In this article, we explore the power of shared embodiment for the constitution of an affective community. More specifically, we examine how people afflicted by long-term, arduous experiences of war, migration, and discrimination sensually articulate and, at least temporarily, renegotiate feelings of non/belonging, care, and in/exclusion. Methodologically, we draw on emplaced ethnography and systematic phenomenological go-alongs with a group of elderly migrants, born and raised in different parts of Vietnam, who had arrived in Germany within different legal–political frameworks and who, during the time of our psychological–anthropological research, frequented the same psychotherapeutic clinic. We apply the notion of “affective communities”  to grasp how the group experienced a sensual place of mutual belonging outside the clinic when moving through different public spaces in Berlin as part of their therapy. Particular attention is paid to the participants’ embodied and emplaced memories that were reactivated during these excursions. Shared sensations and spatiality, we argue, made them feel they belonged to an ephemeral community of care that was otherwise hardly imaginable due to their distinct individual biographies, contrasting political attitudes, and ties to different social collectives. In analyzing this affective community, we highlight how significant spatio-sensorial modes of temporal solidification can be in eliciting embodied knowledge that positively contributes to therapeutic processes. On a grey, cloudy, and windy day in late March 2017, we organized a boat cruise  on the Spree river for the participants of a bi-weekly group therapy for Vietnamese migrants that usually took place within a psychotherapeutic outpatient clinic in Berlin.Over the course of this article, we aim to show that this short vignette marks one salient and consolidating moment of what this specific group came to experience as an ephemeral community of care. Despite its ephemerality, the affective intensity of this experience gave the participants new orientations for considering their selves, lives, and surroundings and for reframing their feelings.In the following, we will first introduce the notion of “affective communities” Zink , based oDespite different reasons for frequenting the psychotherapeutic clinic, there were at least three common aspects that united the elderly participants. First, they had all to different degrees lost their capacity to relate and resonate with others in ways which made them feel safe, included, and properly cared for by others, as well as their capacity to care for others on emotionally recognized terms. Second, they had felt incapable of openly addressing this loss over many years within and beyond their circle of peers. Due to severe afflictions and increasing social conflicts, the participants had either gradually or abruptly withdrawn from society, depending on their individual affective lives. In speaking of “affective lives” . Affective communities are momentary connections of social immediacy that are driven by ‘the impulse of sociability’ (…), that is, of a playful form of practicing convivial connectivity” Zink :289–290.Affective dynamics are part and parcel of feelings of belonging. As the editors to this special issue suggest “to belong […] is to share values, networks, and practices and importantly to feel accepted and recognized as a morally equivalent member of a community.” Thus, as the example above indicates, we learned that the participants’ social and spatio-sensorial senses of belonging had been strongly mitigated, which in turn negatively impinged upon their capacities to live sociable lives within society. Put differently, they felt socially displaced and were no longer part of “affective communities,” understood here as the spaces that afford actors the possibility to establish (new) common ground or an “educated social sensibility” Zink :291 withand “emplaced ethnography.” Following Sarah Pink, we do not just make a plea for “the integration of mind and body” as posited by embodiment theories but apply an “emplaced ethnography that attends to the question of experience by accounting for the relationships between bodies, minds, and the materiality and sensoriality of the environment” (2015:28). A focus on “emplacement,” then, needs a corresponding methodology in motion, to which we will turn later.Zink explores a phenomenologically inspired notion of relational affects in order to point to the significance of shared, embodied experiences “between affected and affecting social bodies” :289 for Zink’s notion of affective communities is productive for us as well because of the linkage she makes to process-oriented thinking in social theory . They encompass practices, politics and discourses undertaken by individuals and social institutions, immersed in diverse relations of power” , a former border crossing point between East and West Germany which was turned into a documentation center reminding visitors of Germany’s partition, and the visit of a traditional German café. Our second excursion in June 2017 led us to Berlin’s Botanical Garden where we did “mindful movements”Botanical Garden, we decided to take our third excursion in September 2017 to the Pfaueninsel (‘Peacock Island’), a well-known, tiny, and picturesque island in the Havel river in the southwest of Berlin. On our last excursion, which took place almost a year later in August 2018, we planned to visit another public park. Due to bad weather, however, we changed plans and visited another museum depicting Everyday Life in Communist East Germany. Again, we were asked to end the day with a shared meal, this time in a Pan-Asian restaurant that one participant recommended.Prior to each excursion, we handed out basic information in Vietnamese about the locations that we wished to visit and asked the participants for their opinions. The first excursion in March 2017 encompassed a boat cruise on the Spree river, a visit to the The participants, four women and five men, first met each other in the clinic in 2016. They all had afflictions stemming from long-term arduous experiences of war, migration, and discrimination but were diverse with regard to social status, age, and migratory history; the youngest being around 50, the oldest around 70 years of age. As mentioned earlier, in the beginning of the therapy most of them faced each other with mistrust resulting from different legal–political circumstances or “regimes of mobility” , the women said the situation was reversed in the Eastern part where predominantly Vietnamese women had been hired as contract workers. Mrs. L laughingly explained “When people took first steps to find out about the Vietnamese on the other side of Berlin, a baby boom, of course, followed these encounters.” Compared with the men on the boat, the women obviously more easily gained common ground by means of instantaneous affective contagion, a fact that, we suggest, relates to gendered dimensions of their “emotion repertoires”  Mr. A discovered a peacock and approached the animal slowly. On the island, (…) the animals roam free. He made cautious steps and reached out his hand to touch the peacock. At first, the peacock went in the opposite direction, and Mr. A followed it carefully. The others [i.e. the other participants] closely observed this unusual encounter, stood around with some distance and talked about it with excitement. Mr. A commented on what he did by saying “I try to get closer…” Mr. C, Mr. S, the psychologist, and I pulled out our smartphones to capture the scene. Mr. A kneeled with an outstretched arm and admired the peacock from close. Then, for a short moment, his fingers touched the beak of the bird. Watching this affecting moment connected and captivated us, we all looked curiously at the peacock and Mr. A. Then the peacock turned around and vanished into the bushes. Mr. A stood up, walked towards us, and smiled. The dense affective intensity that captured the observers’ focus on this human-animal encounter suddenly dissolved as Mr. C turned to Mrs. Q and Mr. B and explained how he would prepare a meal of the peacock; he was a trained cook sharing his culinary knowledge. He listed different cooking recipes and preparation steps and contagiously evoked laughter in the others. Mr. C took this as an opportunity to cite more recipes. At that moment, Mr. S appeared next to me and shared yet another impression: he had observed that in Germany all free-roaming animals are so trustful because they knew that nothing would happen to them. In Vietnam, he said, if you saw a free-roaming animal, it would immediately run away because even young children hunt animals to eat them. He said these words with fascination as mirrored in his smile and his wide-opened eyes. (…) Although Mr. C mocked this interaction in the first place, we later observed how he himself approached another peacock while we had a picnic. Like Mr. A, he also assumed a compact body posture and slowly moved towards the peacock with his arm stretched out in front of him.The group dynamics during the third excursion to Peacock Island created another series of emplaced affective exchange as an extract from Edda′s fieldnotes illustrates:This rather random situation marked a significant moment of mutual recognition, acceptance, and inclusion. The participants displayed something seemingly simple, which had been overlaid by the pressure related to daily struggles and a deficient self-perception: in this affective community, they joked and laughed, they mocked each other, and with a renewed ease, they attentively resonated with each other. In other words, they solidified their ephemeral community of care.the German society.” Second, they recognized a commonality in existing felt differences based on estrangement whose long-term affective consequences they had neither noticed nor addressed before.Apart from shared spatial explorations, we also paid attention to shared foodways. In several ethnographic encounters, both Edda and Anita had learned that the sharing of food matters greatly in socio-emotional ways. In terms of care, it is worthy to note the difference between approaching people in ‘German’ and ‘Vietnamese’ contexts. A common German introductory phrase is ‘How are you?,’ whereas in Vietnamese contexts it is usual to ask ‘Have you already eaten?’ Our first go-along ended with a visit to a traditional Berlin café, a somewhat noisy location underneath an S-Bahn arc, furnished with old carriages and utensils hanging from the ceiling. The participants took seats according to internalized gender roles, which means that women and men sat separated, and we ordered coffee, tea, and cake. Two men kindly refused our invitation to order a cake because “German cakes are too sweet.” In the end, they suggested that next time we should instead eat Phở, a traditional Vietnamese soup. In terms of embodied senses, we found out that the specific spatial and material environment of the café merged with other and obviously discomforting place-memories of some participants. For instance, it was apparent that the location was still reverberating in Mr. B’s sensorium when, in an ensuing encounter in the clinic, he asked us several questions about “German” table manners. He wanted to know about how and where to sit at the table, whether to cross legs and where to place arms, how to hold fork and knife and so on. Asking these seemingly practical questions raised the attention of the other participants who eagerly added further questions. Two aspects became clear: first, due to un-negotiated misunderstandings on the level of direct sensual practices, they felt socially disembedded and displaced within what they considered “Botanical Garden with everyone contributing something. It turned out to be a culinary medley with potato salad, flavored sticky rice, cake, fruits, and spring rolls. We took off our shoes, sat on blankets, and started to chat in the shadow of some trees. Fruits were cut open and handed around, and plates and bowls went from hand to hand so that everyone could taste the different dishes. Both Mrs. L and Mrs. N had prepared spring rolls. In discussing the ingredients which they had used, they referred back to the different geographies or “sensescapes”  or a Chị (older sister), but these were not present in Germany or had already passed away. Despite being younger, Mr. A and Mr. C, in their wish to care for Mrs. N in this particular situation, eventually applied a modified sense of shared social sensibility. Normally, men and women would not exchange such personal feelings according to internalized gender roles. Based on a normative understanding of their patriarchal society, however, they felt their male status obliged them to express care for her.In speaking—almost poetically—of the wilting flower, Mrs. N spoke of her feelings of loneliness, unhappiness, and the end of life. In this exercise, Mrs. N did adhere to an indirect mode of communication she was familiar with in regard to the expression of felt tensions. She did so, however, in a somewhat altered way which shows the dynamics of care relations. According to the participants’ habitualized understandings, conflicts between persons were to be mediated by a third party. In the case of internal conflicts, by contrast, people were expected to either keep their feelings to themselves or to entrust their concerns only to specific social others. One’s own children do not belong to this circle, and neither did the other female participants in the group because they were much younger. Instead, Mrs. N could have approached a In comparison to the power of shared embodiment that became visible in relation to shared movements and foodways, the photovoice elicitation was certainly less impactful in terms of immediate sensual contagion. After all, it was less emplaced and less relational; the participants went around on their own to take the photos and interpreted the depicted scenes only later in front of the group. Nevertheless, the results of the photovoice exercise made clear that individual afflictions based on both biographical experiences and current positionalities did not completely dissolve in this ephemeral community of care. Importantly, however, the method pointed out the importance of being able to embed individually felt and deeply embodied intensities in a wider dynamic social and spatio-sensorial framework of recognition.Why did we choose to speak of the affective community that we were able to trace with its consolidating and dissolving moments as a particular ephemeral community of care? Affective communities can have different purposes. During our go-alongs, we gradually discerned that the purpose of this specific affective community was built on the need to express and renegotiate non/belonging and in/exclusion in relation to care. In our understanding, care is a social as well as affective process and always embedded within specific and deeply embodied “emotion repertoires” established a sense of belonging that the participants practiced within a temporal frame of solidification. Despite their otherwise deficient self-perceptions, over the course of our excursions and through sharing their photos they came to feel accepted as an equal and relational part of an ephemeral community of care. Even though, according to Zink , affectiAs argued in the beginning of this article, the reactivation of the knowing body in the clinic was a systematic approach to work with bodily engrained memories and intensities. Systematic phenomenological go-alongs outside the clinic proved a valuable and, indeed, necessary supplement to clinical psychotherapeutic treatment. Not only did they help to trace hidden knowledge but also, to become durable tools of meaning-making, cognitive learning processes in general have to merge with processes of embodying and habitualizing cognitions. Phenomenological go-alongs, we believe, are one way to foster these processes in more random situations of everyday life-worlds.Coming back to the particularities in our case, it is important to keep in mind that the participants had lacked words and voices to express feelings of estrangement and discomfort in relation to migration, on the one hand, and were not able to make sense of this lack, on the other. Therefore, their bodies had to be ‘asked’ and their senses had to be synchronized. Our anthropological approach of ‘asking bodies and synchronizing senses’ was based on systematic phenomenological go-alongs outside the clinic during which we paid specific attention to our participants’ immediate sensorial perceptions and affective appropriations of spatio-social worlds. We noticed that the participants’ modes of being differed markedly when they actually moved through and interacted with social, material, and spatial enviroments compared to when they just talked about such interactions in the clinical setting. They were able to bring out and share implicit and hidden stresses and strains in concrete situations of affecting and being affected by others. Later, in the therapy, they eventually addressed and contextualized these hidden stresses and strains. As a result, a shared sensual space unfolded in which words or phrases such as “we are all sick” eventually could become a starting point to express and negotiate what was commonly felt.To conclude, we hope to have conveyed the idea that (psycho-)therapeutic treatments in a world in motion could benefit from methodologies in motion such as the phenomenological one that we pursued with a group of elderly Vietnamese migrants in Berlin. Through an emplaced exploration of shared sensations and spatiality we were able to reveal some of the health-related and deeply embodied ruptures in regard to people’s feelings of non/belonging and in/exclusion that often remain unaddressed in current politics of belonging and health.


For a long time, since China’s opening to the outside world in the late 1970s, admiration for foreign socioeconomic prosperity and quality of life characterized much of the Chinese society, which contributed to dissatisfaction with the country’s development and government and a large-scale exodus of students and emigrants to foreign countries. More recently, however, overestimating China’s standing and popularity in the world has become a more conspicuous feature of Chinese public opinion and the social backdrop of the country’s overreach in global affairs in the last few years. This essay discusses the effects of these misperceptions about the world, their potential sources, and the outcomes of correcting misperceptions. It concludes that while the world should get China right and not misinterpret China’s intentions and actions, China should also get the world right and have a more balanced understanding of its relationship with the world. Chinese people have always had only two terms of address for foreigners: either “beasts” or “majesties.” They have never been called friends, nor said to be the same as us.— Lu Xun (1919), “Random Reflections No. 48”How does the Chinese public perceive the world? Studies on Chinese citizens’ international outlooks focus on subjective attitudes toward foreign countries and international affairs including nationalistic sentiments . The former view has characterized much of the Chinese society since China’s opening to the outside world in the late 1970s, and the latter has become more conspicuous in recent years. Both (mis)perceptions are unhealthy, with the former sometimes leading to an inferiority complex and helping engender a large-scale exodus of students and emigrants to foreign countries, while the latter has resulted in arrogance and egotism and contributed to China’s overreach on the global stage in recent times.I will discuss in particular how the Chinese society often does not have a proper and balanced understanding of foreign nations, which negatively affects China’s own development and foreign relations. The Chinese public tends to have either an overly romantic view of the outside world, thinking “the moon is rounder abroad” (月亮是外国的圆), or an overly bleak view of foreign countries, overestimating China’s power, popularity, and influence in the world, which is perhaps best illustrated by the title of an influential 2018 documentary film, As has been shown in previous studies, information is essential for opinion formation and decision making, and having wrong information can be more detrimental than having no information Gilens . SimilarFacing a China ascending on the world stage, often with clumsily aggressive behavior Hille , much ofRiver Elegy ” (p. 51), and that “just about everyone I met complained incessantly about China’s inferiority to developed countries” (p. 54). When the realities abroad did not quite meet their high expectations, they “increasingly saw China as a paradise lost and the developed country they once imagined as paradise as a barren, unsatisfying trap” (p. 200),The perceptions about the rounder moon abroad are often characterized by significant over estimation of Western prosperity and purity. For example, Vanessa Fong’s  ethnograang)” p. 1, and thThis phenomenon is not China-specific. Studies have suggested that immigrants to Western countries from other nations often have similar erroneous information or expectations about opportunities in their destinations  leads to lower evaluations of China, more dissatisfaction with the Chinese government, and higher inclinations to exit the country among the Chinese public, while underestimation has no clear effects Huang , 2017b. 6Domestic Evaluation variable, rescaled to lie between 0 and 1 for easy interpretation, in Fig. Figure As shown in Fig. A critical question is why misperceptions about foreign countries are so prevalent in China after decades of opening to the world. Part of the reason is likely that most Chinese people have little direct experience living in foreign countries so that their perceptions about the outside world are based on second-hand information from interpersonal communication, media, and the internet , or China’s Generation Z. This is a generation born during China’s golden era of rapid growth and overall stability. It is a generation growing up with the Olympics, high speed rails, and mobile payments, but with few direct personal memories of poverty or turmoil. Naturally, these experiences in people’s formative years would shape their memory and political attitudes  stories about foreign countries’ plight and problems. During the Covid-19 pandemic, for example, Chinese social media was awash with copy-paste stories that exaggerated hardship and chaos in various foreign countries that differ from each other only in the country’s name and a few minor details Zhang . This kiad Zhang .Chinese social media have also been full of nationalist-chauvinist fake news exaggerating China’s influence and attraction on the world stage. Recently, for example, a spate of WeChat posts claim that various countries or territories want to “return to Chinese sovereignty,” which prompted Kazakhstan, one of the countries implicated, to summon the Chinese ambassador to protest Reuters . ConsequWith such a misinformation bubble, as well as the prohibition of “frivolous comments on the Center” and loyalty-signaling local officials’ competitive reinforcement of central policies, a spiral of silence perceptions about foreign countries, whether about what those countries are like or how people in those countries think of one’s own country, also have critical importance for people’s attitudes and, consequently, behavior. In the interconnected world, opinion formation is an international process, not one confined to the domestic arena.


Purpose Whether or not to disclose mental illness or mental health issues in the work environment is a highly sensitive dilemma. It can facilitate keeping or finding paid employment, but can also lead to losing employment or to not being hired, because of discrimination and stigma. Research questions were: (1) what do stakeholders see as advantages and disadvantages of disclosing mental illness or mental health issues in the work environment?; (2) what factors are of influence on a positive outcome of disclosure? Methods A focus group study was conducted with five different stakeholder groups: people with mental illness, Human Resources professionals, employers, work reintegration professionals, and mental health advocates. Sessions were audio-taped and transcribed verbatim. Thematic content analysis was performed by two researchers using AtlasTi-7.5. Results were visually represented in a diagram to form a theoretical model. Results Concerning (dis-)advantages of disclosure, six themes emerged as advantages  and two as disadvantages (discrimination and stigma). Of influence on the disclosure outcome were: Aspects of the disclosure process, workplace factors, financial factors, and employee factors. Stakeholders generally agreed, although distinct differences were also found and discussed in the paper. Conclusion As shown from the theoretical model, the (non-)disclosure process is complex, and the outcome is influenced by many factors, most of which cannot be influenced by the individual with mental illness. However, the theme ‘Aspects of the disclosure process’, including subthemes: who to disclose to, timing, preparation, message content and communication style is promising for improving work participation of people with mental illness or mental health issues, because disclosers can positively influence these aspects themselves. The aim of the present study was to explore views of five different stakeholder groups. Specifically, the research questions were: (1) what do stakeholders see as advantages and disadvantages of disclosing a mental illness or mental health issues in the work environment?; (2) what factors are of influence on a positive outcome of disclosure (in favour of the discloser)?In December 2016 and January 2017 five (homogeneous) focus groups were conducted, including 27 participants in total. Groups consisted of: (1) People with mental illness; (2) Human Resources (HR) managers, involved in hiring decisions; (3) employers; (4) work reintegration professionals; and (5) mental health advocates. The focus groups were part of a larger project in which the CORAL decision aid  was tranI.people with mental illness. All were male, previously diagnosed with one or more of the following diagnoses: autism spectrum disorder, schizophrenia, ADHD, addiction problems and psychosis. Four had paid employment, two were unemployed.A focus group of six II.employers, four of whom were male. They represented companies in consultancy, catering, cleaning, construction and the plastics industry. One represented a small company (< 50 employees), all others a large company (> 250 employees). The average number of years they worked as a manager was 5, ranging from 3 to 12.A focus group of five III.Human Resources (HR) managers. All were female. They worked for moderate (> 50 employees) to large (> 250) organisations, in education, one in a local municipality and two in (different) health care organisations. The number of years they had worked as HR manager dealing with hiring decisions was 1, 6, 17 and 25, respectively.A focus group of four IV.mental health advocates (hereafter: advocates), who had mental illness and who worked as volunteers, pro-actively fighting stigma for the Dutch Anti-Stigma Association. Three of them were females. Previous diagnoses included dysthemia, schizoaffective disorder, posttraumatic stress disorder, recurrent depressive disorder, personality disorder not otherwise specified, and attention deficit disorder. Three had paid employment.A focus group of four V.work reintegration professionals , including five job coaches, two occupational physicians and one occupational social worker. Six of them were female. The average number of years they had worked as a work reintegration professional was 13, ranging from 6 to 32.A focus group of eight To select stakeholders involved in the employment of people with mental illness, purposive sampling was used. Participants were recruited with help from mental health care staff, an occupational health service, a network of employers, a peer support organisation for people with mental illness, other researchers, and the Dutch Anti-Stigma Association. Seven people with mental illness, 15 employers, eight work reintegration professionals, and two HR managers declined participation due to a lack of time or interest. The recruitment procedure resulted in the following focus groups:In each focus group, participants received a gift voucher of 10 euros  for their participation.The 2-h focus groups took place in a conference room at Tilburg University (The Netherlands) except for the one of mental health advocates, which took place at the Dutch Anti-Stigma association in Amersfoort. All focus groups were conducted by two researchers . Each group was facilitated by an experienced researcher (EB or CvZ), who guided the group discussion, and an observer . Focus groups started with the general question what stakeholders’ views were on whether or not it is wise for an individual with mental illness or mental health issues to disclose them in the work environment. Topics discussed referred both to disclosure of psychiatric disorders, and to common mental health issues, such as high stress and burnout syndrome. The topics discussed can be found Table All discussions were audiotaped and transcribed verbatim to enable deductive and inductive thematic content analysis . TranscrMedische Ethische Toetingscommissie Brabant) was obtained declaring that the project did not fall under the Dutch Medical Research Involving Human Subjects Act (WMO), for which reason a more elaborate ethical review was not necessary.All participants were informed verbally and in writing about the study before signing a written informed consent form. They were aware that participation was voluntary, that their information would be kept confidential and would be used for research. Prior to the study, a statement of the Medical Ethics Committee  disclosure can improve relationships at work; (2) authenticity is important for wellbeing at work; (3) the work environment can help; (4) disclosure can help create a friendly and inclusive workplace culture; (5) disclosure can lead to discrimination; and (6) disclosure can lead to stigma.Employer, :“I would advise an employee with mental illness or mental health issues to disclose [to the manager], and to indicate what you have already done about it yourself, and what you need as an employee to function well. I believe that once you’re open about it, that 9 out of 10 times it will be really appreciated by the employer”.All groups agreed that disclosure improves understanding of the disclosers’ behavior and situation, and as such can improve relationships at work. Moreover, it was believed that honesty would be appreciated by others in the work environment, and would yield respect.Advocate :“That I did not have to lie anymore, that was great. That I did not have to tell them I had the flu again, whenever we had a team building activity. I had started to feel so bad about that…”Person with mental illness :“I believe that if you cannot be your true self…. whether it concerns mental illness or something else, … you will never be able to reach your peak performance. And you will never feel great, which I believe is a prerequisite for doing your job well….This theme was strongly supported and discussed by three groups: people with mental illness, advocates and professionals. Concealment of mental illness or mental health issues made people feel dishonest, guilty, and exhausted. In contrast, being able to be yourself in the workplace felt like a weight was taken of their shoulders, and was also seen as important for optimal work performance.Person with mental illness :“In my case, it [concealment] led to an extra crisis. A new crisis started just because I simply could not tell.”The stress that people experienced from having to conceal their mental illness at work could be so high that it in itself increased the risk of developing mental health issues.Whereas for the people with mental illness and the advocates, being allowed to be yourself was regarded as extremely important for wellbeing at work, this theme was not discussed by employers or HR managers.Employer :“I believe it is important to disclose. I, as an employer, would appreciate it, so I can be of help”.All groups strongly endorsed this theme as an important advantage of disclosure, especially the role the work environment can play in the prevention of adverse outcomes, e.g. by providing work adjustments and understanding.Advocate :“[once you disclose] you get great talks. It opens a dialogue and you notice that there is more mutual trust. Because you share information that makes you vulnerable, you get some in return. Then you have a very different interaction than if you are both hiding information”.The effect of disclosure on enhancing a friendly and inclusive workplace culture was neither discussed by employers nor by HR managers. However, it was mentioned as an important advantage of disclosure in the remaining three focus groups, especially the effect on reducing stigma on the work environment.own point of view, they were in favor of disclosure during the hiring period, because this would enable them to avoid hiring the discloser and protect their employer from financial risk.HR manager :“..I notice that I wear two hats… because if you ask me “What do you want, as an employer?” I want to know everything. Yes, seriously! Because that allows me to assess the risks. But if I wear my hat as an employee, I say: if you know that it does not influence your work, it is best not to say anything because then you will not be treated differently”.In all groups, the risk of discrimination was discussed as a major disadvantage of disclosure. This generally referred to the discloser being seen as a financial risk for the employer. The HR professionals came up with considerable more ways in which disclosure could lead to discrimination than the other groups. These were all related to reducing the employers’ financial risk and included the following: trying to get rid of the employee, no continuation of a temporary contract after it finishes, not hiring, offering the discloser only temporary contracts, a shorter contract or lower salary. HR managers were the only group discussing this theme (discrimination) after disclosure as a useful phenomenon. They viewed it as a successful hiring decision, for which they carried responsibility in their own jobs. From their In all groups, the risk of being stigmatized was discussed as a major disadvantage of disclosure. Generally, the groups agreed that disclosure can create social distance or yield disrespect from others at work. Similar to the theme of discrimination, most examples of stigma were mentioned by the HR managers. These included: (a) increased chances of gossip, or unpleasant verbal reactions by others (e.g. jokes); (b) lower performance expectations of the employee  too much focus on what goes wrong at work and attribution of mistakes to the mental illness; (e) the discloser has to perform better than others in order to be seen and treated as equal.Here, four main themes emerged from the data. These were: (1) aspects of the disclosure process; (2) workplace factors; (3) financial factors; (4) employee factors.When discussing factors of influence on a favorable outcome, the disclosure process itself was one of the most extensively discussed factors, and 5 important subthemes emerged within that theme.who to disclose to. Generally it was agreed that disclosure should primarily be directed towards the supervisor (unless there is a bad relationship). Moreover, overall it was agreed that selective disclosure rather than being completely open to everyone at work would yield better outcomes.Professional :“[Prior to a job interview] it is important to discuss with the client to what extent he is going to disclose…because every company has different [management] layers, and not everyone has to know everything. But someone.., in a higher [management] position, who has the power to make important decisions? Yes I would inform him/her, together with my client of course.”The first was the timing of disclosure. Generally, it was believed that if work functioning is not or minimally affected by the symptoms, for the employee’s wellbeing and employability it is best not to disclose, in order to avoid stigma and discrimination. However, all groups agreed that disclosure is necessary when health problems start to influence work performance and preferably even before, if preventive measures can be taken. Furthermore, four groups strongly believed that disclosing a mental illness or mental health issues during the hiring period (e.g. job interview) substantially decreases the risk of being hired.Mental health advocate :“An HR manager wants to avoid [financial] risk of course. I am a risk, that is actually what I have been called, a risk for the company”.Employer :“If you apply for a job… by saying something like that [i.e. disclosing]… I think that is a ‘no go’. Then they [employers] will say: ‘thanks for warning us’”.HR manager :“During the hiring period, it is a rat run. It is the survival of the fittest….and having a [mental health] condition means reduced employability and possible [financial] risk”.The second subtheme was Employer :“I don’t think you should choose a moment [for disclosure], you should earn it.”All groups believed it was best to first build up a relationship and earn respect, before disclosing.Professional :“If you know that work adjustments would help this employee…, well than it is great if these can be discussed, because this will just increase the chances of success”In contrast to the other groups, the work reintegration professionals believed disclosure was much better than concealment:Professional :“[If the employee does not want to disclose]… it makes it very difficult for me to help… Then you automatically get to the point where you try to promote disclosure”.However, professionals also had a personal interest in their clients’ disclosure, as it made their jobs easier.Professional :“I once had a kleptomaniac as a client, and her disorder was not entirely under control yet. I found it so difficult because an employer was very willing [to offer her a job] but she did not want me to tell him…… I felt so bad towards the employer, because I could not tell him… Then something was stolen and he called me up and said ‘We think she did it’, and I could still not say anything… I felt so miserable about it”.In addition, disclosure was regarded as beneficial for their own professional relationships with their clients’ employers:preparation of the disclosure process. Several groups discussed that disclosure would yield better results if well thought out and prepared. It was suggested that others (e.g. a coach) could help by increasing self-esteem and focusing on qualities, and that the form of disclosure  should suit the discloser’s personality and communication style.The third subtheme was the content of the disclosure message. Almost all groups believed the discloser should be specific about under what conditions he/she would be best able to perform at work, considering the health problems. Also, they believed that the disclosure message should preferably be like a sales pitch: strongly emphasizing one’s qualities. The stakeholders also believed that only information with direct relevance for adequate work performance should be disclosed, and that the discloser should be reticent about additional medical or personal information. Solely mentioning the diagnosis can instantly lead to labelling and stigma, as was shown from this quote from the HR managers:HR manager “The moment I hear a [mental health] condition during a job interview, it is stored in my memory… After that, the job applicant can talk all he wants, but I have already heard it”.The fourth subtheme was communication style. This theme referred to showing a respectful tone and attitude towards the work environment, and emerged in the employers’, HR managers and work reintegration professionals groups. Here, the ‘give and take’ aspect of relationships was emphasized, which was an important and central theme in the employers’ group. It was believed that disclosure message should show that the employee is also considerate of the employers’ needs instead of having a claiming, self-centered attitude.HR manager :“We once had an employee who had been with us for 40 years. When she was 60 years old she was diagnosed with ADHD. Well, from that moment on, she leaned backwards and said she couldn’t do this because she had ADHD. I thought: “You have had this for 40 years and now you need to lean backwards?” ….I believe it should be from both sides, I don’t like the attitude of ‘I want to be open, that is who I am, so I just throw it at you’”.The final subtheme regarding the disclosure process was Whereas all other groups believed that many aspects of the disclosure process itself  were of crucial effect on its outcome, the mental health advocates did not discuss any of these aspects, except for timing.workplace factors. Generally, the groups believed that the level of responsibility of the job would be a determining factor. More negative outcomes of disclosure were expected in high responsibility jobs (e.g. chief executive officer) than in low responsibility jobs (e.g. cleaner). Furthermore, the social climate was also believed to be of influence on disclosure outcomes. Some organizations have an inclusive workplace philosophy, which was believed to be beneficial for disclosure. Finally, it was mentioned that in some sectors, where more ‘macho’ workplace cultures exist (e.g. construction) disclosure may yield less positive outcomes.The second major theme that was believed to be of influence on a (for the discloser) favorable outcome was Overall, it was believed that in a poor economy, chances to be hired strongly diminish after disclosure. Also the probability of losing work was believed to increase after disclosure. In contrast, it was believed that if employers receive financial incentives (e.g. from the government) they will be more open to hiring people with mental illness or mental health issues.employee factors, which consisted of three important subthemes. First, it was generally believed that the type of mental health issues or diagnosis matters. For instance, it was expected that autism, ADHD, burnout and PTSS would yield more positive reactions after disclosure than schizophrenia, bipolar disorder or substance use disorder. The second subtheme was the extent to which the discloser was (still) experiencing symptoms. It was believed that if the employee has recovered and seems in control, the work environment would react more positively to the disclosure. The final employee related subtheme was the degree of self-esteem and empowerment. Here, two groups stressed that higher self-esteem, empowerment and negotiation skills will yield better outcomes after disclosure.The final theme that was believed to be of influence on disclosure outcomes concerned All major themes found for research questions 1 and 2 are graphically depicted in Fig. own perspective. HR managers may form an important target group for destigmatizing interventions. From the many factors discussed that are of influence on the disclosure outcome, especially the theme ‘Aspects of the disclosure process’ seems promising, as it entails subthemes that disclosers can influence themselves. From the results, particularly three important findings warrant further study as they may help increase work participation of people with mental illness or mental health issues.The aim of the study was to explore different stakeholder perspectives on advantages and disadvantages of (non-) disclosure, and on factors determining a successful outcome. Generally, it was believed that disclosure can have important benefits, but if work functioning is not or minimally affected by the symptoms, for the employee’s wellbeing and employability it is best not to disclose—especially during the hiring period- in order to avoid stigma and discrimination. Whereas stakeholders generally agreed in their views, some distinct differences were also found, especially when it considered how they viewed disclosure from their First, by contrasting perspectives, a discrepancy emerged between HR managers on one respect, and people with mental illness and mental health advocates on the other. Specifically, all were in favour of disclosure, but for opposite reasons. HR managers were in favour of disclosure, because it enabled them to discriminate and avoid financial risk. They had mixed feelings about it, but viewed it as a core responsibility of their jobs. However, the other two groups emphasized that authenticity in the workplace was extremely important for wellbeing and work performance. The finding that concealment was associated with feeling dishonest, resulting in a weight on one’s shoulders causing stress and exhaustion has also been found in previous studies , 13–18. A second important finding warranting future study was that the work reintegration professionals were convinced the hiring period was a good time for disclosure, whereas all others strongly believed this was the worst time for disclosure. The finding that employment specialists are in favour of and encourage their clients’ disclosure has also been found by others , 25. In cannot be influenced by the discloser (e.g. the economy). The results provided a variety of suggestions for a successful disclosure process, regarding as who to disclose to, when, how to prepare, message content and communication style of the message. Moreover, empowerment, self-esteem and negotiation skills which were believed to be of influence on the outcome, also are aspects that can be influenced by appropriate training and preparation. Future intervention studies investigate these aspects in more detail.Third, the findings suggest that by thorough preparation, workplace disclosers can themselves have a positive influence on the outcome. The findings are in line with those of other studies, suggesting that strategic disclosure can decrease discrimination and stigma , 21, 24.Whereas this paper focused on mental health stigma, the problems discussed are not illness specific and plausibly can just as well be applied to other groups. For instance, several very recent studies have described that people with concealable physical illness, e.g. with HIV , diabeteThere is limited qualitative research with employers  and a stown perspective. HR managers seem an important stakeholder group whose predominantly negative attitudes and behaviour should be confirmed in future studies. As HR managers act on behalf of their organization, their attitudes and behavior may not change unless destigmatizing interventions are also aimed at the level of their organization (e.g. including management). Finally, as shown from the Fig. can be influenced by the individual with mental illness or mental health issues and the several specific suggestions for successful disclosure warrant further investigation.In conclusion, whereas stakeholders generally agreed in their views, some distinct differences were also found, especially when it considered how they viewed disclosure outcomes from their


Local and organic foods have shown increased importance and market size in recent years. However, attitudes, sentiment, and habits related to such foods in the context of video social networks have not been thoroughly researched. Given that such media have become some of the most important venues of internet traffic, it is relevant to investigate how sustainable food is communicated through such video social networks.This study aimed to explore the diffusion paths of local and organic foods on YouTube, providing a review of trends, coincidences, and differences among video discourses.A combined methodology involving webometric, framing, semantic, and sentiment analyses was employed.P=.03).We reported the results for the following two groups: organic and local organic videos. Although the content of 923 videos mostly included the “Good Mother” , “Natural Goodness” , and “Undermining of Foundations”  frames, organic videos were more framed in terms of “Frankenstein” food , with genetically modified organisms being a frequent topic among the comments. Organic videos (N=448) were better connected in terms of network metrics than local organic videos (N=475), which were slightly more framed regarding “Responsibility”  and expressed more positive sentiment (M ranks for organic and local organic were 521.2 and 564.54, respectively, Z=2.15, The results suggest that viewers considered sustainable food as part of a complex system and in a positive light and that food framed as artificial and dangerous sometimes functions as a counterpoint to promote organic food. Sustainability has been receiving global attention with the United Nations promotion of Sustainable Development Goals. Goal 2 “Zero Hunger” involves food security and agriculture development . In thesThe global organic food market size was estimated at US $90 billion in 2016, with the United States, Germany, and France being the main consumers and India, Uganda, and Mexico being the main producers . Lee andOn the other hand, the marketing of food products showed a change in the 2000s from industrialized processes to artisanal, small, and locally based processes . In 2007There is evidence that sensationalist and erroneous content is being fueled by social media search engines owing to their business focus ,12. How To find diffusion paths of local and organic food products on YouTube by collecting information on related videos and comparing their network levels with social network analysis.To review trends and differences among discourses through framing analysis on video content.To explore the opinions, attitudes, behaviors, and emotions expressed by viewers through semantic and sentiment analyses on comments extracted from the videos.With the advent of internet 2.0, online collaboration and activism increased, transforming the internet into a conversational space through the rise of social networking sites. Internet 3.0 incorporated location and real-time aware devices and apps, prompting more personalization of products and services.Social networks can reduce the communication gap between producers, consumers, and other interested people. For example, business engagement on Twitter is related to consumers’ web-based word-of-mouth communication, and its influence reaches consumers with a second-degree relationship to brands . HoweverPrevious social media studies on food communication through text included two-way communication by public organizations related to food safety and nutrition, and it was found that the main themes were queries and complaints, benefits of social media in query and complaint services, content redesign driven by social media use, and social media to learn about consumers . PanteliStructural and social factors of web-based communication channels affect their roles in the image construction process of organic food brands . StudiesComments from Mexico’s Starbucks Facebook page (a shop chain that sells organic coffee) reflected that people interacted more through happiness, but anger and longing were often used to generate participation . PredictHowever, video networks related to organic or local food have not been thoroughly researched. Video social networks account for over half of the internet traffic when measured in bytes , and YouThere is no consensus on what is organic or local food. A definition adapted from previous reports ,29, estaWith regard to local food, the most recognized feature is the marketing arrangement . Thus, lAccording to applicable institutional and national guidelines and regulations, ethics approval was not required for this study, as we focused on publicly available YouTube data. Video data were extracted in 2015 with YouTube Data Tools , which uThe following three queries were used to extract video data: “organic food,” “local food,” and “local organic food.” The resulting three files were appended into one. Videos that appeared only with the “organic food” query were labelled as “organic food videos.” There were no videos that appeared exclusively with the “local food” query; thus, all videos that were not labelled as “organic food videos” were labelled as “local organic food videos.” Videos were watched by an investigator, and in case the content was not in an understandable language, the investigator requested a native speaker to interpret the content. Content that clearly was unrelated to food was discarded, reducing a total of 964 videos to 923 videos. The videos were also classified according to country and uploader. The types of uploaders considered were as follows:Business: It included businesses related to food production, processing, and distribution. Businesses linked to health, tourism, and banking were added to this category as well.Community: It included citizens and communities.Education: It included citizens disclosed as professors, researchers, students, and lecturers; research institutions; universities; and informal education-related accounts.Media: It included both traditional and internet-based media.Others: It included government, politicians, and celebrities.Undisclosed: It included all accounts that did not fit in the previous categories.Video content was also classified according to food frames. Framing is the action of using images and words to influence how audiences interpret a message, promoting specific versions of reality. They are useful tools to infer what people think is important.Food-related framing usually falls into the corporative-political category  or into This type of analysis involves theories, methods, and techniques to study social relations and their structures . A sociaBased on the study by Tsou et al , a randoThis is a type of network study where the unit of analysis is keywords. The software employed was TI, an open source tool that generates a word frequency list, a word-occurrence matrix, a word co-occurrence matrix, a normalized co-occurrence matrix, and a word list from a set of short texts . In ordeThe sentiment analysis aimed to determine the polarity of text through natural language processing. Although most sentiment studies on social networks do not consider emoticons, this tendency has reverted in recent years, as their inclusion increases accuracy. Thus, the value of emoticons  was assigned based on the SentiStrength software package  and in tAmong the 923 videos related to organic and local food, 448 were included in the organic food video list and 475 in the local organic food video list. Overall, 606 videos disclosed location (47 countries). As the keywords employed were in English, the lists contained videos mostly from the United States (n=393). The second most frequent location was undisclosed (n=317), followed by India (n=25) for organic food videos and Canada (n=39) for local organic food videos. Overall, organic food videos had higher metrics in terms of views, likes, dislikes, and comments .P=.42).As for types of uploaders, media-related YouTube channels were the most common for both lists . In the The top organic-related videos in terms of views and likes were uploaded mostly by media channels and contained short educative facts about food products. However, some of them were sensationalist. The top video was “Grocery Store Wars,” a stop-motion parody of the movie franchise Star Wars, contrasting organic food products and conventional food products in a supermarket. On the other hand, the top videos related to local organic food were business oriented and sometimes employed humor. The video with the highest number of views and likes was a three-dimensional animation commercial, which was part of a campaign by Chipotle Mexican Grill, an American restaurant chain. This video contrasted chemically treated and mechanically processed food products with food produced and processed by farmers. It can be concluded that the top videos in both cases were story-telling driven and showed a contrast between sustainable and nonsustainable foods.Based on van Gorp and van der Goot , the GooIn order to visualize how different is the structure of the two video groups, their network metrics were compared. Because both lists share ties, metrics for the entire video network were also calculated. Local organic food videos had higher connected components, modularity, diameter, and average path lengths . DensityThe top videos in terms of betweenness and in-degree centrality explained the basics of organic and local food and were predominantly uploaded by media channels. In contrast, videos with high out-degree centrality were uploaded mostly by businesses and individuals. A few organic-related videos identified the food as expensive, while local organic-related videos usually presented a specific area where such food products were available.Spearman correlation analyses between YouTube metrics and network-related metrics were performed to find how much the popularity features are related to communication patterns in the network. The number of views, likes, dislikes, and comments were moderately correlated with degree, modularity class, eigenvector, and betweenness centralities in the organic food video network . As for The Gephi software was used to visualize the semantic networks corresponding to the two video lists. The 107 most frequent words found in the comments sample from the organic food videos were represented with nodes .The word “organic” was the most frequent in these comments, with the term “food” closely related to it. Verbs connected to “organic” were “grow,” “know,” “like,” “need,” “say,” and “think.” Frame-related words are presented in In summary, while both groups of comments featured fruits and vegetables, organic food videos featured dairy and proteins, and local organic food videos featured grains and cereals. Moreover, the organic food network had a greater variety of Frankenstein frame–related words.There was no relevance with regard to negativity valence. However, comments made on local organic videos had a higher rank for positive valence in comparison with comments made on organic videos .Organic and local food products were communicated on YouTube by several actors articulating efforts to educate the public about food. In particular, the position of organic food videos in the network strengthened the diffusion paths, with a better structural capital than local organic videos, whereas the high in-degree (ties directed to a video) suggested a broadcast network. The relationship between network metrics and negative reactions (number of dislikes and less positive sentiment in comments) implied that negativity might play a relevant role in the diffusion of videos. This coincides with the theory that negative relationships might explain social network outcomes better than positive relationships , althougAnother relevant finding was the words related to “organic” and “local.” The frames have been summarized in Words like “love” and “thanks” were used often in the case of comments for local organic videos. As they also employed the Responsibility frame more frequently, it implies a more human and social dimension for the word “local.” It also has implications for activating the viewer in areas besides food consumption, as images involving future generations and nonhuman living beings are part of this frame. This partly explains why comments for local organic videos were more positive than those for organic videos.Finucane et al  argued tThe persistence of uncomfortable feelings among the public towards GMOs, which are considered as “monsters” according to the Frankenstein frame, points to a failure in scientific communication. This is particularly true regarding information on pesticides, soil depletion, and nutrition. Such communication patterns could be improved by closing the gap between scientists and the public, as attempted by some of the videos uploaded by education channels. This could potentially bring more transparency and trust to the food production chain.Dissimilar ideas of what is food influence the outcomes of guidelines and food policies. There is little knowledge on the effect of YouTube’s ranking criteria in areas other than politics and entertainment. Hence, a multimethod analysis of the communication of basic human needs, such as food, can provide us with more understanding of the consequences of algorithm usage in rich social media and its interplay with human users. Moreover, we uncovered communication patterns and specific visual and textual cues, providing more comprehensive insights of a complex ecosystem of actors involved in food production, distribution, and consumption. The case of organic and local food intertwines consumerism with environmental concerns that have the potential to impact public health.As the language of analysis was English, there was partially limited access to videos from non-English speaking cultures. Sentiment can be influenced by many contextual features, such as weather  and geogThis study explored the communication paths, discourses, opinions, attitudes, behaviors, and emotions related to sustainable food products in YouTube video networks. Based on our objectives, we can make the following conclusions:The organic video network was more consolidated than the local organic video network and was driven mostly by media and business YouTube channels.The “Good Mother” and “Natural Goodness” frames were most frequently employed in the videos, followed by “Undermining of Foundations.”The concept “organic” has become consolidated among both specialists and the public, while the term “local” is in the process of acquiring a formal definition. Nevertheless, the term “organic” was slightly more associated with health risks and negative feelings, while the term “local” was perceived as more human/social and more positive.Further studies could incorporate more languages, as well as a larger data set. Time-based analysis and segmentation of semantic analysis across different geographical locations would also deepen the present understanding of the diffusion of both organic and local food products. Another area for further exploration is GMOs, as this technology will continue to transform food production and consumption patterns in contrast with traditional agricultural methods.


China holds one fifth of the world’s population and faces a rapidly aging society. In its ambition to reach a health care standard comparable to developed countries by 2030, the implementation of palliative care gains special importance. Until now, palliative care education in China is limited and disparate. This study aims to explore and determine factors that have impeded the development and implementation of palliative care education in China.n=28 medical teachers from seven Chinese universities. Interviews were transcribed, and thematic analysis applied.We conducted semi-structured interviews with Three themes with two subthemes were constructed from data analysis. Theme 1 covers the still ambivalent perception of palliative care and palliative care education among participants. The second theme is about cultural attitudes around death and communication. The third theme reflects participants’ pragmatic general understanding of teaching. All themes incorporate obstacles to further implementation of palliative care and palliative care education in China.According to the study participants, palliative care implementation through palliative care education in China is hindered by cultural views of medical teachers, their perception of palliative care and palliative care education, and their understanding of teaching. The study demonstrates that current attitudes may work as an obstacle to the implementation of palliative care within the health care system. Approaches to changing medical teachers’ views on palliative care and palliative care education and their cultural attitudes towards death and dying are crucial to further promote the implementation of palliative care in China.The online version contains supplementary material available at 10.1186/s12904-020-00707-w. Palliative care (PC) as defined by the World Health Organization (WHO) is an approach to improve the quality of life for patients with life-threatening illnesses and their families. It “prevents and relieves suffering through early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial and spiritual” .Access to Palliative Care is a designated human right , 3. The China holds one fifth of the world’s population and is the world’s largest developing country. The country faces demographic change, with an increasingly elderly population , 6, 8, 9Palliative care education is an essential step in implementing palliative care into a health care system  and provThis study aims to explore and determine factors that affect the development and implementation of palliative care education in China. It is hypothesised that prevailing teachers’ beliefs, possible misconceptions and understanding of palliative care as a discipline, have a deleterious impact on education , 16.We conducted interviews with Chinese palliative care teachers and general medical teachers about their views on palliative care and palliative care education from Sep-Nov 2018. All interviews were conducted by the correspondent author. No repeat interviews were held. A COREQ  checklist can be found attached  text marked with explicit or implicit ideas. These meaning units were subsequently coded, reducing and abstracting the original data into analytical themes. Reflection notes or memos were taken throughout analysis process. No software was used during the coding process.In a second step, codes were assigned to groups along their similarities or possible generalizations. In that process, codes were compared, linked, and sometimes changed. Code groups were labelled with a word or phrase from the original data summarizing the main idea of each code group. Code groups were further linked and structured to build the first themes and subthemes. In a process of distancing from the data for some time and rereading the codes multiple times, themes and subthemes were rearranged and reconstructed multiple times to answer the research question in the best possible way.The analysis took place without immediate peer checking. However, the correspondent author was frequently supervised by two co-authors involved in data collecting process. Findings were not sent back to participants to check or comment the findings.n=28 participants from seven Chinese universities were conducted. Participants’ characteristics can be found in Table From 30 persons asked for participation, two persons refused. In the end, 26 interviews with Apart from the thematic analysis, the conduct of the study itself revealed some aspects on the structure of palliative care education. None of the hospitals visited for this study had a palliative care department. If palliative care was practiced, it was done so as part of another specialty such as oncology or traditional Chinese medicine. At none of the seven universities participants worked for, palliative care was taught as a distinct subject.Three themes were derived from the data in the process of analysis. They show that the views of medical teachers build a barrier to the application and education of palliative care in China.The first theme, “Ambivalent perception of palliative care and palliative care education”, includes the subthemes “Judgement on/interest in palliative care and palliative care education” and “Understanding of palliative care and palliative care education”. The second theme, “Cultural attitudes”, includes the subthemes “General culture of communication” and “Death culture”. The third theme, “General understanding of teaching” contains the two small subthemes “Teaching as conveying knowledge” and “Generating workforce as aim of teaching”. Subthemes may contain multiple aspects. An overview of themes, subthemes and individual aspects of subthemes can be found in Fig. Overall, there was no remarkable difference between answers of participants with long clinical experience (> 15 years) or shorter clinical experience (< 15 years). In both groups, there was a great variety of answers and behaviour. No group showed a specific pattern or emphasized certain aspects.The first theme shows that medical teachers in China have an ambivalent perception of palliative care and palliative care education. It includes two subthemes.“Because palliative means no hope.” (T = Transcript 15)In the future, participants expected palliative care to play an increasingly important role in China’s health system, others were convinced that little changes are to be expected in the future due to a lack of interest among physicians. Some were contented with the status quo of palliative care education, some emphasized the need and desire for more palliative care practice and palliative care education in the future, and some showed no interest in the topic.“I think it’s, to be physician, if you want to be a physician, you must have this courses, because [ … ] You’re dealing with the dying patients. So, you should have this kind of knowledge. [ … ] You don’t need to be an expert, but you should know the knowledge about the palliative care.” (T23)Interestingly, it was noted during the interviews that several participants evidently felt uncomfortable discussing the subject of death and dying. Accordingly, this may indicate a lack of comfort or willingness to teach the subject.FN = Field Notes: „He seemed to be a bit uncomfortable when we actually pronounced the words ‘dying’ and ‘death’ but he managed it” (FN14)The second subtheme depicts participants’ understanding of palliative care and palliative care education. When asked about what palliative care is, most participants referred to symptom control. Others defined it through its application within the disease journey, mostly as part of oncology or as the last option of therapy.“Palliative medicine, we usually know that from the oncology department.” (T17)The first subtheme, “Judgements on/interest in palliative care and palliative care education” reflects the range of perceptions among medical or palliative care teachers. Some participants associated palliative care with enabling a peaceful way of dying, yet others with hopelessness.“[ … ] I would say, palliative care makes living better.“ (T11)“Because chemotherapy, radiotherapy, or the surgery, they also bring vary kind of symptoms and adverse reactions for this kind of treatment. So, palliative treatment also help these kind of patients to have a good dealt with this kind of treatment. To accept the treatment more smoothly.” (T05)Those participants highlighting the importance of palliative care mentioned the benefits not only for the individual, but also for the families, the physicians, and the society.On the other hand, it’s also a great burden for the family or for the city. If everyone thinks like that, operate, drugs, it’s also very expensive. Many families living on the countryside are financially very burdened, maybe. They have to sell houses. Misery again.” (T18)“The interviews recorded various reactions to the subject of palliative care, for example grief and insecurity, highlighting the subject as taboo or, on the other side handling it with normality.“So, [the patient] didn’t want to change the therapy, and she want to come back in two months later and you know that the circle of therapy is three weeks to four weeks. So, after two months, then maybe the lesions grows up. We tried … I tried my best. (laughs) To give her suggestions and blablabla, and … she go back. (laughs)” (T03)),FN: “He avoided the subject of palliative medicine [ … ]” (FN19)When talking about palliative care education, participants judged various addressees as ideal target group, such as nurses, young physicians, small children, oncologists or physicians in general. Views on the main emphasis in terms of content of palliative care education ranged from symptom control to communication.I = Interviewer: “If you would decide to teach palliative medicine [ … ], what would you consider especially important in teaching? What would you teach?” – P = Participant: “I think most important the symptoms. And then how you deal with them. That’s it.” (T01)More details and quotations on Theme 1 can be found in Table The ambivalent understanding of palliative care also became clear when talking about the aims of palliative care. Many participants mentioned quality of life and respect for the patient, but some also highlighted the goal to make the patient accept curative therapies.The second theme identifies barriers to palliative care and palliative care education via the cultural attitudes of participants or their perception of cultural attitudes in society with the general culture of communication (subtheme 1) and death culture (subtheme 2) playing a major role.I: “Can you describe me more about this feeling?” – P: “(laughs)” (T02)Death culture covers multiple aspects impeding palliative care application and education.Participants reported that communication with patients is often characterized by euphemism and indirectness and little conversation about feelings and emotions. These patterns were also present in the communication of participants themselves. This complicates communication about palliative care in both practice and education.“So, if your parents are ill, you cannot give them up. Because you will feel suffer yourself, you will think you are a bad person, and people around you will criticize you. Because you did the worst thing.” (T17)According to the participants, death has a very negative image within Chinese spirituality. Among both Buddhists and atheists, death is viewed as something tragic and very difficult to accept. Death and communication about it are socially stigmatized.“So, they [Chinese people] don’t think it’s good things to discuss death with others. Not polite. Very impolite.” (T24)The wish not to die is perceived as a basic characteristic of being human, and this results in an absolute and collective request for healing and curative treatment. Hospitals are viewed as healing places, where “bad results” and non-curative treatment options are very difficult to accept.“If she doesn’t want to live, then she will not go to the hospital.” (T03)Most patients who realize that they are going to die leave the hospitals to die at home or in community hospitals near their home. This contributes to palliative care being rarely conducted at university hospitals, providing students with little, if any experience or appropriate role models.I: „And what about other death related symptoms [ … ]. Are they present in education?“ – P: „Actually not [ … ]. Because most patients, they want to go home. They know, that’s incurable, they are going to die, they won’t die here at the hospital.“ (T04)The culture of truth telling or discussing prognosis is often referred to as an obstacle to palliative care. Participants had varying views on the culture of truth telling. Some supported and accepted it, whilst others judged it negatively. Still, most participants reported acting according to the family’s wishes, who generally ask physicians not to inform terminally ill patients about diagnosis and prognosis.„[ … ] the family always tell the doctor, don’t tell (chuckles) the truth to the patient. So, I respect the family [ … ]” (T19)Information disclosure though is seen as a precondition for practicing palliative care, and the culture practices in relation to truth telling therefore work as a barrier for palliative care practice in China.“But whether or not, whether to receive the palliative treatment or not is decided by comprehensive reasons, like economic status. [ … ] And psychology status. How his ability to tolerate or accept the truth.” (T16)More details and quotations on Theme 2 can be found in Table The role of family in society is huge, and equally so it is in dealing with death or making medical decisions at the end of life. Participants reported that families largely decide about medical aspects in disease at end of life. The social importance of family also pressures decision makers to favour curative approaches, as doing everything for the family is a high social ideal.ital.” T0Most patiThat’s our main emphasis, to enable the students to learn, to master this knowledge.” (T04)““First, it has to meet the need of the state. We need more physicians.“ (T18)The third theme describes participants’ general understanding of teaching. Teaching was mostly understood as the conveyance of knowledge and the primary aim was to generate workforces to meet the needs of the state.Results from our study suggest that medical teachers’ views impede the application and education of palliative care.The prevailing ambivalence in the perception of palliative care among the participants shows different levels of openness to both application and education. This includes ambivalent judgements on palliative care and interest in the topic, ambivalent views on aims and effects, as well as ambivalent definitions and reactions.The culture-bound views of both medical teachers and society impede palliative care and palliative care education. The general culture of “death as a taboo” complicates communication about end of life care, where exchange is centred on the high social value of the family and a negative cultural and spiritual understanding of death. As patients prefer to die at home or near home and seek help mostly in community hospitals, the number of palliative care patients in university hospitals is low. Restrictions to discuss the prognosis further than “the patient is at the end of life” impede communication about the provision of palliative care as an option at the end of life.The general understanding of the purpose and function of teaching is very pragmatic. Conveying knowledge is the centre of education and its primary aim is the generation of a competent workforce. This may be a barrier for holistic and reflective approaches such as palliative care to establish a role within medical education.The general effect of culture as a barrier to palliative care education has received little direct attention until now. Yet, associations between culture and palliative care have been subject to research for years. For example, culture and culture-bound belief systems play a major role in the provision of high-quality palliative care –25. ApprAs our participants report, a culture of withholding information on diagnosis and prognosis from terminally ill patients in preference for the family, is largely practiced in China. Information is first communicated to the family, who will mostly ask the physician to withhold this from the patient for fear of doing harm: a practice widely described in literature , 27. In In recent years, the Chinese culture around truth telling within end of life care has been widely discussed. Research shows that patients prefer information disclosure more often than their families  or physiTeachers’ understanding of their role has an impact on the quality of education . In our n=28 participants, we believe that enough data were collected to have valid results. Still, we cannot rule out that more interviews could have revealed additional information.Malterud and colleagues have argued that the prevailing concept for sample size in qualitative studies is “saturation.” They also have pointed out that this term is inconsistently applied and proposed the concept “information power” in order to guide adequate sample size for qualitative studies. Accordingly, information power indicates that the more information the sample holds, relevant for the actual study, the lower amount of participants is needed . FollowiThis study is the first to examine medical teachers’ views and perceptions on palliative care and palliative care education. It enables a better understanding of the role of palliative care in the Chinese medical educative system and possible reasons for the slow implementation of palliative care education. This understanding plays an important part inone day being able to overcome the existing obstacles for the implementation of nationwide palliative care education and through this for achieving nationwide access to high quality palliative care.Interviews were held in different regions in China at multiple universities, and participants held various positions. Through this, our data gives a very rich picture on participants’ views and perceptions on palliative care and palliative care education. This is enforced through the method of thematic analysis, which enables a complex and detailed reflection of interview contents.At the same time, this study is subject to various limitations.Findings are at risk of language and interpretive bias. Interviews were not held in participants’ mother tongue. Further, the use of translators may have resulted in small changes of meaning and nuance, particularly as translators were mostly non-professional and not familiar with core characteristics of qualitative research.Another weakness of the study is the sample generation. Due to the limited structure of palliative care education in China, it was difficult to identify key persons in palliative care education or general medical education. We often relied on snowball or convenience sampling to conduct interviews. Therefore, sample specificity is limited.Interviews were possibly influenced by noisy settings, disruptions and on occasion the presence of an uninvolved third person, possibly exerting social pressure. Indeed, the interview itself might have exerted a form of social pressure, as participants might have experienced discrepancies in palliative care knowledge between them and the interviewer. Some participants gave the impression of feeling ashamed about their little palliative care knowledge; some appeared to feel uncomfortable to discuss end-of-life subjects due to social stigma. Additionally, social desirability in form of participants aiming to please the interviewer might well have affected participants’ statements and answers, despite the interviewer’s efforts to show an open and unjudging mind frame.Additionally, the interviewer was rather new to the interviewer’s role. Therefore, information power of some interviews is limited, and sympathy, antipathy or personal views may have influenced the course of interviews. As thematic analysis was conducted by only one author, subjectivity may have influenced results.It has been suggested that thematic analysis, as a flexible and useful research tool, provides a rich and detailed, yet complex, account of the data. Thematic analysis is “a reiterative process without finite interpretation”, however, it is a key methodology when it comes to generating hypotheses and theories . As onlyCurrently, palliative care implementation through palliative care education in China is hindered by prevailing cultural views. The prevailing culture promotes ambivalent perceptions of palliative care among medical teachers and the wider society. A pragmatic general understanding of teaching works as further barrier for palliative care education, which is elsewhere characterized by holistic approaches, communication, and reflection. However, developing research is challenging the cultural orthodoxy and highlighting the value of rethinking end of life culture, reducing harm not through withholding diagnosis and prognosis, but by enabling high quality end of life care through a more open communication.Approaches, such as train the trainer sessions, to change medical teachers’ views on palliative care and palliative care education and their cultural attitudes towards death and dying are crucial to further promote the implementation of palliative care in China.Additional file 1. “Interview Schedule – First and Final Version”, format: .pdf, first and final version of the semi-structured interview schedule used in the interviews, final version as product of multiple adjustments of the first version.Additional file 2. “COREQ-Checklist”, format: .pdf, a list of COREQ-guidelines for reporting qualitative studies with all requested information and references where to find them in the manuscript.


COVID‐19 outbreak prompted health centres to reorganize their clinical and surgical activity. In this paper, we show how medical genetics department's activity, in our tertiary pediatric hospital, has changed due to pandemic.We stratified all our scheduled visits, from March 9th through April 30th, and assessed case‐by‐case which genetic consultations should be maintained as face‐to‐face visit, or postponed/switched to telemedicine.Out of 288 scheduled appointments, 60 were prenatal consultations and 228 were postnatal visits. We performed most of prenatal consultations as face‐to‐face visits, as women would have been present in the hospital to perform other procedures in addition to our consult. As for postnatal care, we suspended all outpatient first visits and opted for telemedicine for selected follow‐up consultations: interestingly, 75% of our patients’ parents revealed that they would have cancelled the appointment themselves for the fear to contract an infection.Spread of COVID‐19 in Italy forced us to change our working habits. Given the necessity to optimize healthcare resources and minimize the risk of in‐hospital infections, we experienced the benefits of telegenetics. Current pandemic made us familiar with telemedicine, laying the foundations for its application to deal with the increasing number of requests in clinical genetics. In this paper, we show how medical genetics department's activity, in our tertiary pediatric hospital, has changed due to COVID‐19 pandemic. Given the necessity to optimize healthcare resources and minimize the risk of in‐hospital infections, we experienced the benefits of telegenetics. Current pandemic made us familiar with telemedicine, laying the foundations for its application to deal with the increasing number of requests in clinical genetics. Since virtually every aspect of the human figure and physiology is influenced by genetic information, it is not surprising that physicians who work in this field often must specialize further. Genetic subspecialties encompass almost all the different fields of the clinic, not only prenatal diagnosis, pediatric, and tumor genetics. The relationship between physician and patient has always been and remains a keystone for assistance and in the field of genetics it also takes on a greater purpose: the means by which data, diagnosis and treatment plans are collected, imply sharing for other members of the family. The relationship between patient and physician is, therefore, more demanding for both parties and must be based on mutual trust.https://www.who.int/emergencies/diseases/novel‐coronavirus‐2019/situation‐reports), making our country one of the worst affected. COVID‐19 outbreak has proven to be a rapidly evolving and complex situation: the fast spread of SARS‐CoV‐2 infection in Italy at the end of February led Italian government to set a nationwide lockdown starting on March 9th. Given the state of emergency, health centres were asked to reorganize clinical and surgical activities in order to reduce the risk of contamination within the hospital as well as to get prepared to admit the prospectively growing number of affected patients. In this unexpected scenario, national and regional authorities suggested to identify and perform only urgent and non‐deferrable procedures, suspending elective and postponable activity. In absence of standardized guidelines, each surgical , type of appointment (first or follow‐up visit), and, finally, type of setting (outpatient clinic or inpatient consultation). We, therefore, took note of how many and, more interesting, which type of consultations we decided to (1) maintain as face‐to‐face visit, (2) reschedule later in time or (3) switch to telemedicine consultation, trying to draw up as standardized as possible criteria. To test the appreciation of telemedicine, we sent an email survey to the families’ address, after the consultation.During that period, every member of our hospital's medical staff was tested for SARS‐CoV‐2 virus, through both rapid serologic test and nasopharyngeal swab simultaneously, in order to reduce hospital‐acquired SARS‐CoV‐2 infections. Similarly, all patients, who had to be hospitalized for scheduled or emergency procedures, were tested just before admission, in order to exclude a SARS‐CoV‐2 contamination. Outpatients and their caregivers were not routinely tested for COVID‐19 but they underwent temperature screening with a thermal scanner at hospital entrance. For each child, only another person (parent/caregiver) was allowed to enter the hospital. In exceptional cases and after physician's specific request, both parents could be admitted to the hospital, for example, to sign informed consent. Lastly, all patients and all members of hospital staff were provided with surgical masks.3Out of 288 scheduled appointments, 60 were prenatal consultations and 228 were postnatal visits Figure .In our hospital, prenatal genetic consultation is generally programmed so to be performed along with other prenatal either invasive or non‐invasive procedures, providing women with a thorough and well‐scheduled prenatal diagnosis program. Given the non‐postponable nature of most of our prenatal consultations and considering that women would be admitted to the hospital on the same day to undergo other procedures, we performed all the scheduled consultations as face‐to‐face visits. As for post‐test counseling, we decided upon a face‐to‐face consultation in case of pathological results, opting for a telemedicine meeting to return normal results, subject to patient's agreement. In our department, postnatal genetic activity is divided into outpatient clinic, for both first and follow‐up visits, and inpatient consultations, generally prompted by other specialists’ requests. Given the rapid spread of SARS‐CoV‐2 virus infection in Tuscany, all outpatient first visits were suspended from March 9th. The subsequent need to reschedule so many appointments has meant a significant organizational issue, which will probably require us to establish criteria in order to stratify consultations, based on their urgency and on the possibility to perform them as telemedicine visits. Concerning already scheduled outpatient follow‐up appointments, in these last two months we had to go through our working plan case‐by‐case, so to decide which ones could be performed as telemedicine consultations and which ones actually required an in‐person visit, rescheduling these last ones. Interestingly, once called by our medical staff, most of our patients’ parents (75%) told us that they would have cancelled the appointment themselves, fearing to contract COVID‐19 inside the hospital. We also opted for telemedicine consultations to return genetic tests results: following every remote consultation, we drafted a detailed report and sent it by e‐mail protected by a password communicated exclusively to the patient's family/caregiver.Out of 90 telemedicine consultations performed , 84 (93%) families responded to the survey, reporting a satisfying level of communication.With regard to inpatients’ genetic consultations, we observed a reduction in the number of requests received by our department in this period; we usually perform a minimum of 50 inpatient visits a month, but only 25 consultations have been requested from March 9th to April 30th. This noticeable decrease in the number of inpatient consultations reflects the reduction of routinely elective clinical and surgical activity in our hospital in this period. As reported in Figure 4Fast spread of SARS‐CoV‐2 virus infection in Italy prompted our hospital to rapidly reorganize clinical and surgical activities, in order to optimize healthcare resources and minimize the risk of in‐hospital infections (Cini et al., Therefore, in addition to an extensive illustration of possible results and clinical implications of a given genetic test, it is important to provide support to patients and to reassure them (Harding, Hammond, Chitty, Hill, & Lewis, Regarding the postnatal setting, we maintained very few of the scheduled follow‐up appointments, choosing to either postpone or convert to telemedicine consultations most of them. We opted for telecommunication in selected cases, thus finding an efficient alternative to the classic face‐to‐face visit for ensuring continuity of care. Telemedicine consultation proved to be an effective method to provide genetic counseling, receiving positive feedback from both patients and genetics specialists: in a systematic review (Hilgart, Hayward, Coles, & Iredale, Previously, some experiences about the use of telegenetics across United States and Europe have been reported; however, application of telemedicine appeared to be different among the various hospitals (Otten, Birnie, Lucassen, Ranchor, & Van Langen, Despite this reluctance to employ a method already in use in other European countries and so sporadically in our territory, the provision of support through a telehealth approach has been really useful to maintain the psychological well‐being of our patients.According to our recent experience, telemedicine made it possible to remain in contact with patients, to follow and to answer questions about the clinical course of a given condition and to communicate genetic tests’ results providing an exhaustive explanation. So far, we opted for telemedicine only in selected post‐test consultations in the prenatal setting, and in case of follow‐up consultations in the postnatal setting, suspending all the first outpatient appointments for these two last months. Given the uncertainty of the current pandemic situation, it is now mandatory for us to think about how to deal with to the increasing demand for genetic counseling, also taking benefit from telemedicine.a priori assessment of the first visits in terms of urgency, also trying to discern whether they can be performed as telemedicine consultation or must be done as in‐person visit. Being a tertiary referral centre, our hospital mostly attracts pediatric patients who need a multidisciplinary diagnostic approach, within which geneticist has the role to coordinate various investigations: in this specific setting, the experience of the clinical geneticist is essential and, usually, a detailed face‐to‐face evaluation is pivotal to guide the diagnostic path in order to reach the diagnosis (Malinowski et al., Since there is currently no standardized approach or guidelines on telegenetics, we need to establish specific criteria to make an In conclusion, spread of SARS‐CoV‐2 virus infection in Italy forced us to change our working habits. With regard to prenatal care, we opted for in‐person consultations, for they are scheduled on the same day of other procedures and also because we prefer to maintain a face‐to‐face approach in this delicate setting. As for postnatal care, we experienced satisfactory communication through telemedicine, for both returning genetic test results and receiving updates about our patients. Although we have always been used to a face‐to‐face counseling, the current pandemic situation made us get acquainted with the benefits of telemedicine in such a complex situation, also in terms of reducing waiting times.Furthermore, given the limited number of clinical geneticists in our country, telegenetics services, which make genetic counseling feasible through the internet, can provide consultations faster and with a reduction of waiting lists. We experienced that genetic consultations performed with telemedicine revealed to be equal to face‐to face visits. Both patients and providers reported a greater appreciation of real‐time videoconferencing over telephone call to perform the consultation. It is interesting to note that, in addition to the fear of contracting an infection in the hospital, most families appreciated the proposal for telemedicine consultation because they could carry out the visit without travelling long distances.Given the uncertainty of COVID‐19 outbreak's course, we must define a new plan to manage postnatal first consultations: developing a network to share clinical information among geneticists, pediatricians and other pediatric specialists might represent an essential step to prioritize the increasing number of requests, in order to choose wisely which cases should be approached with an in‐person genetic consultation in a multidisciplinary setting. Improvement of real‐time videoconferencing with high‐speed technologies will hopefully help us integrate telegenetics consultations in our clinical routine and will allow us to tele‐communicate even more complex and clinically significant results, providing a satisfying connection between patient and physicians.Nothing to disclose.PA, GS designed and conceived the project. PA, FG, DGF, GG, TG collected and analyzed data and survey results; PA, GS wrote the manuscript; IA, MG revised the manuscript; and GS supervised the project.