonstrated an accurate assessment of the extent to which an unhealthy diet is indeed a threat by accepting their T2DM, and acknowledging their own influence on their health. They also internalised being a healthy eater as a part of their identity.Annie:  That is what I eat. And people who really know me will recognize me in this because I eat healthy nowadays.should and could eat instead of what they could not eat. Their new eating strategies were characterised by eating more instead of less  and by being creative with foods .Dennis: The thing with food is, as I have already mentioned, that if you have good food, you don’t need any sauce, so there won’t be any excess sugars.Secondly, their coping strategies for challenges for healthy eating were more flexible and creative than the other participants. Firstly, they generally focused on what they Dennis: For now, my values are okay, my weight is going down, so I am satisfied. Then I will not continue to hurt myself with the thought of having to do this or that, or worry about what’s allowed or not. [...] If I do that, it becomes an obsession and I don’t want that.Saskia: I want something that is entirely tailored to my needs – identify what makes me fat, like meat, so I can leave that out. I figured that out a bit and implemented it myself.In addition, they did not want to become obsessed about dieting and weight loss, and, therefore, lost weight rather slowly by changing diets gradually. Thirdly, they were actively involved in a trial-and-error process to understand their bodies better with the help of self-monitoring blood glucose.Tygo: Well, I’ve been to a dietitian before [...], but they switched jobs a lot.. I have had three or four different ones there. And then the next one left and so on... That didn’t work. And then I started exercising here, and there was Fleur [dietician]. Then Adam [fitness trainer] said: “Do you want to go to a dietician?” I wanted to, so then I went two or three times and then she [Fleur] quit, then she went to Loenen [another city]! I said: [...] “I would like to continue working with you!”. And then we went to Loenen [...] That click that was there. If I have a good feeling with someone...Dennis: Josien, [practice nurse] she talked about it and then she said she could also send me to a dietician. “Would you like that?” she asked. It wasn’t that I had to, but she really asked for my consent. “If you want, she can call you to make an appointment.” Well, I thought it wouldn’t hurt to try. And that whole conversation with the dietitian then also came back to Josien [...] You are not rushed along or anything. Because you get that a lot, those professionals who just become snappy if you don’t do as they ask.Lastly, almost all reached out for professional dietary help; either from a practice nurse/general practitioner or dietician. Notably, these participants reported pleasant and more positive experiences with their healthcare professional. Compared to the other participants, they felt trusted and supported by their healthcare professionals. They appreciated their healthcare professional’s clear communication and ability to connect to their personal lives.Mark: We eat a lot of vegetables, lots of fresh vegetables if possible. And in the evening I do eat eggs or nuts for 2 or 3 days a week instead of a sandwich. So, no bread on those days, that’s how I started this diet. And I feel very comfortable with that [...] She [practice nurse] always pushed for those medicines. But then those shows about diabetes were on television [shows on national TV in which people improved their T2DM by making dietary changes]. Then I thought: if it works that way with food, why wouldn’t it work me? I will just go for it and see what the results will be.Diane: And then I stopped smoking last year and then I was at 109–110 [kilos]. And now I am a year further and I am around 105 [whispering]. So, I lost five kilograms in a year’s time .. even though my life [style] [...] this is very small, don’t you think? Five kilos in 1 year [...], I really don’t understand how that is possible. And if I were to have a bad week, I’d easily gain 3–4 k again.However, there were individual differences in the level of satisfaction with, and attitudes towards current eating strategies. For Mark, Jan and Dennis, adhering to new eating strategies was easier than for Diane, Annie, Saskia, Henk and Tygo. The two extremes in this type of coping were Mark and Diane; while Mark seemed to be ‘effortlessly healthy’, Diane seemed more ‘miserably healthy’.Two clear differences between Mark and Diane were that Diane’s diet tactics were more restricted and less flexible, and that Diane changed her diet without the help of a professional due to prior negative experiences. Together, this could lead to a situation in which Diane’s frustration about healthy eating per se becomes a stressor.Ria and Freek did not necessarily have the most optimal, healthy diets, and were also aware of this, but, nonetheless, were satisfied with their diets as they were and did not have a wish to improve their diets. It is important to emphasise that they were not careless about their diets: both were eating healthier compared to how they used to eat before. Yet, they were simply not willing to restrict themselves any further. Feeling good and being able to do the things that they wanted to were more important to them than improving dietary habits and losing weight. They were focused on the ‘here and now’, rather than worrying about their future health.Ria: It is not important to me, eating. I mean, let me put it this way: I care very little at all for food.Freek: Just do what you have to do and what makes you feel best. And that’s it in a nutshell [...] It’s the little things, but if you do it that way every day, you can do a lot.remaining on the same weight rather than actively losing weight. Their eating strategies were overall less drastic, more restricted  and less creative  compared to ‘healthy’ coping.Ria: No, I thought that I was [eating healthily], I’m satisfied with it [...] I will keep it up, if nothing else comes into my body. And that I get the answers of ‘yes you are doing good’ when I go to the GP check-ups.Compared to the ‘healthy’ coping, the willingness of these participants for developing and considering new eating strategies seemed to be lower. They were more focused on preventing health complications by Interviewer: Has anything changed [in how you view the disease] compared to 10 years ago?Mieke: No, no. I still think ‘oh, that one is sick’ [points to empty seat on couch]. Not me, you know.Passive coping is defined as cognitive attempts to avoid actively confronting problems and/or behaviours to indirectly reduce emotional tension through such behaviours . These pMarja: In terms of food and drink, we just ate the same things as always, nothing special. You can cook nasi once, but then you bear in mind what you put into it. And that you would eat that once. We also never eat at a Chinese restaurant or anything.Mieke: but it is often his job, [...], which always causes problems. So, now I’ve told him [her husband] if you have some event again, then I’ll stay home. [...] especially when it involves food, you know? If I have to hand over control to someone else. That I no longer have control of it myself. Yes, that, that’s difficult for me [...] Regularity is actually best for me. Just go to bed on time, eat on time, and get up on time.Secondly, they expressed to a greater extent that healthy eating in combination with T2DM is complex, particularly adjusting medications to sudden dietary changes. In addition, they were more confused by conflicting information from healthcare professionals and family members and/or friends . They also did not know how to eat healthily without starving themselves and/or comprising their enjoyment of eating (i.e. lacking knowledge/cooking skills). Instead of thinking of new ways to handle difficult situations better (i.e. active coping), these participants eating strategies were characterised by being more restricted  and more avoiding (e.g. eating at home as much as possible).Claudia: I lost a lot of weight years ago, at that time, I went to the dietitian and everything. [...] But when I stopped, it immediately came back again, so I said to myself that I wouldn’t do that anymore.Finally, they felt less supported by healthcare professionals and have disappointing experiences with dieting in the past  which made them reluctant towards dieting.Karin: So ... yes. That’s why I just do it. I also have no idea if my sugar gets too high, what I have to do then.. how I can notice it or something. I don’t know that either [...] So.. I do actually find it a bit tricky. [...] And why you do it or not; I don’t think that my doctor would be concerned.Mieke: I’m really getting sick of it. [...] And then I also said to Marijke [practice nurse] “I’ll just give up”. I’d say, take me as I am, even if that means I’m overweight. I don’t care anymore. [...] Do you understand? I mean, ... then you have peace with yourself. And maybe that’s when you will lose weight.Instead, they try now to accept themselves as they are. This can be seen as a ‘last resort’: instead of changing diets, they changed their attitudes towards diet and health.Interviewer: And what are things that make it easier for you to eat healthily?Karin: Well.. I don’t really know that. I don’t find it easy at all. But it just has to happen. I have to be careful. If my sugar is too high then you will also have problems and I also think about being a mother where the father is no longer there for the children. I then think, yes, this mother should of course continue to live a little longer. Yes, it sounds a bit strange but that is of course how it is. That can make me a little bit emotional [crying].There was individual variation in the attitude towards this type of coping: some (e.g. Karin) were overwhelmed by worries, stress and emotions at the time of the study, however, most seemed to have been moved past this initial ‘crisis’ stage.Impactful, and unfortunately often bitter, life stories, rather than a lack of motivation or nutritional knowledge, explained the development unhealthy eating practices in people with T2DM and of low socioeconomic position. Adverse childhood experiences followed by an unequal share of hardship in later life deprived participants from developing strong psychosocial resources important for both managing emotional stress and healthy eating, paving the way to developing unhealthy eating practices. Indeed, a meta-analysis showed that adverse childhood experiences – especially neglect – increased the risk of T2DM by 32% . The finThe study identified moments when people are potentially more open for dietary change , but also under which circumstances dietary change is more difficult or even impossible . A confrontational health turning point was the most powerful turning point for healthy eating. The powerful impact for T2DM self-management of such an experience has also been observed in previous research , 33, 34.if health professionals recognise them at the right time and provide appropriate guidance for a self-reflective process. In addition, this study emphasised the importance of the timing of life-events: turning points for healthy eating only occurred when someone was not facing (too many) stressors at the same time.The period after a confrontational ill-health turning point is an opportune time for changing eating practices. However, it should be stressed explicitly that confrontational health turning points cannot be forced externally; they come from within the individual. A meta-analysis showed that confrontational health warnings are only effective if the receiver’s self-efficacy is already high, but, otherwise, have minimal and even negative effects for health behaviour . Therefocan turn back from turning points due to the fact that life – maybe particularly in socioeconomically disadvantaged conditions – is ever-changing in terms of (stressful) circumstances, physical (ill)health, and/or significant resources. For example, Robert regained weight due to Parkinson’s disease as it complicated his healthy lifestyle. Positively, an initial negative event for healthy eating such as childhood neglect can have a positive effect under different life circumstances (becoming a parent). In addition, participants were even at later age still motivated to change lifestyle behaviours, given the right conditions.Finally, the results show that people unhealthy eating lead to overload of the SoC-GRR-SRR pathway whereas turning points for healthy eating were ‘SoC-strengthening’ experiences. The detrimental effect of turning points for unhealthy eating can be explained by the incapability to manage stress in combination with an unequal share of life adversities; healthy eating was no priority under such circumstances. There was so much tension that the pathway’s full capacity was required to handle the emotional aftermath of the turning points for unhealthy eating . This necessitated appraising diet as a comparatively small stressor or non-stressor. Even more troublesome, some individuals used eating to cope with the tension resulting from the turning point, which can lead eventually to a situation in which diet becomes an additional stressor on top of the already unmanageable tension. Turning points for unhealthy eating seemed also to affect psychosocial GRRs negatively . This complicated dealing with stressors further.Applying a salutogenic lens, turning points for ing Fig. . This nehealthy eating strengthened the SoC-GRR-SRR pathway as they involved reflexivity and self-redefinition, an observation in line with previous research [meaningfulness) and it gave them insights into what needed to be changed  and what is needed to realise this . Turning points for healthy eating also seemed to affect psychosocial GGR positively and directly , which strengthened the overall SoC-GGR-SRR pathway  and a smaller group seemed to adhere to dietary guidelines . This argues that self-examination alone may be a start for health behaviour change, but actual change requires also the presence of (other) well-developed internal and external GRRs/SRRs. Difference between passive- and active coping can be largely explained by difference in the extent that GRRs and SRRs were developed. Important GRRs were coping strategy, preventive health orientation, ego identity and social support. Important SRRs were disease acceptance, a flexible approach to eating, creative cooking, food literacy, self-monitoring blood glucose, and a supportive dietician/healthcare professional . In active coping, these GRRs and SRRs were used to deal with the tensions created by the turning points. This enhanced their capability to eat in line with their intentions and develop effective and flexible diet strategies.Participants with passive coping on the other hand had difficulties in successfully overcoming the initial emotional consequences of turning points and incorporating active coping strategies. Passive coping seemed not so much the result of deliberate decisions, but of frustration caused by the incapability to implement nutritional advice successfully into new eating strategies. Among participants with passive coping, feelings of anxiety, confusion and being a failure were more profound compared to participants with active coping. SoC and psychosocial GRRs might be developed to a lesser extent, which may explain the less frequent (use of) SRRs for healthier eating (manageability) and the perceived complexity of healthy nutrition (comprehensibility). They also felt less supported by healthcare professionals, so in a way, participants with passive coping were lacking this important and highly valued SRR of participants with active coping. Lacking well-developed GRRs and SRRs necessitated suppressing fears/worries and avoiding confrontation with T2DM in order to cope with the tensions caused by confrontational turning points.Happy coping can be easily misinterpreted as having less developed SoC and/or GRRs as well, however, this type of coping seems not so much the results of incapability to implement nutritional advice, but rather of not prioritising  health to the same level as in ‘healthy’ coping. Other aspects of life  were simply more meaningful to these participants. Prioritising diet more than they already do, would possibly interfere with their quality of life.A particularly important SRR for the individuals with ‘healthy’ coping was a flexible approach to eating. Adopting a positive and flexible attitude also has been identified previously as an important resource for individual resilience for coping with T2DM self-management , diet 6, and acathemselves identified what they considered to be a turning point by preparing the timeline in advance, therefore, the study was closely connected to the participant’s lived experiences. In previous research, the definition of which experiences were turning points and which were not seemed more part of the analysis, and thus, more dependent on the researchers’ interpretation [An important strength is the use of timelines and food-boxes, because these are easy, informal and accessible tools that facilitate a quick establishment of a trust relationship between the participant and the researcher. Participants easily opened up and enjoyed being part of the research. They felt someone was listening sincerely, and the interview gave them new personal insights. One participant even explained in the final phone call that the interview in itself was a turning point in a way. In our experiences, the current methodology led to richer data compared to structured interview methods that addressed eating practices and health behaviours more directly. Another related strength of the methodology is that participants retation , 82, 83.Yet, an important practical limitation of the present methodology is that it is more time-consuming regarding both execution and analysis. Secondly, this study did not include measurements on actual food intake and HbA1c (glycated haemoglobin) and blood glucose levels were self-reported, therefore, no firm statements could be made as to what extent the participants were truly eating in line with dietary recommendations. Some of the ‘healthy’ copers managed their glycaemic measurements in line with recommended targets, others did not. However, this should not be interpreted necessary as social desirability, because multiple factors  influence glycaemic control , 95. InsRegarding externally validity, it can be argued that the participants were of medium-low rather than of low-socioeconomic position. SoC values were also relatively high. In addition, the present study focused on native-Dutch. The onset of T2DM is generally at an earlier age in migrant-Dutch , 97, andThis study demonstrates the consequences of the social environment for healthy eating over the life-course. The findings imply that individual differences in coping strategies for healthy eating are not the result of specific experiences or personal factors, but of a reflective, positive attitude towards life, and the presence of psychosocial  resources. Healthy eating has the potential to improve long-term health, but the exploitation of that potential requires self-examination and supportive psychosocial resources. A stress-free state-of-mind, a flexible approach to eating, and feeling supported seem crucial in this. Overall, the findings are in line with previous research, stating that healthy eating is associated with an internal motivation, autonomy, self-efficacy, flexible dietary strategies, social support, effective stress management, and overall more psychological strength and stability , 100–104positive emotions – independent of negative emotions/stress – are associated with lower cardiovascular morbidity and mortality via suggested indirect  and direct physiological mechanisms  [Therefore, especially individuals with T2DM with more passive coping might benefit from a healthcare system that is dedicated to empowerment of individuals by involving them actively in learning trajectories focused on reflexivity, self-examination, psychosocial well-being and social support. Crucial for this is that healthcare professionals are equipped with the right skills and sufficient time to do so , 105. Whsystems) . Finally


Understanding health beliefs is important to facilitate health promotion and disease prevention as they influence health behaviors, outcomes, and disease management. Given the rise of hypertension-related diseases in the Dominican Republic, the purpose of our study was to identify hypertension-related health beliefs of Dominicans in order to inform the development of culturally appropriate interventions for hypertension prevention, care, and treatment. Semi-structured interviews were conducted with 20 Dominicans, 15 of whom were receiving treatment for hypertension. Operating within the interpretative paradigmatic framework, we conducted thematic analyses of interview data to identify hypertension-related health beliefs and practices. Iterative data analysis revealed the following themes: 1) Negative emotions are a primary cause of hypertension, 2) Medication is the best treatment but adherence is challenging, 3) Systemic barriers impede treatment access, 4) Hypertension negatively impacts mental and physical well-being, and 5) Lifestyle changes, relaxation, and social support help manage hypertension. Data gathered from member checking validated these findings. This study enhances understanding of the beliefs and experiences of Dominicans and emphasize the importance of implementing culturally competent health programming and care. According to the World Health Organization, over 1 billion people are estimated to be living with hypertension, a preventable, but major cause of premature morbidity and mortality ), recognThe DR is of particular interest as nearly 35% of Dominicans have hypertension. With prevalence rates escalating annually, the condition has become a concern of growing importance . These bDespite the research on general health beliefs, research on the health beliefs of Dominicans regarding hypertension is scarce and much less information is available on those in low resource communities. Given that health beliefs are associated with lifestyle choices, use of healthcare services, and medication adherence ,12, the The Institutional Review Board (IRB) at Virginia Commonwealth University approved this study . Verbal consent was obtained from all participants. This study was part of a larger IRB approved health needs assessment study that sought to identify community needs and health beliefs related to chronic illnesses, specifically hypertension and diabetes. The needs assessment was conducted in an effort to improve the healthcare services being offered by a medical mission group.Participants were recruited during the summer of 2013 from a small community in Santo Domingo, DR’s densely populated capital city, where 3 of the country’s 10 million inhabitants reside . About 2To recruit, we employed purposive, convenience, and snowball sampling strategies. Participants were referred by word of mouth by interviewees, a medical mission doctor, and members of a Community Health Committee (CHC), a group of community residents selected by community members to promote health and serve as a point of contact for health initiatives. Referred individuals were primarily persons with hypertension. However, this was not a requirement for participation. To be included in the study, eligible individuals had to self-identify as a Dominican citizen, resident of the community in Santo Domingo , and be at least 18 years of age.In this study, we operated within the interpretive paradigm, which maximizes subjectivity, places participants at the center of the research, and encourages researchers to use information gathered to produce meaning from the perspective of participants rather than simply conduct observations . We condInterviews began with a review of confidentiality, followed by obtaining verbal consent for participation and permission to record the interview. Written consent was not obtained due to traditionally high rates of illiteracy in the community of interest. The verbal consent procedure was approved by the IRB and documented via a consent log. After asking demographic questions, participants were asked a series of questions to assess beliefs, knowledge, and experiences related to hypertension and diabetes. Questions relevant to the current study included: 1) What do you think/how do you feel about high blood pressure?; 2) What do you think provokes (or produces) high blood pressure?; 3) What can be done to control high blood pressure?; 4) Why do people get high blood pressure?; What impact, if any, does high blood pressure have on your life ?; What can be done/what are you doing to control high blood pressure? What makes it difficult to control high blood pressure? What is the best way to treat high blood pressure? After all questions had been asked, the interviewer asked participants if they had additional comments or questions. Participants were then thanked for their participation. Interviews were conducted until data saturation  was achieved ,18.Thematic analysis of data was based on qualitative research guidelines outlined in five basic phases: (1) become familiar with the data, (2) generate initial codes, (3) identify themes, (4) review/revise themes, and (5) define and name themes . Five trGuided by the recommendations of Braun and Clarke , each reIn sum, the data analytic approach was cyclical and involved continuous development of new codes and constant comparison of themes. This emergent design was essential to capturing the experiences, voices, and beliefs of respondents ,20.Several recommended strategies  were utin = 10; 53%) and CHC members (n = 5). Although CHC members were not interviewed, they helped to clarify misunderstandings and elaborate on native colloquialisms. During the follow up interviews, individuals received a copy of the study’s themes and subthemes (printed in Spanish) and the form was reviewed with participants to ensure understanding. After having the opportunity to review and discuss the document, participants were asked if any information should be omitted or added to the findings. Member checking participants did not receive any additional incentives. Results of the member checking are presented after results of the thematic analysis.Member checking, or respondent validation, was conducted to validate the veracity of information gathered and to further ensure an accurate representation of data after translation and analysis. Member checking was conducted via brief discussions with original participants  and women  from a low resource community in Santo Domingo, DR. Participants ranged in age from 32 to 92  and half were employed . Fifty five percent of participants (n = 11) were living with their partner, 30% (n = 6) were married, 10% (n = 2) were single/never married, and 5% (n = 1) identified as a widow. The majority identified as nonsmokers . Fifteen participants (75%) reported having hypertension.In total we interviewed 20 Dominican men (n = 9) and 32% (n = 6) of participants respectively. Psychological distress included the experience of anger, frustration, anxiety, and stress. For the individuals interviewed, stress was characterized by various daily hassles and the experience of being overwhelmed with life. One woman shared her experience with how she believed stress contributed to having hypertension, “My children, they make me have bad blood… I have so many things to do… and then I’m fighting with the children. I’m worried! I’m the man and the woman here, for everything… So it’s the stress…” (55 year-old woman). “Bad blood” was described by participants as having difficult interpersonal interactions that caused internal anger, stress, or frustration. For example, the participant who referenced her children appeared to be burdened with responsibilities and stressful interpersonal interactions and believed that these experiences directly contributed to her having high blood pressure. In like manner, a 62 year-old woman explained, “So many times… people have these diseases that … they weren’t meant to have …It’s just from worry, from things that happened in the home.”Although participants discussed heredity, fatigue, and pain as precursors to hypertension, the most commonly referenced causes of hypertension were forms of psychological distress and associated lifestyle habits, mentioned by 47% . Specifically, some participants believed that anger and frustration could contribute to the heating up of blood, which could cause blood pressure to rise and lead to adverse health outcomes. “When you fight your blood can heat up and [the blood pressure] goes up and then you can have a heart attack” (53 year-old man).n = 4; 21%) believed the heat was related to having high blood pressure. “At times it goes up, especially when it’s really hot… in the wooded areas where there is a lot of shade I feel great but when the heat goes up I feel bad, I don’t feel well” (70 year-old man). Another participant commented on how the heat could indirectly cause a person to have high blood pressure by preventing health promoting behaviors known to reduce hypertension such as exercise. “It has impacts because sometimes you want to do exercise but you can’t.” (35 year-old woman).Relatedly, other participants  believed medication, commonly referred to as “treatment,” was useful in controlling or treating hypertension. Despite more participants using lifestyle changes versus medication (11 compared to 9) to control their hypertension, overall most participants believed that medication was the best treatment–highlighting a discrepancy between beliefs about the best treatment (medication) and the practices engaged in to control hypertension. Many viewed medications as superior to lifestyle changes as the “medication from the physicians… [is]…the most effective” (64 year-old woman). A 55 year-old woman stated, “for me that’s the best…Those are the best, it’s been four years, taking pills and medications.” As stated simply by a 47 year-old man, “the medications, those are better.” Medications were also viewed as more effective than home remedies such as herbal teas or plant based treatments .Most participants  expressed feelings of aversion and distrust. “Home remedies, those aren’t the solutions because if they were the solutions then the problems would already be resolved. So you go to the physician” (41 year-old caretaker of hypertensive brother-in-law). Relatedly, participants also expressed a desire for healthcare providers, domestic and foreign, to provide educational sessions about hypertension so that community members could be aware of disease causes as well as how to best care for themselves when they do not have access to provider or medication.When asked more specifically about home remedies as a treatment option for hypertension, some participants  citing poverty and challenges with money as an obstacle. A 53 year-old man explained, “Here, the money, we don't have much of that. Sometimes you have it and sometimes you don't, you know. We’re poor in this neighborhood; sometimes you don't have enough money to buy what [you] need, [like] the medications.” Likewise, a 35 old year woman mentioned that money was a barrier to obtaining medications, highlighting that “the medications are so expensive.”Seventeen of the 19 individuals (89%) interviewed about hypertension, referenced barriers to treatment of hypertension. Twelve participants (63%) indicated difficulty in accessing healthcare services or treatments, with most  discussed barriers to treatment associated directly with the healthcare system. These issues included apathy from providers, overcrowded hospitals, and lack of available medications. One participant expressed annoyance as she imitated the lack of concern for patients displayed among healthcare professionals. “A lot of times and you go see the physicians and they are like ‘Ha Ha Ha.’ And you just wait [and after waiting so long] that’s when you go to the emergency room” (35-year-old woman). A 53 year-old man elaborated on difficulties experienced with the healthcare system, “so we have a public health system where we can go and they can give us medication only if it’s available because when there is none available then they can’t give [it to] us.”n = 4; 21%) mentioned the healthcare system’s neglect of individuals with physical impairments, discussing how mobility challenges are a barrier to making appointments and accessing treatment. A 49-year old woman with a hypertensive husband stated that “if [people] have the ability to go, they can get treatment but there are some people who can't really leave home because they have other sicknesses that won't allow them to.” In sum, barriers to treatment of hypertension referenced by interviewees included money, an unstable healthcare system, and physical difficulties that limit mobility and subsequently access to healthcare and treatment.Additionally, several participants (n = 13) discussed the impact of hypertension on their life. Conversely, four (21%) individuals stated that hypertension had no impact on their life. About 32% of participants (n = 6) reported an impact on their physical health, such that the condition altered their body, making it difficult to sleep and leading to fatigue. Hence, they felt unable to go outside in the sun, work, complete chores, or do strenuous activities. One participant claimed that hypertension is caused and exacerbated by heat such that “you can’t handle things that are hot … so you need fresh things…” (41-year-old man). A 64-year-old woman described the impact of hypertension on her everyday life, highlighting the physical symptoms:Nearly 75% of interviewees  expressed changes in mental health from hypertension. Mostly, interviewees reported feeling sad and overwhelmed, but also highlighted “needing to take things slow” or “relax.” A 64 year-old woman reported… not feeling very well. It’s like if you were lying down and you had been sick for three days but nothing’s really wrong with you and it’s like you just feel, it’s like your face is down. It’s something that’s silent; the other thing is… it doesn’t hurt… [Like when] I’m walking and doing my house chores and [my neighbor] for example she asks me how do you feel and I don’t feel anything but she says your face looks … downward.This woman believed she experienced melancholy because of having hypertension. For her, and others, the condition manifested physically and mentally.n = 10; 53%) discussed the benefits of relaxation on hypertension. Interviewees expressed that keeping calm and “taking life as it comes” were one of the best ways to manage hypertension. “The best treatment for conditions like what I have is to be calm, to not have bad blood, not to get mad, not be in fights … That’s what I do, that’s the best treatment” (53 year-old man). “Relaxing in terms of lifestyle… can also treat it” (41 year-old woman). Other participants highlighted the significance of maintaining good psychological health, stating that it is important to “not have worries” (32 year-old woman) and have “control in life …and be calm” (70 year-old man). A few participants that highlighted “relaxation” as a form of treatment stated that doing so would be best in combination with taking medication and making better dietary and exercise choices. About 58% (n = 11) of participants believed that a lifestyle change, including dietary changes, increased exercise, and relaxation, could help treat hypertension. Specifically, participants stated that it is important “to have a personal step by step vigorous activity [plan]” (41 year-old caretaker of hypertensive brother-in-law) and “not to eat a lot of fat” (53 year-old man).Several other participants .n = 6) mentioned that assistance from others in the community, including family members, was not always available when they needed it. A 60 year-old man explained, “I don’t have any medication… my children they’re too busy.”However, more than a quarter of those interviewed  and CHC members. Interviewees mostly reinforced perceived causes of hypertension, non-medical methods of hypertension management, and experiences with difficulty accessing healthcare services. However, one 38 year-old man did not support the contention that sun exposure and strenuous work caused hypertension. Spicy food and lack of food, and lack of medications for hypertension control were cited as causative factors of hypertension flare ups, mentioned by a 41 year-old woman and a 47-year old male. Individuals supported findings that highlighted drinking cool liquids and living a tranquil lifestyle as methods that help ameliorate high blood pressure. When discussing barriers to healthcare services, many agreed with responses from original interviews, stating that a lack of money prevented the purchase of medications and food and that obtaining medications was difficult due to institutional barriers. Two participants further explained that when people go to the hospital, they are sometimes sent home due to lack of medical personnel or medications. A CHC member also endorsed these views and added that such difficulty can force people to turn to home remedies.Member checking was conducted via brief discussions with half of the original participants . Both participant financial situations and barriers within the healthcare system  influenced access to healthcare. Barriers to care and treatment adherence identified in the current study are similar to those identified by other qualitative studies conducted in low-middle income countries ,30.However, in addition to highlighting barriers to obtaining care, participants identified medication sharing as a personal barrier to treatment adherence, another unique finding of the current study. Specifically, participants explained the process of giving their medication to loved ones in need and/or taking medication prescribed to a loved one. This practice may help explain poor rates of treatment adherence in the DR. For example, in a sample of 6,400 Dominicans, 75% of those with hypertension did not follow recommended treatment . It is pFindings of the current study highlight the need to address barriers to care and treatment adherence at macro and micro levels. While several organizations have developed plans to create multi-stakeholder partnerships between governments, care providers, and patients to reduce the burden of non-communicable diseases, many health programs in the DR have not been reviewed or implemented due to a lack of human resources and inadequate funding and organization . ResultsResults of this study can also inform the work of foreign and domestic health professionals that provide hypertension-related care in the DR. Due to the expansion of university and faith-based service projects, rising numbers of short-term health missions have expanded healthcare access to global communities in need . HoweverBeyond health missions, one can then use results from the current study to inform and strengthen approaches to other domestic and foreign prevention and treatment efforts . For exaAlthough these findings are valuable, there are limitations. One limitation is the potential for participants to have misunderstood interview questions. It is possible that translation rendered researcher questions and participant responses unclear. Researchers attempted to minimize this possibility by utilizing a trained and certified medical Spanish interpreter, and asking CHC members to clarify questions and responses for researchers and participants. Further, researchers utilized member checking to ensure accurate understanding and representation of participant responses. Another limitation is the use of participant referral was utilized as a sampling strategy, which may have resulted in selection bias. Despite these limitations, results contribute to the growing body of research on health beliefs among Latin Americans and Dominicans in particular.Results of the current study emphasize the necessity and challenge of conducting culturally relevant health related programming and connecting individuals to reliable healthcare services in low-middle income countries. Health beliefs of participants revealed a myriad of personal, communal, and institutional challenges to obtaining care. All of which should be considered by health professionals interested in delivering culturally competent healthcare services abroad. Participants in this study were aware of the risk of uncontrolled hypertension and recognized the value of ongoing medical care. Such findings further support the importance of developing local and national action plans for diagnosing and treating hypertension, and moreover, lend themselves to guiding the work of both foreign and domestic health professional organizations.S1 File(DOCX)Click here for additional data file.