Smoking is one of the most significant factors contributing to low life expectancy, health inequalities, and illness at the worldwide scale. Smoking cessation attempts benefit from social support. Mobile phones have changed the way we communicate through the use of freely available message-oriented apps. Mobile app–based interventions for smoking cessation programs can provide interactive, supportive, and individually tailored interventions.This study aimed to identify emotions, coping strategies, beliefs, values, and cognitive evaluations of smokers who are in the process of quitting, and to analyze online social support provided through the analysis of messages posted to a chat function integrated into a mobile app.In this descriptive qualitative study, informants were smokers who participated in the chat of Tobbstop. The technique to generate information was documentary through messages collected from September 2014 through June 2016, specifically designed to support a smoking cessation intervention. A thematic content analysis of the messages applied 2 conceptual models: the Lazarus and Folkman model to assess participant’s experiences and perceptions and the Cutrona model to evaluate online social support.During the study period, 11,788 text messages were posted to the chat by 101 users. The most frequent messages offered information and emotional support, and all the basic emotions were reported in the chat. The 3 most frequent coping strategies identified were physical activity, different types of treatment such as nicotine replacement, and humor. Beliefs about quitting smoking included the inevitability of weight gain and the notion that not using any type of medications is better for smoking cessation. Health and family were the values more frequently described, followed by freedom. A smoke-free environment was perceived as important to successful smoking cessation. The social support group that was developed with the app offered mainly emotional and informational support.Our analysis suggests that a chat integrated into a mobile app focused on supporting smoking cessation provides a useful tool for smokers who are in the process of quitting, by offering social support and a space to share concerns, information, or strategies. Smoking is one of the most significant factors contributing to low life expectancy, health inequalities, and illness at the worldwide scale . Every yThe rise of internet use and mobile phones has introduced 2 key features in the way we communicate with each other: communications are now (1) ubiquitous, that is, you can talk with almost anyone anytime (24 hours a day) anywhere and (2) nearly instantaneous, as messages can be received and answered within seconds or minutes. Moreover, individuals can be connected at minimal cost, eliminating barriers to in-person participation in group programs such as childcare, disability, and employment responsibilities .The current guidelines recommend that all smoking cessation programs incorporate some type of social support . This maHowever, little is known about the efficiency and the importance of online support in smoking cessation programs. To our knowledge, previous studies published about this topic found that the support of social networks may be beneficial immediately when smokers want to quit and also during the first weeks of a smoking cessation program ,7.Lazarus and Folkman model defines the concept of stress by referring to the interrelationships that occur between a person and the context in which that individual finds himself or herself. The Lazarus and Folkman model may be transferred to the smoking cessation field to study psychological factors. Their model suggests that anxiety levels depend on the ability to handle external demands and internal evaluations that exceed the resources of the individual and on the strategies used to cope with them. This framework is appropriate for this study because smoking cessation is considered an important stressful factor. Although most smokers aged 18 years or older expressed a desire to quit and 52% had attempted to do so, only 6% of them had successfully quit at 12 months. Previous studies have found stress-induced craving response to be particularly important in smokers with high levels of nicotine dependence, who may be at greatest risk for cessation failure . Stress-The Lazarus and Folkman model addresses 6 categories : (1) emoThe discussion of emotions is a key element of online support groups. Cutrona and Suhr developed a coding scheme to classify social support behaviors as emotional, informational, self-esteem, social network, and tangible support . They idThe Tobbstop trial was a multicenter randomized clinical trial  carried out in Tarragona, Reus, and surrounding areas in Catalonia (Spain) that aimed to assess the efficacy of a mobile phone app for smoking cessation. Smokers were recruited from primary health care centers and were randomized into 2 groups: (1) an intervention group that included access to the Tobbstop mobile app and the usual counseling about smoking cessation provided in primary health care consultations  and (2) This study analyzed one of the components of the Tobbstop app, a private chat that allowed study participants to communicate with each other . The objDescriptive qualitative study to identify the emotions, motivations, and perceived benefits that could be observed in daily experiences within the process of change experienced by people who used this chat function during the action phase of the change process.Of the 309 participants randomly selected for the intervention group, 102 participated writing comments in the chat, constituting our study population. The sample was opportunistic . InclusiThe Prochaska and DiClemente model describes stages related to addictive behaviors in individuals trying to abandon substance use. The stages according to this model are precontemplation , contemplation (self-awareness of problem begins), preparation stage , action stage (reduction and cessation of smoking), and finally, a maintenance stage.The Tobbstop app was designed to support participants during the first 3 months of the smoking cessation progress, with 3 main goals in mind: (1) to help individuals record their progress in the smoking cessation program; (2) to increase the user’s knowledge about the problems related to smoking and the health benefits associated with smoking cessation; and (3) to provide distraction for moments of craving.The Tobbstop app included 4 components: (1) a library with information about tobacco; (2) a private chat for study participants where they could ask for help, share concerns, or offer help to others; (3) a set of minigames designed specifically to entertain and educate participants; and (4) a progress registry to show the evolution of the participant’s health throughout the treatment process. The app also included a panic button and consultation with an expert.The technique to generate information was documentary through written text messages. During the Tobbstop study period (September 2014 to June 2016), 11,788 text messages were written in Catalan and Spanish by participants. These were downloaded into an Excel table for analysis, replacing personal information about the participants with identification codes that protected anonymity.A thematic content analysis of the messages posted in the chat was performed by 2 members of the research team (EGF and GFM) as follows: (1) an initial reading of all messages; (2) identification of relevant topics and text messages; (3) fragmentation of the texts into units of meaning; (4) codification of texts by topics; (5) creation of categories based on the Lazarus and Folkman and the Cutrona model, grouping the codes; and (6) interpretation of the meanings of each category. Analysis was conducted with the support of the ATLAS.ti 7 program.To ensure the rigor and quality of the study, the following criteria of rigor suggested by Calderón were followed: epistemological and methodological adequacy, relevance, validity, and reflexivity . The conThe study entitled “Efficacy of an application for mobile devices in smoking cessation in young people (Smart_Smoke): a cluster-randomized clinical trial” was approved by the ethics committee of Instituto de Investigación en Atención Primaria (IDIAP) Jordi Gol (P12 / 041). The app used was called Tobbstop.Participants voluntarily agreed to participate and provided their signed informed consent. The research team coded the stored messages with an identification number to guarantee confidentiality and protection of the participants’ identity. No names were used in the reported quotations.On the basis of Lazarus and Folkman model, analysis revealed the following 5 main categories:Participants express positive and negative emotions related to smoking cessation process following Ekman classification : fear, sI have a dinner tonight and I’m really scared about it.ID 548, woman, 56 yearsWell, I passed an important test, a calçotada party with friends.ID 399, woman, 58 yearsThe emotion of surprise also appeared when a participant realized he or she had not thought about tobacco for a long time:...which means that I did not have time to think about smoking, and even I was surprised.ID 422, woman, 57 yearsI think I’m the newbie here, but it is truly surprising, the changes you notice, from smell to taste...and I’m only on my fifth day!ID 192, man, 41 yearsSome people resort to the emotion of disgust to avoid smoking again:I pressed the panic button because I would like one cigarette. I’m not so well today.ID 452, woman, 54 yearsAs the following dialog shows, in the early stages of the cessation process, sadness emerged as a powerful emotion and there was a sort of a duel about quitting smoking, a habit that had been with them for a long time. This mourning for what participants got out of smoking is also observed in these statements acknowledging that the pleasure of smoking was because of addiction:I wonder if other people have also felt sad, thinking how happy they were to smoke and now not smoking...I enjoyed the ‘misbehavior’ of smoking...ID 647, woman, 41 yearsYes...I didn’t even want to get out of bed because I thought, What will I do if I don’t smoke???ID 548, woman, 54 yearsAnd did you get over it?ID 647, woman, 41 yearsOh, sure. But it will take you a few more days yet.ID 548, woman, 54 yearsOnce the first few weeks have passed, participants reported an immense joy. Many were counting the days that they had gone without smoking and expressed pride in their achievement:Happy Wednesday. Today makes 120 days I have not smoked. I am very happy and proud of what I’m doing. Don’t give up, everybody!!!ID 548, woman, 54 yearsThe Tobbstop app asks about emotions  every day when individuals start the app. Emotions are dynamic and responsive, and some emotions can be replaced by others throughout the smoking cessation process. The negative emotions appeared in the first days when participants started to quit smoking:Every time I open the application and it asks me how am I...the first days I answered I am angry, sad, badmood...and now I have been saying for some time that I am happy.ID 543, woman, 54 yearsExternal and internal demands assessed as excessive or overwhelming might be confronted with different coping strategies. The most frequent coping strategy identified to decrease psychological stress, anxiety, and fear of relapse was physical activity. Other strategies used to decrease psychological distress and avoid thinking about tobacco consumption included listening to music, cleaning, reading, cooking, or playing:Stationary bicycle...to not think about tobacco.ID 279, woman, 40 yearsAll I do is clean and listen to music to not think about it.ID 429, woman, 40 yearsI fix supper and spend time on that.ID 406, man, 52 yearsWhen I get overwhelmed I look for a game and I get over it.ID 363, woman, 54 yearsEating certain foods, drinking liquids, and eating candies as a distraction were also used as a way to reduce stress:I’m sure that sunflower seed salesmen are happy about my not smoking!!!! I’ve already eaten 2 packages today!ID 192, man, 41 yearsI don’t know how to get over that need, I’m trying right now to think about other things and I am at work but I would really like to smoke. I am going to drink water or a Coca-Cola I might find around the office.ID 259, woman, 42 yearsIn order to decrease symptoms of nicotine abstinence, the participants used different types of treatments such as Varenicline, a nicotine substitute. The participants explained the difficulties they experienced with nicotine substitutes to calm the anxiety produced by not having nicotine, especially patches in the case of those receiving no treatment or a different treatment:I take the pills but now the doctor called to give me the patches because I had a problem with Champix but the truth is that they work.ID 399, woman, 58 yearsFor now, the patch gives me the nicotine I need...I only miss having a cigarette between my fingers...ID 266, woman, 51 yearsThe following dialog shows that humor is another strategy that was frequently used to reduce stress and anxiety:So, how’s the car repair going?ID 647, woman, 41 yearsNo defects. Hahaha.ID 485, man, 49 yearsAnd the O2 buffer?ID 647, woman, 41 yearsBad joke, no? “carboximetry at 2.”ID 485, man, 49 yearsTell the nurse to send the carbon dioxide meter out for repairs. It must not be working right...ID 422, woman, 57 yearsAt follow-up visits, participants tested their carboximetric level; seeing a score of 0 became an element of self-reinforcement. In addition, they thought that a low (or 0) score meant they had clear lungs:Today at the exhalation test I almost jumped out of the chair, I was so happy. I never thought I’d react like that!ID 422, woman, 57 yearsI went to see the nurse and I got a “2” on lung toxicity.ID 491, woman, 44 yearsBeliefs are cognitive configurations individually created or culturally shared preexisting concepts of reality that act as a perceptual lens. Despite being counseled to follow a healthy diet and drink a lot of liquids, the chat participants showed a belief that it would be impossible to avoid gaining weight during the smoking cessation process. If the timing coincided with menopause and other aspects of aging, they believed there would be greater weight gain:Did you gain weight too?ID 694, woman, 50 yearsFive kilos (10 pounds) in three months!! But it was worth it. Later on you can lose them, but slowly.ID 577, woman, 43 yearsAge is helping me [gain weight] too...ID 548, woman, 54 yearsThat could be.ID 577, woman, 43 yearsWell, with menopause besides, I can’t tell you what all else is going on with me, hahaha.ID 422, woman, 57 yearsNonetheless, they believed it was worse to smoke than to gain weight and that they would not be able to lose the weight while trying to quit smoking. Instead, they proposed it as a challenge for the near future:The weight doesn’t worry me too much if we don’t put on too much! Anyway, better 10 extra pounds than smoking again, no?ID 192, man, 41 yearsYeah, we’ll get rid of the kilos and we will also be rid of the addiction to tobacco.ID 399, woman, 58 yearsParticipants believe that physical activity is positive and useful to decrease craving symptoms. Most participants explained that they were exercising regularly:The truth is that doing sports helps a lot to overcome this vice.ID 192, man, 41 yearsDoing sports is the best !!ID 164, woman, 32 yearsAlthough many participants were quitting smoking with the help of medication, there was still a belief that it was best to do it without any pharmacological help:Anyway, if you can leave without anything, that’s the best. It's just a head issue. Be strong. And say no. In a week, the cold turkey effect just no longer exists.ID 164, woman, 32 yearsI don’t know anyone who has used medication to quit smoking. My friends have quit with nothing.ID 429, woman, 40 yearsParticipants believe that being in a tobacco-free environment would help them in their quit process and were concerned when they faced situations where they normally would have smoked and where they knew they would meet other smokers:I’m lucky that my circle of friends does not smoke, almost nobody.ID 499, woman, 47 yearsMy son and daughter-in-law also quit a few years ago. My daughter sees it as more difficult for her partner, who also smokes.ID 422, woman, 57 yearshealth, which was stated as the main motivation to quit smoking:Values are expressions of what is important for that person. The most important value expressed by participants was I want to quit for my health and for my wife and my son. If I get sick they will have a very hard time.ID 406, man, 52 yearsI’m quitting because I do not want the doctor to tell me one day, either quit or you will die.ID 470, woman, 57 yearsNot even 24h yet but I am happy because I need to quit smoking. To health!!!ID 548, woman, 54 yearsThey also highlighted the benefits of smoking cessation for their health. They described benefits they perceived in their body, how food smelled and tasted better, how they did not run out of breath while exercising, and how the various follow-up tests reinforced their decision to stop smoking:but it really is surprising, the changes you notice, from the sense of smell to taste...and I’m only on my fifth day!ID 192, man, 41 yearsI can breathe better, I can smell better AND I smell better. Food tastes better, and I’ve saved 280 euros.ID 164, woman, 32 yearsFamily was another important value and one of the main motivators to start the process of smoking cessation. Concerns included having a negative influence on their children, grandchildren, or other relatives, or impairing the health of family members, especially children, with second-hand tobacco smoke:My 4-year-old granddaughter, whose parents do not smoke, saw me and her aunt smoking, and told my daughter-in-law that “when I grow up I’m going to smoke like yaya and auntie.” You should have seen my face, and I told her that I would not smoke anymore because it makes ‘owies’.ID 422, woman, 57 yearsI have 2 little children who have a lot of bronchitis and the smoke is really bad for them...and then for my health...I’m 33 years old and I have a lot of breathing problems.ID 843, man, 35 yearsIn other cases, the family had asked them to stop smoking, but the participants were not always receptive to these messages when they were in the early precontemplative stage. They still did not see that smoking would cause any harm and it was not until the contemplative and preparatory stage when they became aware of all the messages they had gotten from relatives, health professionals, and friends:My two children asked me to quit and I am doing it for them.ID 280, man, 55 yearsMy husband is anti-smoking and has been telling me to quit for 9 years and I paid no attention; then one day, looking at Facebook, I saw [the TOBBSTOP study] and I decided.ID 429, woman, 40 yearsfreedom when participants tired of being dependent on tobacco and became conscious of their nicotine addiction. Once they had started the cessation process and were aware they had regained their freedom, this awareness became an important motivator to succeed. They were also critical of people who continued to smoke:Another important value was First of all, I didn’t smoke because I liked it but because I was addicted. Tobacco tastes bad.ID 485, man, 49 yearsI’m tired of being dependent on tobacco.ID 577, woman, 30 yearsI won’t go back to it because even when I smoked the monkey stayed on my back. Many times, right after I smoked, I thought, “Really? Again? and I would have smoked another one...”ID 647, woman, 41 yearsLook, yesterday I was inLes Gavarres and for the first time I was inside, not out on the terrace, and I looked at the smokers who were out there. The image was grotesque to look at. It was like they were being controlled. Think about that.ID 337, man, 41 yearshelp others to quit smoking, especially friends and family:Another value was to I have convinced three people in my circle to quit...I’m on a crusade against tobaccoooo!ID 192, man, 41 yearsMoney was a great motivator to begin a cessation attempt although it was combined with other elements. Saving money was an important value in remaining abstinent. The participants talked about what they wanted to buy with the money saved:I don’t want to smoke -- for my health, the money, the smell on my clothing...ID 541, woman, 56 yearsWith what we spent on tobacco, my partner and I could take a cruise you won’t believe...ID 364, woman, 49 yearsCognitive evaluation is the process that determines the consequences of smoking cessation in the individual. When participants smoked a cigarette or just took a drag, they were less active in the chat group because they felt sad, guilty, and ashamed although the group encouraged them to continue trying:I keep reading you...but I have not been able to quit.ID 259, woman, 42 yearsI feel bad because I wear the patch and don’t smoke cigarettes (it bothers me) but I use the electronic cigarette. With non-nicotine liquid and I don’t inhale. I don’t inhale the smoke but I use it and feel guilty about it.ID 399, woman, 58 yearsAlthough they were aware that the first days are the most difficult, and are when it is easiest to have a relapse, in some cases, they minimized the risk they had overcome during the first weeks:No prob, man. Once you get through the first week and say a few times, “No, I don’t smoke anymore,” that’s it.ID 192, man, 41 yearsSo, yeah, it’s true that it’s hard at first but after that it’s not.ID 422, woman, 57 yearsAccording to the Cutrona model, online social support was classified into 5 subcategories:Chat was perceived by participants as a strength, as it provides cognitive support by sharing advice and practical information with others. Many of the messages offered suggestions about not gaining weight during the cessation attempt:My advice is to be careful; enjoy the food, which will taste better than ever...but do not forget that you can go from gaining 4 kilos to 10 without even noticing.ID 164, woman, 32 yearsTry with natural juices and sport. Cheer up!! These are the first few days.ID 429, woman, 40 yearsIn many messages, participants recommended physical exercise as a method to control anxiety and described the different activities they performed:The trick is to make up your mind that you really want to stop and do some sport. Try a “fun run” event and I’m sure you will get hooked on it.ID 192, man, 41 yearsSport or physical activities works well !!!ID 162, woman, 32 yearsAmong the advice given to help overcome the withdrawal syndrome was natural remedies :It is important to stand firm and not smoke or take even one puff. Lime-blossom or valerian tea can help you.ID 623, woman, 37 yearsOften the participants had made previous attempts to quit smoking, and they shared these experiences with the group, including the reasons that led them to relapse. They warned the others not to smoke even a single cigarette because that was what led them to fail:From all this I learned that if you stop smoking you should never smoke even one.ID 363, woman, 54 yearsYou’re right. I did not smoke with the pregnancies and then people offered me one and I went back to smoking.ID 422, woman, 57 yearsSome messages referred to the opinions and advice of experts, sometimes with verbatim phrases of what a doctor had told them:As my doctor says, quitting smoking is learning and there is no learning without relapses.ID 320, woman, 50 yearsThe group offered compliments to those who were achieving their goals and considered them to be role models:Thank you, you have become champions!ID 422, woman, 57 yearsCongratulations!!! A good example to follow.ID 477, woman, 30 yearsRecurrent messages were found to provide group support to overcome the worst moments, especially in the first few days. In the group, people found others who were in the same situation and understood what was happening to them at that time:It’s my second day. I’m having a nervous breakdown!!!!ID 354, woman, 43 yearsHang in there! It’s my FIRST day and I don’t have to tell you anything you don’t already know.ID 348, woman, 42 yearsTogether we’ll make it through!ID 363, woman, 54 yearsThe chat also allowed those who were just beginning the program to ask questions to, instead of those who had been in the process longer:[NAME], I have a question. After 103 days, do you still think about smoking?ID 355, man, 42 yearscraving episodes  a kiss.ID 422, woman, 57 yearsI am so sorry...there are situations that require your energy...When you start again, you will achieve it, and will do better with experience! Asuper-hug!ID 477, woman, 30 yearsThank you. Everybody in this group is super-cool!!!ID 548, woman, 54 yearswhatsapp group was proposed:First of all, the group decided to make closer contact and a We could do a whatsapp group.ID 299, woman, 49 yearsYes, that would be cool.ID 192, man, 41 yearsGreat, so who’s going to do it?ID 299, woman, 49 yearsIf you want, I’ll set it up.ID 192, man, 41 yearsAs new participants were being integrated into the chat, they were invited to join the group:Some colleagues formed a whatsapp group a few days ago to help us more personally in case someone needs it. It is a complement to the [study] app. Anybody who wants to join will be welcome.ID 192, man, 41 yearsThe connection between participants that was made in the group was so strong that the need arose to get to know each other outside of the study:It would be good to meet someday, and not just those fromTarragona – everybody whowants to and can!ID 548, woman, 54 yearsIn total, 10 people arranged a day to meet. As a separate whatsapp group was established, to which the research team did not have access, we do not know exactly how many people got together. We do know that it was satisfactory because they talked about organizing a second one for the people who could not attend:A great get-together!!!! At the end of summer, another one, ehhhh?ID 647, woman, 41 yearsaction stage of change who were trying to quit smoking.This study found that a chat integrated into a mobile app was a useful tool for offering social support and sharing emotions, information, or coping strategies to smokers in the process of quitting the habit. To our knowledge, this was the first qualitative descriptive analysis of a chat included in an app aimed at people in the The analysis of the chat messages showed that it was an active forum used by participants to exchange information, concerns, and social support. Some of the emotions described by Eckman appeared in the chat . In the Values and beliefs are essential to initiate the smoking cessation process as well as to maintain abstinence. As in previous studies -21, we fAlthough cigarette taxes have shown dramatic increases in Spain, following the European Union legislation (Council Directive CD 2011/64/EU), participants infrequently reported money as a reason for quitting smoking. When they did report it, money appeared as a motivator in combination with other elements such as health. These results differ from a previous study in France in which money was the most reported reason for quitting smoking . MoreoveMost information provided in the chat was related to avoiding weight gain. Although weight varies greatly after quitting cigarettes, a published meta-analysis found that about 16% of quitters lost weight and 13% gained more than 10 kg . The parWithin the chat group, we observed that people who had a relapse were embarrassed and, although some sought the help of the group, some participants might not have asked for help because they felt guilty about deceiving themselves and above all for deceiving the group at the same time.the group acquired such importance that its components wanted to connect in person.Within its social support, the group also offered emotional and informational support. We found similar results in other research, such as the study by Coulson et al, which indicates that group members offer informational and emotional support ; Ko et aThe Tobbstop app was designed to accompany the process of quitting for the first 90 days, the most critical days for a possible relapse. Participants who succeeded in abstaining from smoking used the chat to help newcomers providing advice, information, and emotional support. However, previous studies found that more than half of the messages from the support group were posted during the first months of the smoking cessation process indicating that people require more support in the first steps of quitting .We found an important online social support community that complemented the information and support provided in primary health care consultations and other resources  in the first phases of smoking cessation programs. Moreover, online support groups have the potential to provide a unique opportunity for health professionals to learn about the experiences and views of individuals.Online social support from an established group during the change process has several benefits. Participants are not restricted by the temporal, geographical, and spatial limitations typically associated with face-to-face groups; individuals can send and receive messages at any time of the day or night. In addition, online support groups may bring together a more varied range of individuals to offer diverse perspectives, experiences, opinions, and sources of information.The emotional support obtained from the app may help some people deal with relapses. Little is known about how online discussions transform into real-life behavioral changes . EfficacNew technologies and, more specifically, chat as a channel of communication may be able to help us to create groups of people who are engaged in the same process such as smoking cessation. The chat group can provide support and help 24 hours a day.We neither know the reasons why some participants did not use the chat nor what their comments might have been; it is possible that some users only read posts and did not contribute to them. For those users, it would be useful to determine which channel of communications would work best. A descriptive analysis has been done. It would be interesting to conduct a more in-depth and interpretative analysis according to sex, age group, studies, and other characteristics considered. According to the study protocol, participants who relapsed to tobacco consumption were removed from the Tobbstop app . Those wAmong the strengths of the study was the interaction between participants who were in different phases of the process. Some people were just starting and others had already gone 180 days without smoking. A person who has already passed through a given stage will show empathy, respect, and confidence in others’ abilities and reinforce the social support. In addition, the chat showed a diverse and pluralistic discourse.The results of this study suggest that a chat integrated into a mobile app can be a useful tool for smokers who are in the process of quitting. In our study, the app offered social support and a space where participants shared concerns, information, and strategies This type of online social support could complement the information and support provided in primary health care consultations and other resources in smoking cessation programs.


Value and waste in preclinical and clinical research projects are intensively debated in biomedicine at present. Such different aspects as the need for setting objectives and priorities, improving study design, quality of reporting, and problematic incentives of the academic reward system are addressed. While this debate is also fueled by ethical considerations and thus informed by bioethical research, up to now, the field of bioethics lacks a similar extensive debate. Nonetheless, bioethical research should not go unquestioned regarding its scientific or social value. What exactly constitutes the value of bioethical research, however, remains widely unclear so far.The American Journal of Bioethics, Bioethics, BMC Medical Ethics and Journal of Medical Ethics) were analyzed. The value dimensions of “advancing knowledge” (e.g. research results that are relevant for science itself and for further research) and “application” (e.g. increasing applicability of research results in practice) were used as main deductive categories for the analysis. Further subcategories were inductively generated.This explorative study investigated possible value dimensions for bioethical research by conducting a qualitative literature analysis of researchers’ statements about the value of their studies. 40 bioethics articles published 2015 in four relevant journals (The analysis resulted in 62 subcategories representing a wide range of value dimensions for bioethical research. Of these, 45 were subcategories of “advancing knowledge” and 17 of “application”. In 21 articles, no value dimensions related to “application” was found; the remaining 19 articles mentioned “advancing knowledge” as well as “application”. The value dimensions related to “advancing knowledge” were, in general, more fine-grained.Even though limitations arise regarding the sample, the study revealed a plethora of value dimensions that can inform further debates about what makes bioethical research valuable for science and society. Besides theoretical reflections on the value of bioethics more meta-research in bioethics is needed. Bioethics as an academic field has emerged impressively since the 1970s and is characterized by its highly interdisciplinary nature and the need to integrate normative expertise with empirical data and practical experience . Having exchanged for the currency of the professional school in order for bioethicists to pay their rent”  withIn analogy with biomedical sciences the value of bioethical research must be critically examined regarding those aims which can be reasonably expected from this specific kind of investigation. In particular, it cannot be taken for granted that just because research is addressing ethical aspects, implications or arguments, it automatically provides valuable results for science and society. In fact, there can be several reasons why the value of bioethical research itself becomes questionable. Even though ethics deals with fundamental questions of good and bad, right and wrong or just and unjust, ethicists, as experts of normative questions, might fail regarding the value of their own research. For example, they can be biased concerning the relevance of the topics chosen or the practicability of a suggested solution. In addition, bioethicists are—like any other researchers—in danger of addressing predominantly those questions which are (i) of personal interest to them, (ii) help to promote their career (e.g. regarding publication and funding) or (iii) increase the power and/or reputation of their institutions or organizations, or of the field as a whole . As a special aspect, bioethical researchers may face the danger of confirming their own ethical convictions as a result of their research. Lastly, bioethics runs into danger to be used as a mere fig leaf in politics and for health care organizations, which is another factor that may reduce the value associated with bioethical research.goals, the problems of measurement of goal attainment, and different pathways to “translation” of bioethical research and scholarship. Furthermore, there are several attempts to strengthen the quality of bioethical methodology, for example, regarding applied philosophical bioethics [Whereas there is an ongoing intensive discussion about the value (and waste) of biomedical research, a debate of similar proportions regarding bioethics is yet lacking. There are contributions to the topic, for example the proposed conceptual model of bioethical research from Mathews and colleagues , albeit ioethics , empiricioethics , 20 or  reflections about what generally constitutes “valuableness” in research, but is subsequently amended by a qualitative analysis of statements about the self-ascribed value of published bioethical research. The study has a “proof of concept” character in applying a qualitative approach to authors’ statements in journal articles as one source of information about value dimensions of bioethical scholarship.The research question underlying this study can is therefore biomedical research, for example, through evaluation of projects in research ethics committees. In addition, this contribution will confine itself to the “value” aspect of the debate and does not aim to identify possible “waste” in bioethical research. In mapping the field, this contribution can be understood as a first preparatory step towards defining and operationalizing criteria which would finally allow the measurement of the value of particular bioethical research projects.The aim of the present study is, therefore, neither to determine the value of concrete bioethical projects nor to deal with the impact of bioethical scholarship which assesses the value of The American Journal of Bioethics (Target Articles only), Bioethics, BMC Medical Ethics and the Journal of Medical Ethics. Regarding their relevancy, these four journals also corresponded to our own experience as researchers who publish and read papers in the field. There are of course also other important bioethical journals , and a considerable amount of bioethical work is published in non-bioethical journals . The restriction to four journals was, however, necessary to limit the quantity of articles undergoing qualitative analysis.We decided to collect research articles from relevant publication organs in the fields of bioethics and medical ethics as sources for statements about the value of research in bioethics. The journals were selected using a list based on Harzing’s “Publish or Perish” rating , excludiWe then retrieved the first ten original articles published in each journal in 2015 see . We exclAdvancing Knowledge mainly in terms of “pure basic research” [Application as “pure applied research” that aims at increasing the applicability of research results in practice or at establishing policy decisions, i.e. implementation or translation of research [The identification of relevant text passages was guided by the two main value dimensions suggested by Chalmers et al. . Chalmeresearch”  that doeresearch . We decicategories for the subsequent data extraction and analysis. This means a text passage was only included if it contained something explicitly or had, at least, to imply clearly something about the theoretical or practical value of the research. Typical examples for explicit and implicit statements can be seen in in vivo” codes when analyzing the material, i.e. we adopted the original wording using only slight paraphrasing, while reformulating and heavily paraphrasing the content of the more implicit statements.Methodologically, these two value dimensions served as main deductive Advancing Knowledge and Application can be conceptualized regarding bioethical research. After reconciling the interpretations of each text passage and the initial coding of these passages, the main analysis started.Two authors (MM and SS) read the full texts of the 40 articles to extract the data, and identified text passages within these articles which contained statements about the value of the research reported. They started independently with a tentative analysis and comparison of a subsample of eight articles  in order to test the method and general approach, and to develop a shared understanding of how the two categories of As part of the main data analysis, MM and SS first coded the same 25% of the sample  and developed a list with definitions and examples of the codes independently. This procedure followed the principles of qualitative content analysis , includiThe code lists of both coders were then merged through a comprehensive critical exchange of the respective understanding, also regarding the original text passages extracted that were anchoring the codes. Subsequently, the remaining 30 articles were coded independently based on the list of codes developed jointly and compared repeatedly after completion of the next eight to ten articles. The goal of the analysis was to reach a theoretical saturation with respect to our project’s research question. Regular team discussions took place on the application of the codes, the further development of the code list and the categories that could be built on this basis to enhance intercoder reliability.Advancing Knowledge and Application. The category building was performed concurrently with coding, with new codes generating inductively new possible categories. After comprehensive discussions about the categories between MM and SS, and after a critical review by TF as a third author, some categories were merged, some codes redefined as being just examples for a specific category, and some categories eliminated as being “too far off” for our research question or as being redundant. Some categories also became first order categories for other categories, or new categories were introduced as first order categories to subsume hierarchically other, more concrete categories. These were rearranged as second or third order categories. The final categories were then streamlined by adjusting the wording to a consistent style.The categories aimed at capturing value dimensions, corresponding to the two a priori main categories of 40 articles published in 2015 in four major bioethics journals were subject to analysis. 12 articles were considered to be empirical studies, 28 articles conceptual papers; an overview of the different types of articles, as classified by the raters, can be found in Advancing Knowledge and Application. Of the 62 total categories, 45 related to Advancing Knowledge and 17 related to Application. In the 40 articles, the range of author statements (text passages) that were coded using the 62 categories was 1 to 6 (i.e. up to six author statements were coded in an article); no article was without an author statement that was coded. 21 articles did not mention any dimension of Application; their value was restricted to Advancing Knowledge. The remaining 19 articles mentioned both—thus, no article only mentioned Application. The richness and complexity of the Advancing Knowledge part of the coding system was, thus, considerably higher compared to the application dimension.The qualitative data analysis resulted in a comprehensive coding system with a first basic division between the main dimensions of The range of categories which were developed as result from the qualitative literature analysis can only be presented in an exemplary form in this paper  to issues related to ethical theories , and include practice-related issues, such as the assessment of legal norms or the presentation and discussion of structures, organizations and professional codices.The code “Normative discussion of an ethical issue” is, for example, further spread into sub-categories, such as “Defending a specific ethical stance” or “Providing a conceptual test for evaluating the ethicality of a decision” see . “DefendAdvancing Knowledge is related to the development of ethical theory and comprises such aspects as suggesting and criticizing ethical norms, giving direction to an ethical debate and solving theoretical problems  systematization and our understanding of the world around us is augmented or extended, even if this does not necessarily lead to altering the world .Chalmers et al. understand “advancing knowledge” mainly in terms of “pure basic research” . IThe presence of this type of research, whose value has an effect particularly within the scientific system itself, is also mirrored in our study results on the self-declared value of bioethical publications. According to the data analysis, advancing knowledge in bioethics is mainly related either to a fuller understanding or appreciation of moral phenomena  or to the further development of ethical theory or ethical methodology. Thus, advancing bioethical knowledge has a double character: It is either descriptively or normatively related to a concrete ethical topic, which may (ultimately) lead to an ethical judgment; for example, about ethically contentious practices, structures or technologies. Or it is related to bioethical “tools” in the form of theories, concepts or methods.medical knowledge” to “advancing bioethical knowledge” is, however, not unproblematic. In bioethics there is a distinction between “pure basic research”  and “applied ethics research,” which utilizes general moral theories for the discussion of concrete moral challenges or issues. However, two limitations arise in the analogy to biomedical research: Firstly, in practice, “applied ethics research” often has the character of “basic research,” even though in a more focused way. Secondly, in ethics some kind of “application” is always implied, as ethics—being a mainly normative discipline—deals basically with the question: “What shall we do?”. Ethics research, therefore, does not aim primarily for explanations or predictions, but for finding out what would be “the right thing to do,” a question which is always related to practical relevance. The qualitative analysis of bioethical publications, however, highlights how the specific value of bioethics in advancing knowledge lies either on the generic or on the case level.According to these findings, the analogy of “advancing bioThe peculiarities of bioethics as academic discipline as arising from the text analysis also shed light on the question of scientific value in this field of research. When “science” is understood in strict terms of natural science or social science, one could even deny that bioethics provides any scientific value at all. If we understand “science” more broadly, however, also scholarly research from the humanities has to be included. As long as we then accept that scholarly work in the humanities can be research , bioethical research—which uses philosophical, theological, historical and other methods of humanities—can have scientific (scholarly) value. This is illustrated by the results of our study that are part of the advancing knowledge dimension, e.g. in codes such as “Developing a better understanding of a moral phenomenon”, “Developing ethical theory”, “Normative discussion of an ethical issue” or “Adding a new topic to an ethical debate”. More generally spoken, scientific value here means contributing to an ongoing scholarly debate by providing new insights, questions, arguments, analyses of concepts, theories about bioethical topics etc.some scientific value to others must be seen as uncontroversial, as research is a collective process that is characterized by the exchange and dissemination of results, so that other researchers can uptake, react to and expand on them. Also “directed” research funded or conducted by private organizations might have some scientific value, as the results—when openly published—provide a contribution in the way of arguments (and counter-arguments) or a conceptual elaboration of a specific  position. However, just “thinking and writing for oneself” on bioethical topics would not count as “research”, but would indeed more be akin to a personal hobby. Therefore, contributing to bioethical research is necessarily related to the attempt of generating scientific value—which is also current practice as part of peer review or editorial processes when submitting a bioethics paper.The expectation towards bioethics to provide social value of  research . Research .bioethical research and scholarship often appears rather in the long-term, and as a consequence of several research projects, not of a single piece of research [Research which falls under the category of application thus is thought to have actual consequences for practice—at least conceivably—in the short-term. However, the impact of research . Regardiresearch , 66)). TBeyond such concrete examples it can still be discussed, however, whether bioethical research generates social value , and whether it should be required to do so. The reason for this is twofold. Firstly, social value is—compared to scientific value—a more contested concept concerning its meaning as well as its scope, even in clinical research . In the clinical field, social value is, for instance, defined as “improvements in health”  foethical research. Bioethical research does not typically lead to direct improvements of the wellbeing of patients, especially when “wellbeing” is understood physically, e.g. in terms of curing a disease or alleviating symptoms. Transferring the understanding of social value to bioethical research may thus work better if “wellbeing” is extended also to psychological and existential dimensions . Looking at the list of possible value of bioethics as provided by Hofmann and Magelssen [Such an understanding of social value that is restricted to the improvement of wellbeing could, however, be too narrow for bioagelssen  or at threquiring bioethical research to have social value is much harder than it is for biomedical and especially clinical research. Whereas in clinical research risk-benefit  there are human participants at all, and (II) they could be harmed in some way by participating [While the characterization of social value might thus not be a general problem for bioethical research, giving a rationale for k-value” ) assessmcipating . And altcipating a generalsome advocacy or even activism regarding the topics at hand  social value in bioethics. As e.g. Rogers argues , in bioesee also ). Even tFurthermore, when a bioethicist is paid for her/his research via public funds this is also related to the concomitant duty to publish and provide some benefit for the society. However, the extent to which bioethical research is publicly funded depends on political and societal circumstances, with countries funding vast institutions, chairs or specific projects in bioethics (as e.g. is currently the case in most European countries), and countries where bioethics research is not well covered by public resources but rather dominated by private and institutional initiatives (e.g. foundations or churches). The demand for social value might be weaker when there is private funding for bioethics research. In extremis, the funder could be an organization that aims for a “legitimation paper” serving their specific political purposes or advocacy. If we, however, consider research as an open and unbiased endeavor which must principally be open towards new and unexpected results, the requirement of providing social value holds for both, publicly and privately funded research.In summary, bioethical research serves a genuine function with respect to its application dimension. It also has various target groups, such as health care professionals, patients, relatives, health care managers, policy makers and the general public , whereaIn summary, both dimensions analyzed in the publications serve the aim of “making the world better” as an inherent goal of bioethical research: Without elaborated ethical knowledge, an appropriate basis for determining the best solution regarding ethically contentious questions is missing. Without the orientation towards application, however, no one profits from bioethical research results, and the benefit of this enterprise for individuals and society becomes doubtful. The qualitative data analysis revealed that a considerable proportion of publications do not address the application dimension and that the quantity and complexity of codes within the dimension of “advancing knowledge” is generally higher. If we regard the two dimensions as being inherently related with respect to bioethics, the application dimension often missing can be seen as a shortcoming in bioethical publications. In addition, both dimensions may come into conflict regarding policy making and the role of ethics experts in interdisciplinary commissions and councils. The relationship between “pure” ethical analysis and more practice-oriented approaches is, thus, context-dependent and has to account for the wide spectrum of tasks which can potentially be expected from bioethical scholarship.JAMA, NEJM, BMJ, Lancet, Science, Nature etc.). Although generalizability does not constitute the aim of qualitative research, the scope of the results must nonetheless be interpreted with care. Further limitations accrue from the data analysis. Category-building and identifying text passages in articles both rely on interpretative tasks, especially regarding implicit statements. We tried to enhance the intercoder reliability of our analysis by consensus procedures between the three researchers. However, other researchers might have built different categories and would have assigned text passages to different categories. Nevertheless, as our study did not intend to classify particular articles and their possible value, but to use the articles only for collecting different value dimensions, we do not think that this limitation bears too much weight, i.e. it would not vastly reduce the usefulness of our results if other researchers had categorized a value dimension in another subcategory or found another value dimension we missed.Study limitations arise from the sampling of bioethical publications. The sample size and the procedure for selecting journals as well of selecting articles in these journals do not allow generalizable findings. Selecting other journals and articles, respectively, would possibly have resulted in other findings, particularly concerning the proportion of value dimensions attributed to “advancing knowledge” or “application”. This is especially true if articles representing bioethical research from non-bioethical journals would have been considered  normatively adequate, albeit they are empirically adequate, i.e. the value dimensions are corresponding to what researchers actually deem valuable. In contrast, a theoretical approach for determining value dimensions, for example based on reflections on what goals bioethics should reach  or what policy” ), might our paper contributes concerning the future development of bioethical scholarship and practice. Regarding the “advancing knowledge” dimension, the paper presents one possible approach for determining—in a first step—value dimensions of bioethical research. Additionally, it gives a limited insight into how researchers understand the value of their research. It also addresses the “application” dimension, as it aims at encouraging self-reflection about the value of research in bioethics and provides first ideas regarding this value. It is, therefore, a contribution to meta-research in bioethics, following the example of meta-research in biomedicine [With respect to the self-application of our research approach the question arises what value medicine .One upshot of our paper is that, irrespective of the factual reasons bioethical researchers have to research and publish , bioethical researchers should nonetheless reflect more upon the scientific and/or social value of their research and publications. This implies that they should not only address this question more prominently in their publications or other forms of research presentation, but should also try to align their research agendas, secondary interests of research (e.g. academic career prospects) and focus of their publications  regarding the expected scientific and especially social value.Further investments in meta-research on bioethics could include empirical work. In addition to the present study bioethicists’ perspectives on the value of their own work, for example, could be elicited in an explorative qualitative study followed by a survey of the scientific community. In combination with our study such research could build the basis for a development of more concrete criteria or “assessment tools” to estimate the value of particular bioethical papers or research projects, adjusted to different types of bioethical research , as alsoFinally, the evaluation of the impact of bioethical research could be improved: Does bioethical research change social practice in biomedicine and health care, and, if yes, is it in an ethically desirable way? What happens if ethical norms or “tools” are implemented in a practice? And how could implementation be improved (cf. )? We thiS1 Fig(TIF)Click here for additional data file.


The Tall Office Building Artistically Considered, protomodern architect Louis Sullivan famously declared that ‘form follows function’. Could this concept also hold true in biology? Have cells, through evolutionary optimization, adopted a 3D architecture (‘form’) that reflects their function? Or, to keep with the architectural metaphor, how does ‘form’ relate to the cell's ‘intended function or purpose’? Is there an ultrastructural signature that reflects the ‘constraints and requirements’ of a cell's function in its specific spatial and temporal context?In his watershed 1896 essay To be fair, cells of similar function will very likely never display the exact same ultrastructural 3D organization. Like in architecture and design there is not one single solution, but instead a variety of 3D organizational solutions that satisfy the constraints of function. Just as the many houses in any given city are different from one another, there are also many shared similarities such as doors, windows, roofs and walls. And just like office buildings in their function and layout differ from single-home residences, so will cells that face different ‘functional constraints and requirements’, even though they use the same components and display an overall similar inventory.For example, epithelial cells—independent of the organ they reside in—are highly similar to one another, e.g. in terms of cell polarity, cell–cell adhesion and the 3D organization of cytoskeletal filaments. Epithelial cells Fig. A are disOne may argue that the combination of their respective abundance, size, shape, 3D distribution and other characteristics constitutes an ‘ultrastructural fingerprint’ see Fig.  or a ‘ceWhither Structural Biology, Steven Harrison [For centuries, observation of structure has been key for an understanding of life, first at the levels of anatomy, then histology/neuroanatomy, and more recently cell biology and biochemistry. The two disciplines that study of the organization of cells and the 3D structures of proteins are called structural cell biology and structural molecular biology, respectively. Structural biology in its classical sense aims to determine the precise shapes of proteins and other macromolecules, ideally at atomic resolution. In a well-received commentary called In the last four decades, structural molecular biology  has stroTo be clear, what is proposed here is not a classical structural biology approach. Instead, the goal here is to identify which of several categories a certain ultrastructural feature belongs to, e.g. to the category of cell–cell adhesion complexes. Categorization is followed by the determination of its abundance and 3D localization, by measurements of its dimensions (i.e. the cell–cell contact size) as well as the number and 3D organization of attached cytoskeletal filaments. The relative strength of cell adhesion for respective cells can be inferred from these parameters without the knowledge of any atomic-resolution model for the individual proteins involved. Likewise, for the cytoskeleton, one may want to determine its abundance and distribution, the degree of cross-connectivity and the regularity of its pattern, as well as the abundance, distribution and type of all of its interaction partners (such as the nucleus or adhesion complexes). Such cytoskeletal signatures may eventually serve as a starting point for the computational simulation of mechanical properties under different 3D architectural scenarios .Given that every cell is unique, one key challenge is to discriminate truly different signatures from the heterogeneity inevitably inherent in biological systems. A promising route may be a rigorous statistical analysis, which in turn requires large-scale 3D data sets, ideally of entire cells and small tissues/organoids at a resolution that allows the simultaneous identification of the major supramolecular assemblies and organelles.Focused Ion Beam Scanning Electron Microscopy is an ideal technique for imaging such large cellular volumes .Apart from instrument access and data acquisition time, there are no limits on the size of volume it can cover at a resolution of ∼7–10 nm. Such intermediate resolution will be too coarse to identify individual proteins by shape alone , but allows the discrimination of supramolecular complexes such as the cytoskeleton and cell–cell adhesion complexes, as well as organelles. With careful (e.g. cryogenic) sample preparation methods that avoid artifacts such as aggregation and extraction, cells retain the 3D organization of their supramolecular complexes and organelles, even when samples are subjected to heavy metal staining, dehydration and resin-embedding .The challenge of turning voxel information into knowledge arises in part from the size of the data sets, which can reach tens of terabytes, and in part from the high feature density combined with the high complexity of cellular constituent supramolecular complexes and organelles, which are in close contact with one another. Supervised machine learning, also known as deep learning, requires a large amount of so-called ‘ground truth’ that typically needs to be established manually (and thus painstakingly) by a human expert. Deep learning currently lacks the accuracy that is needed to fully automate the process of segmentation. Deep learning may also be employed to assess the similarities between different cells and discriminate cellular signatures from sample heterogeneity.Furthermore, feature extraction and classification is only the starting point for turning voxels into knowledge. To reach that ultimate goal, resolution-faithful simplified volumetric models of supramolecular complexes and organelles need to be built automatically, and subjected to rigorous measurements of volumetric properties. Such a comprehensive quantitative statistical analysis will allow the creation of prototypic models that acknowledge and represent the ultrastructural heterogeneity inherent in biological data sets. Also missing is a semantic mathematical description of cellular 3D architecture, capable of providing the respective relationships of constituents, and their hierarchy. Last but not least, prototypic models ideally will reside in map-centered ‘biospatial’ databases, not unlike ‘Google Maps’, which then could be queried for patterns. Such a ‘Google-Cell Biology’ database would become the platform to integrate—at the model level—additional imaging, metabolic or proteomics data, as well as encyclopedic knowledge.In summary, what I am proposing here builds on, yet goes beyond, traditional structural molecular and cellular biology. Instead of determining the 3D structure of individual macromolecules or cellular sceneries, the objective is to quantify the geometric properties of simplified volumetric models. Instead of determining a single, defined structure, we seek for each cellular state to identify the range of such geo/volumetric model properties with sufficient commonalities to constitute an ultrastructural cellular signature. Such cellular signatures will reflect the ‘form’ and the ultrastructural heterogeneity that is inherent in each state, and will allows us to discriminate heterogeneity from truly altered states and thus yield mechanistic insight into the cell's ‘intended function or purpose’.


N = 3059). Administrative data from the German Institute for Employment Research (IAB) were linked to the survey data. After comparing respondents who provide self-reported histories with the subsample of the ones for which administrative data were available, we investigate the agreement of individual employment histories from the two sources (between 1975 and 2010) using sequence analyses. Almost all participants provided survey data on employment histories (97% of the sample), linkage consent was given by 93%, and administrative data were available for 63% of the participants. People with survey data were more likely to be female, to have a higher education, and to work self-employed and in the tertiary sector. The agreement of individual employment histories is high and similar across time, with a median level of agreement of 89%. Slightly lower values exist for women and people working in the tertiary sector, both having more complex histories. No differences exist for health-related factors. In conclusion, it is likely that missing consent and failed record linkage lead to sample differences; yet, both strategies provide comparable and reliable life course data.Collecting life course data is increasingly common in social and epidemiological research, either through record linkage of administrative data or by collecting retrospective interview data. This paper uses data on employment histories collected through both strategies, compares the attained samples, and investigates levels of agreements of individual histories. We use data from the German Heinz Nixdorf Recall Study with information on employment histories collected retrospectively from 2011 until 2014 (The online version of this article (10.1007/s10680-018-9476-2) contains supplementary material, which is available to authorized users. There is increasing interest in understanding the impact of life course conditions on later outcomes, for example of work and employment on health in older ages , with data on recalled and administrative employment histories ), we have three objectives: First, we contrast respondents who provide survey data on recalled histories and those for whom administrative data are available, in terms of socio-demographic, health and work-related characteristics. Thus, we ask if collecting data via record linkage or via survey data leads to selective samples. Because of required consent, and because employment information is only available for episodes as a salaried employee in the administrative data we expect a smaller sample, dominated by people who worked as salaried employees in the case of administrative data. As a second aim, we compare entire histories for those who provide information from both sources and investigate how similar these histories are. In addition to conventional methods , this is done on the basis of sequences analysis  study (HNR study), a prospective cohort study conducted in three cities of the German Ruhr area . This served as reminder to collect the following details in the interview: the year when a job started and ended, working hours, job sector, working contract (permanent vs. fixed-term employment), the employment status , and an open question about the job title with a brief description of the job task (as a basis to recode and classify jobs). As a result, we can derive individual employment sequences with annual information on the individual employment situation for each year of age between the age they were when they started their first job and the time of data collection (often more than 50 years). Among those who were interviewed in wave 3 (3059 respondents) 97% provided self-reported data on employment histories (2983 respondents).The administrative data of the Institute for Employment Research (“IAB”) are based on employment records from the German Federal Employment Agency (“Bundesagentur für Arbeit”) , name, date of birth and last employer). The forms with linkage identifiers were stored securely at the study center and delivered to the IAB on a regular basis, where staff members entered this information into a database. Then IAB staff derived administrative data in an iterative procedure: If a valid SSN was available, the respondent’s administrative record could be drawn directly. In the case that respondents did not provide a valid SSN, the linkage was based on alternative procedures, for example, according to birth date or name or both  part-time employed “e” and (3) not employed “n”. The two first states are used for an episode as a salaried employee. For the survey data, full time is assumed if respondents reported that their employment was “full-time (35 h or more)”, and part-time work was assumed otherwise. Following the notification scheme for the administrative data, full-time work is recorded if the contracted hour corresponds to the standard working hours, while part-time work consists of large part-time (18 h or more) and small part-time (less than 18 h)  and equal sequence lengths. Concerning sequence length, sequences between 1975 and 2010 are available in both sources on a yearly basis. With regard to states, both sources allow us to distinguish three employment situations: (1) full-time employed “Additional variables: in addition to sex and age, we include education, two work-related factors (main employment status and main job sector during working life) and two measurements of current health , all taken from survey data.We distinguish three levels of education according to the International Standard Classification of Educational Degrees (ISCED-97): ‘low’ , ‘medium’ (secondary or post-secondary education), and ‘high’ (first and second stage of tertiary education). Age (at wave three) is grouped into “55 to 64”, “65 to 74” and “75 years or older”. The two work-related factors refer to the longest job during working life in the survey data . With regard to employment status, “self-employed”, and salaried “employees” are distinguished. The six following categories describe the job sector: “Public service”, “Industry/Mining”, “Craft and trade”, “Sale”, “Other services”, and “Other sectors”. To measure depressive symptoms, we use a binary indicator of increased depressive symptoms, based on the German 15 four-point Likert scaled item version of the Centre for Epidemiological Studies Depression (CES-D) Scale. Increased symptoms are defined as scoring 18 or higher on the sum score . Then, we present trajectory indicators of the employment histories in the two sources (each coming from the respective data source). This includes the average years spent in each state, number of spells and an indicator to describe the general complexity within histories: the “turbulence” (Elzinga and Liefbroer n = 1927). At first, we compare the annual level of agreement. Specifically, we compute Cohen’s kappa for each year individually, separately for the three states. This allows us to study if agreements vary across time, and whether agreements are more likely for specific states. Cohen’s kappa is commonly used to test agreement for nominal scales . The third observation worth noting is that the regression coefficients are generally attenuated, once we include the trajectory indicators in model 2, and that they become nonsignificant in case of women. This result indicates that higher distances for women are largely due to longer time spent in non-employment or part-time employment, and to a higher number of spells—all factors that are related to higher distances. Findings remained unchanged using transformed distances (square root), as presented in Appendix .This paper compares two strategies to gain information on previous employment histories in the German HNR cohort study, either retrospectively in the frame of an interview (survey data), or via record linkage of administrative data from the German Institute for Employment Research (IAB). In the analysis, we first compare respondents with self-reported survey data and with administrative data. Then, we investigate the agreement of self-reported survey data and administrative data (covering 36 years of working life), and finally, we test if the agreement depends on socio-demographic, health and work-related factors. In accordance to these three objectives, the main findings are as follows:We find important sample differences, both in terms of sample sizes and sample compositions. Almost all participants of the cohort study gave retrospective information on employment histories (97%). Administrative data, in contrast, were available for a smaller number of respondents (63%). The lower number of people with administrative data exists because not every respondent gave consent for record linkage and because linkage was not possible for some respondents, for example due to invalid SSN or because data were not available in the administrative data—even if consent was given . This finding is in line with previous studies  and for job sectors, but no such differences for age or health. Compared to industry and mining sectors, differences are higher for people who mainly worked in the tertiary sectors, such as the craft and trade sectors, or the service sector.We need, however, to consider some limitations. Firstly, the used administrative data on employment histories rely on the mandatory German notification scheme, and recording procedures do differ between countries and sources of administrative data, each leading to different samples and recorded information. Thus, our results may not necessarily apply to other contexts. Secondly, the emphasis of our analyses is on entire employment sequences and individual comparisons based on sequence analyses. Thereby—to enable comparisons—we must focus on a relatively rough classification and three states of occupational situations . We could, therefore, not include information on periods of self-employment or on the reason for non-employment . Similarly, we may include additional information when defining the employment situation . In doing so, however, the use of sequence analysis becomes very complex, because the number of possible sequences grows extensively with number of states. In that case, a simple comparison of provided information  may be more appropriate. Finally, although the interviews are conducted by trained interviewers, and respondents are prepared when retrospective data are collected, a calendar interview may have provided more accurate information Below is the link to the electronic supplementary material.


Victoria Fan and colleaguesGDP per capita is a narrow, inadequate metric for capturing the true, full value of health investments, say  Gross domestic product (GDP), which represents the value of goods and services that are produced in a year in a given country, is the standard metric for assessing economic growth and development. Research on the link between health and economic growth has, therefore, traditionally looked at whether investing in health increases GDP . Changes in GDP per capita can capture the “instrumental” effects of better health—that is, the way in which better health generates greater income through factors such as higher worker productivity. But GDP is a narrow, inadequate metric for capturing the true, full value of health investments.Pronouncements on the state of the nation’s economy regularly make headline news. In the United States, for example, politicians and reporters discuss the Bureau of Economic Analysis’s quarterly releases of the nation’s GDP as an indication of the country’s “great” development and direction.Fortunately, people are realising the inadequacy of GDP per capita as a measure of development and wellbeing.Here we ask, why does GDP still dominate discussions about a country’s state of development? What are the flaws in using GDP to measure a nation’s development? And what should be the primary indicator by which to measure a nation’s development and direction?GDP, GDP per capita, and their growth rates are popular in policy and media circles for several reasons. They are important indicators of the current state of the economy. They are available for a long historic period of time, allowing for analysis of an economy’s evolution over time and for comparisons between countries.GDP’s appealing simplicity stands in contrast to the many hundreds of indicators that are now used in development—a “mashup of indices”The modern conception of GDP is credited to the economist Simon Kuznets, who proposed a measure to capture the productive capacity of individuals, companies, and the government in a 1937 report to the US Congress.As Robert F Kennedy said in 1968, GDP fails to measure “the health of our children, the quality of their education, or the joy of their play. It does not include the beauty of our poetry or the strength of our marriages, the intelligence of our public debate or the integrity of our public officials . . . it measures everything in short, except that which makes life worthwhile.”Development as Freedom, Sen argued that “Development can be seen . . . as a process of expanding the real freedoms that people enjoy.”Many others, including economists, have also pointed out the flaws and inadequacies of GDP. One representative view is that of Nobel laureate and economist Amartya Sen, who argued that economic development is the broad process by which the human condition is improved and through which people’s choices are enlarged. In his book The Stiglitz-Sen-Fitoussi commission raised the shortfalls of GDP as a measure of “economic performance and social progress.”www.equalitytrust.org.uk)—has shown another limitation of GDP. In light of such inequality, the emphasis on GDP has shifted to recognise that averages alone are inadequate and that considerations of distribution are valuable. Examples of inequality measures are the Gini coefficient and the total income held by the top 1% of the population compared with the 99%.Furthermore, growing inequality in almost all countries worldwide—emphasised in the US by the Occupy Wall Street movement with its slogan “we are the 99%” In summary, GDP is limited in measuring only marketed goods and services, does not capture inequality, and disregards several aspects of wellbeing such as environmental quality and the utilitarian values of education and health .Box 1Consider this comparison of Bangladesh and Zambia. The two countries have a similar GDP per capita  and $3860, respectively, in 2018, adjusted for purchasing power), yet the countries’ health indicators differ vastly. A baby born in Bangladesh will live 73 years on average, whereas a baby born in Zambia will live for an average of 60 years. Using GDP per capita alone fails to capture the inherent or “intrinsic” value of those 13 extra years of life in Bangladesh. Those additional years have an economic value that goes beyond productivity. As Bloom and colleagues put it: “A country whose citizens enjoy long and healthy lives clearly outperforms another with the same GDP per capita but whose citizens suffer much illness and die sooner.”Clearly, GDP should not be used alone but alongside complementary indicators. Economists have proposed several alternatives and continue to do so. In his influential 2002 paper, Nordhaus—one of the two winners of the 2018 Nobel prize in economics—proposed an alternative called “health income,” which incorporates improvements in health status into measures of national income.But the HDI has not seen much traction among multilateral agencies. It is more difficult to compute than GDP (by virtue of combining GDP with two other indicators), it is not useful as a time series indicator because of its limited availability, its units are not easily understood, and it has other numeric limitations (the HDI ranges only from 0 to 1). UNDP also developed several other indices, such as the multidimensional poverty index and the gender inequality index.Global Health 2035 report, the Lancet Commission on Investing in Health used the VLY approach, arguing that it gave “a more accurate and complete picture of health’s contribution to a nation’s economic wellbeing” than using GDP alone.Another alternative to GDP in valuing health investments—an approach borrowed from environmental economics—is the “value of life years” (VLY) approach .21 In itBox 2William Nordhaus poses the following question: Imagine that you have to choose between the improvements in material goods since the 1950s and the improvements in health during the same period. In other words, you have to choose between today’s cell phones, computers, wi-fi, roads, air travel, and other material benefits versus an extra 11 years of life expectancy without those goods.Most people would choose the second option, indicating that people place a high value on living longer, a value that is not connected to material gain. The concept of the “value of life years” attempts to capture the intrinsic value of living longer.Nevertheless, the VLY, and the related concept of the value of a statistical life, are often subjective measures, and they strongly depend on who is studied when estimating their values. Estimates of the monetary value of VLY come from willingness-to-pay studies and various other study methodologies, such as standard gamble, time trade-offs, and discrete choice experiments.In creating any composite measure, two key but challenging questions arise: what measures should be included and what is their relative value to each other? Invariably, reasonable people will still disagree about which indicators should be used to measure comprehensive notions of development and wellbeing and whose values are reflected in a composite measure. In Box 3We sketch a proposal for constructing a wellbeing measure that is comparable to the HDI in what it captures without some of its shortcomings:Alternative wellbeing measure=(GDP per capita)××(median income)/(mean income)This measure reflects expected lifetime income in good health. It captures the dimensions of income, health , and equality of opportunity . This way of dealing with inequality of opportunity substitutes for the inclusion of schooling in the HDI.Altogether the indicator would have the advantage of getting rid of the difficulty of aggregating fundamentally different things . In addition, it has no upper limit by construction. Finally, and in contrast to HDI, this alternative measure has a straightforward interpretation.We have summarised the arguments against using GDP, which gives a narrow picture of the value of better health and undervalues the true worth of health. We have also discussed a few alternatives, including the HDI and VLY, which can provide a fuller picture. No indicator is perfect. Despite its well known disadvantages, arguably few indicators have posed any considerable challenge to GDP’s hegemony. What hope is there for alternative metrics of development to gain mass popularity? We think it requires three things: repeated use of alternatives, policy leadership that values alternatives, and education supporting diffusion of the alternatives.Behavioural economics indicates that frequent reporting brings concepts to the “top of mind”—a psychological device based on repetition.There are roles for national leadership, authority, and institutionalisation through changing laws, regulations, and rules. Some countries have attempted to counter dominance of GDP by developing their own measures. Bhutan, for example, developed Gross National Happiness , fig 1, Box 4http://www.grossnationalhappiness.com/), each of which has 33 indicators that “are statistically reliable, are normatively important, and are easily understood by large audiences.”Gross National Happiness (GNH) has nine domains  per capita and its rate of growth are simple, important indicators of the current state of the economy and have been measured for a long timeBut GDP per capita is a narrow, inadequate metric for capturing the true, full value of health investmentsGDP should not be used as a standalone measure, but rather alongside complementary indicators of progress—such as “health income” or “value of life years,” which both capture the economic value of health improvements