To understand the medical students’ perspectives and influential factors on their careerpathway decision to be a General Practitioners (GP) in Indonesia.This research usedsequentially mixed methods. The qualitative study was conducted using focusgroup discussions with 30 third-year students, followed by in-depth interviewswith 15 students from one Indonesian institution with the highest level ofaccreditation. The qualitative data, together with the literature review, wereused to construct an online questionnaire with three types of questions.The survey response rate reached 81% from 2,240 students across 64 faculties of medicinein Indonesia. Responses indicated that GP is not preferred as the leadingcareer choice, and 67% of students prefer to become hospital specialists. Thequalitative data revealed several influencing factors in choosing GP as theirultimate career choice: more family time, being closer to the community, andinterest in bio-psycho-social subjects. Meanwhile, the reasons not to choose GPas a career choice were: imbalance in work and life, less authority, being atthe lowest level position in the health care system, high uncertainty, and lowfinancial incentives.GP is not aninteresting career option for most medical students in this study. ConsideringGP works strategically in primary care settings aiming at better healthoutcomes and optimizing the health care financial system with greater patientsatisfaction, influential positive factors to be GP should be nurtured in themedical curriculum. Starfield (1998) defined the term primary care as an integrated and accessible health care service with clinicians who are capable of dealing with community health care needs, building sustainable relationships with patients, and practicing under family and community circumstances.Over time, primary care services have demonstrated their positive impact on low- and middle-income populations.In Indonesia, primary care service is not established as an expert in clinical career pathways. Indonesia has a population of 250 million, the fourth largest in the world, with 20,000 hospital specialists and more than 100,000 registered General Practitioner, who are not specialists but are graduates from 6 years of basic medical education. Essentially, those General Practitioner who work in primary health care mostly serves as ‘gate keepers’ to make appropriate referrals within the universal coverage system that began in 2014. Since General Practitioner works without any supervision and have only limited consultations with hospital specialists, primary care services from General Practitioners lead to lower-than-expected quality of service.,,Recently, trends in the career choice to become a primary care physician have drastically declined in many countries such as Germany, Japan, and the United Kingdom.Several studies have explored the reasons why undergraduate students choose their career pathways. A systematic review of GP career trends divided the reasons into internal and external influences, which encourage or demotivate undergraduate students to select a career as a General Practitioner.Reasons students choose General Practitioner as their career pathway may differ between high- and low-income countries. In developed countries, intellectual challenges requiring a broad range of knowledge is a common reason not to become a General Practitioner. On the contrary, understanding of rural needs, attitude towards social problems, volunteer work, family influence, and shorter length of residency are common reasons to choose General Practitioner as a career pathway. In Saudi Arabia, female students tend to choose their career based on the possibility to get a scholarship and because of closer and more human interactions with patients. Considerably different, male students tend to choose a specialty with technical challenges, higher salaries, and greater opportunities for promotion and prestige.,Motivation is an essential driver for students’ career choices. According to the motivation theory of self-determination by Ryan and Deci (1985), life decisions are based on a personification process. The self-determination theory of motivation proposes that motivation is a fluid and dynamic process which could change over time.Indonesia is a lower-middle-income country with unique multi-cultural characteristics in a developed universal health care system. There is no data on the Indonesian students’ career options yet. Furthermore, there is not much understanding on how medical student in lower middle income country choosing and reasoning on their career yet.This exploratory study used a mixed-methods approach.The setting for the qualitative study was at the top medical school in Indonesia. From a total of 36 tutorial groups in third-year students, one student from every tutorial group was invited to participate in the Focus Group Discussion (FGDs). The invited students were randomly assigned to join the focus group discussion in each focus group discussion participated by six to nine students. The focus group discussion and in-depth interviews were done by using a structured interview guide as follows: (1) their opinion on health care systems, (2) future career choice, (3) their opinion about General Practitioner and selecting General Practitioner as their career pathway, and (4) how education/media are shaping their opinions on their career options. Additionally, fifteen students who had already finished their exit exam agreed to join the qualitative study for an in-depth interview with the principal investigator.Data saturation was reached after the fourth focus group discussion. All focus group discussions and in-depth interviews were recorded, transcribed, and descriptively analyzed. The analysis process was divided into two phases: (1) content analysis of focus group discussion and in-depth interview transcripts, and (2) content analysis of the online survey questionnaire. The first content analysis results gave frame to the second analysis.The qualitative study themes were constructed based on the Focus Group Discussion and in-depth interview data. Afterwards, these items were categorized into a list of several grouped themes by two coders. The coders (the first and second author) worked individually on the open coding and had six meetings (one meeting per week for six weeks) to agree on the final themes. Discussion of the two coders was then validated by the last coder (the previous author) based on the literature framework about student motivation and influencing factors for choosing General Practice’s as a career choice.The quantitative study was a national survey using an online questionnaire that was distributed to final year undergraduate students who had already finished all the curriculum, including clinical rotation, and had done the national exit exam to gain the professional practice license. The questionnaire was constructed based on the results of the previous qualitative study, and on a research report from a Swedish telehealth study conducted in Indonesia in 2017. Some modifications were done in the re-validation process by adding several questions based on a current literature review and previous qualitative data.The final constructs of the online survey questionnaire were: (1) students’ characteristics, (2) students’ perspectives on a professional career, (3) students’ career-choice, (4) determining factors for future career choice, (5) preference in working style for future career choice and (6) educational impact on the career choice. Each part consisted of two to fourteen sub-questions and two short answer items.Before starting the next part of the study, an intra-reliability test was done with 30 students by assessing the Cronbach alpha of each question. There were several questions with α Chronbach <0.70, which were then either dropped or modified. The final version was sent to our Information Technology office to be set into electronic format for the online survey questionnaire. An informed consent section was added in the beginning of the questionnaire, involving a statement that explained to students when clicking open the questionnaire that they agreed to join and complete this study. To determine the reliability of the resulting data, two border levels of missing data were used (above 5% or 10%).The answers of short questions from 1,778 online survey responses were condensed into 300 data items considering institution representational. We selected the 300 data points based on the random number of students per institution out of 64 institutions .The overall results from the qualitative and quantitative studies showed that most students still had positive views concerning General Practitioner, but there were several reasons which made them have low motivation to choose to become General Practitioners as their career pathway, as represented below.Overall, students said that General Practitioner is not their next future career goal in medicine. Becoming General Practitioner  would  only  be  a  temporary option  for  them before they choose specialties in medicine:“GP….it is something positive but how to explain….it is positive as a starting career….” (FGD)“Yes, it is a career option, it will be a phase which should be passed through, all of us should be a GP first” (In-depth interview)The following reasons were mentioned for not choosing General Practitioner as their career pathway, including the science, working tasks/responsibilities, rewards, social hierarchy, and social/community perspectives, as reported below. General Practitioner must have certain competencies which prepare them to fit into the present-day health care system. Regarding their role, General Practitioner are ideally prepared to make the best clinical decisions for their patients regarding their condition and to assist them during both times of good and poor health, as part of a continuity of care during a person’s lifetime. However, patient-centred care was not fully understood by most medical students, and they tended to be more focused on the development of medical knowledge.“First, the science, then secondly also because of the previous one because the science flourish rapidly, getting more specialized even become sub-sub specialty….so with a condition like that, becoming GP just really needs to be upgraded” (FGD)Working tasks/responsibilitiesWe found several interesting responses expressing dissatisfaction toward the General Practitioner they had met. Most students said that health consultations with General Practitioners were often too short and only based on symptoms which make the tasks of primary care not satisfying. Another main reason for their low motivation to become General Practitioner was the large numbers of patients to be seen within the limited time available. Furthermore, one respondent also indicated that General Practitioner were demanded to do more preventive tasks and speak diplomatically to their community which is hard according to some students.“when my experiences met with GP…with my all achieved science, I think I could do more as a GP…” (FGD)“From my personal perspective, I do not want to be a GP because GP only give symptomatic treatment. Only based on criteria, I even went to GP services three or four times, and I received the same medication, that make me underestimate them. That was experienced not only by me, but I also heard my friends had the same experiences, just like me, they also got so many medications, that’s why I do not want to be a GP” (FGD)“If we go to a specialist, they will be more exploring into details, so that’s our impression, they are better, more precise” (FGD)“…..GP should maintain their community health, so they should diplomatically speak to their community, and do more preventive tasks…”  (FGD)For decades, General Practitioner accepted rewards from their patients, which came from patients’ out of pocket payments. They could only accept a limited amount based on the number of patients each day. The development of the national insurance system has greatly impacted the previous payment system. The new system pays the General Practitioner by a per-capita approach which enables them to accept salary-based income, regardless of the number of patients each day. “if seen from the salary point of view, it seems so little, although now we have capitation. Yesterday, it was said that the earning from the capita will be cut for operational costs of the unit and also for the head of the unit, the nurse….so the doctor will receive only a little” (In depth interview)“From the PHC capitation, per patients they had 11 thousand rupiahs, and each PHC got around 10 thousand people, but I saw the doctor only receive 3 million 3 hundred rupiahs for one month, and I was really surprised because it is not enough for this time to live with that amount, I feel that I was not prepared. Then we should be a GP first, so it took a long time, and we are just worth that much” (FGD)Several negative comments reflected the influence of social hierarchy on students’ perspectives of General Practitioner.“’become a specialist! Why would you become a GP? You will regret it, just like me’……heard from a primary care doctor who complained like that, and was disappointed why they were not becoming a specialist” (In-depth interview)In the past, under the previous health care system, General Practitioner had a special position in the community’s heart. However, recently together with the current universal health care system has caused many sociocultural changes within the community. General Practitioner providing primary care services are now seen as “the means to an end”, or as the main source of referrals to specialists. Some students provided the following evidence.“Patients in my area are actually not in the city but in the village. In my village, our people tend to think why should I go to the GP because it will just cost their money twice if they already know the problem they just decide to go to the internist or pediatrics” (In-depth interview)“The community trusts the specialists more, and have greater preference to go to specialist if they get ill which might be not necessarily like that because it might be that they only need GP level competency….” (FGD)“My parents’ opinion is different, they see GP life is so miserable, and they see specialist is much better” (FGD)“If just me, I do not have national insurance coverage, so if I want to have health care service, I will just go to specialist, if I go to GP, they will refer me anyway. So many just like me, if they got ill, they just go to the specialist. Also, besides they should have a long queue, I think that is why they choose to directly go to specialist” (In-depth interview)We identified the same themes from the online survey questionnaire as we did with the first content analysis, which described the responses from the Focus Group Discussion and personal interviews, as illustrated in In the online survey, we found that 70% of the students are not interested in becoming a General Practitioner. We captured this phenomenon by a simple quote shared by many students who had low motivation and were not willing to become a General Practitioner.“it is just because of low rewards, unspecific science, and big responsibility.” (e-survey)From 2,204 students who took part in the national exit exam, 81% completed the online survey questionnaire with only a small percentage of missing data. There were 1,674 fully completed online survey questionnaires, predominantly by female students (60%), with 75% from urban areas and 87% not married yet.In this study, each part of the quantitative analysis had some missing data, involving from 0.1% - 11%, except the identity part. Interestingly, data on ‘determining factors for their career pathway’ had below 5% missing data. As shown from the data pattern, when the students were asked about their preference of work, they did not give firm answers, but when asked about factors that influence the decision of their career pathway, they gave a firm answer. These contradictory patterns showed that the students were not really sure about their own working expectations and future career decisions.Students’ perspectives on their career in medicine in a working place are shown in Preference of working type is one of the influential factors for students to choose their career pathway. As a result, students’ working type preference is dominated mainly by expectations for a positive work-life balance, using more technology, more procedural protocols, teamwork, involving not too complicated cases, and having more patient interaction.The most significant external influencing factor on students’ determination of career pathway is their educational phase, as shown in Data from this study indicate that General Practitioner is not a preferred career pathway for most medical students who are recently graduated. As expressed by one participant, ‘General Practitioner (GP) is not a destination but a destiny’. The students still have mostly positive views of General Practitioners, but they prefer to choose another career pathway. In line with their medical career pathway’s perceptions and preferences, most students plan to work as a GP for only 2-3 years. If there is a chance, they prefer to pursue a position as a hospital specialist or complete a master’s degree rather than staying as a General Practitioner for the rest of their career. This particular point of the results will influence the number of General Practitioners in Indonesia which are necessary for maintaining the current community health care system, especially in a country that has no graduate Family Medicine or General Practitioner specialist training. General Practitioners are essential in developing an effective and efficient health care system since they deal directly with the community and are on the front line in deciding the most effective care management for the people in their community.,Although students’ motivation to choose GP as their career pathway is low, students’ perspectives of General Practitioners is still a respectable career. Moreover, most of them also hope for a positive work-life balance. This balance is one strong reason which encourages medical students to choose GP as their career pathway.In contrast, one strong reason for students not to choose General Practitioner as their career pathway is the low scientific character of the discipline as was also mentioned by Lambert (2012).Moreover, a piece of supporting evidence that reflected the community voices in Indonesia was also revealed a low level of trust between patients and primary care doctors.,As students begin to work in the real world, there is the possibility that they will choose General Practitioner as their career pathway since their expected future work environment does not yet motivate them. Responses also showed that working status, in-dependency-responsibility, research opportunity, networking, serving community, and career development are not the main factors that will influence them to determine their works’ specialty, as well-described in previous studies.,Additionally, from an educational point of view, exposure in rural/remote areas tends to have a positive influence on students to choose General Practitioner as their career pathway.Further research regarding developing a good educational system in nurturing students’ motivation for becoming General Practitioners should be generated through either community-based education or community-oriented education. Furthermore, further study is to respect and listen closely to the voices from the community regarding the primary care system in Indonesia. As consequence, a wider - more comprehensive scope of primary care research is still needed in order to develop a better universal coverage system.In a country without a further developed career pathway as a General Practitioner, like in Indonesia, choosing General Practitioner as a firm career is still not preferable for most medical students. Educational strategies could promote General Practitioner as a viable career pathway in order to provide a sufficient number of qualified General Practitioner for Indonesian people by providing good role models of General Practitioners and exposing students to remote/rural areas. Meanwhile, a more positive environment within the health worker community should be established in order to maintain the current system, i.e., helping the General Practitioners maintain the health care system to work effectively as an essential care coordinator within the system and providing proper rewards for General Practitioner for their delivered services.We are thankful for Prof. Tri Nur Kristina and the UKMPPD team of the national exit exam who gave opportunity for this study to distribute the online questionnaire.The authors declare that they have no conflict of interest.


For women, being employed , engaging in physical activities (exercising) , having good health , having multiple sexual partners , and taking alcohol  were associated with use of aphrodisiacs. Although many participants had used aphrodisiacs, women, in particular, held unfavourable views about the drugs due to perceived negative health implications for themselves and their partners. The findings also show that community-level factors , interpersonal factors , public policy , and organisational/institutional factors  were critical to the sale and use of aphrodisiacs among both men and women in Ghana. A multi-level analysis of the use of sexual enhancement drugs among men and women is crucial to formulating social and public health policies that aim to improve public knowledge of these drugs, reduce uncontrolled production, and protect population health and well-being.The use and sale of sexual enhancement drugs (particularly unapproved aphrodisiacs) have become a public health concern in Ghana and many other sub-Saharan African countries. While most studies have examined this phenomenon from the level of individual perspectives, this study investigates the multi-dimensional and multi-level factors  that influence attitudes, perceptions, and use of aphrodisiacs among men and women in Ghana. Using a concurrent mixed-method design, we derived the data from a semi-structured interview and cross-sectional survey conducted across five administrative regions in Ghana. Interpretative phenomenological analysis and logistic regression techniques were used to analyse the qualitative and quantitative (survey) data, respectively. Approximately 12.6% of participants  had used an aphrodisiac in the six months prior to the study. Approximately 23.4% of the participants had more than one partner during the same period. Among men, being religious (B = −0.238,  Research reports show that an increase in unfulfilled sexual desires and sexual dysfunction globally has led to a rise in the prevalence and use of approved and unapproved aphrodisiacs/sexual enhancement drugs in many places ,2. AlthoThe reasons for the use of aphrodisiacs among men and women tend to be similar across SSA. These reasons include the desire to prolong sexual intercourse, increase sexual desire and satisfaction, and enhance aggression during sexual intercourse ,10,11. ADespite the increasing demand for and use of aphrodisiacs and their potential undesirable effects, public knowledge of using such drugs remains understudied and thus requires further interrogation . RecentlMost studies in Ghana have explored the prevalence of aphrodisiacs, the influence of masculinity on the use of aphrodisiacs, and women’s experience of sexual pleasure, either from quantitative or qualitative perspectives ,13,19,20While this study enriches existing knowledge about aphrodisiac use, it also contributes to the ongoing fight against the proliferation and use of unapproved recreational drugs and risky sexual practices by providing insight into public attitudes and gendered perspectives on aphrodisiacs ,13. ConsTo understand the dynamics of the prevalence and use of aphrodisiacs in Ghana beyond individual characteristics and behaviours, the study uses the social–ecological model of health and health behaviours ,26 as a Aside from these intrapersonal elements, forces outside individual beliefs and characteristics influence behaviours and decisions about aphrodisiac use. From the social–ecological model, one of them is interpersonal relationships, which deals with how social relationships affect the perception of health problems and decisions about how to address such problems and behaviours on specific treatments and drugs . People The organisational aspect of the social–ecological model describes the characteristics and operations of social institutions and their role in population health and well-being . It inclThis study is part of a concurrent mixed-method cross-sectional study that examines the social aspects of health and well-being among young and adult Ghanaians. This study draws data from the larger research work conducted in 2018 across five of the then ten administrative regions of Ghana using a multi-cluster sampling approach. The five regions  and their communities were selected purposively to ensure geographical and socio-economic balance across the country. Likewise, 29 districts and 128 communities  across the five regions were purposively selected due to their relevance to this study. The inclusion criteria comprised religious and ethnic composition, geographical balance, sex, and socio-economic characteristics of residents in the areas, which were obtained with the help of the 2012 population and housing data and living standard survey reports ,31. A syHowever, the qualitative data were gathered from four regions: the Ashanti, Brong Ahafo, and Greater Accra regions. An interpretive phenomenological approach  was usedParticipants were asked to respond to the statement “I have taken aphrodisiacs prior to or during sexual encounters in the past six months” on a four-point Likert scale ranging from “never” to “always”, with the fifth option being “not applicable”. Trained interviewers explained the question with specific examples to participants. Either conventional or non-conventional forms of aphrodisiacs were emphasised.These variables comprised primarily intrapersonal factors such as age (in years), monthly income/stipend, subjective socio-economic status (rated from 1 = low to 10 = high), and religiosity, which measures “one’s pious conformity to a religion through practice and conduct ” . ParticiThe covariates included region of residence, rural or urban residence, marital status . and whether a person had had sexual intercourse in the past six months (yes/no).In order to provide an in-depth perspective on the research topic, a side-by-side technique was employed for the data analyses. By this approach, the results of the quantitative and qualitative aspects of the data were presented separately but interpreted together .p < 0.000), Spearman’s rank correlation analyses were conducted to include only independent variables that correlated with the dependent variable in the regression analyses. However, marital status was included in the regression analyses regardless of its correlation with the dependent variable. This was because sexual relations in the Ghanaian society are culturally considered as the preserve of married couples . People cannot have sex with their partners, so they take drugs…” . The use of these drugs among women was often to meet the expectations of their partners. To some extent, the participants’ views pointed to a social practice where women were expected or even obliged to satisfy the sexual needs of their partners. Women often use drugs to boost their libido and satisfaction and make their private parts extra sensual for their partners. The women felt that consuming these drugs was important to please and show gratitude to their partners. For example, a male participant said, “It’s the same because some women are weak [sexually]. They have no sexual feelings, so those drugs enhance their desire.…” . Another male participant supported this view by saying that “Some women take the drugs just to impress their men. …Maybe a man has bought a woman a car or built a house for her …” .Both men and women also attributed the use of aphrodisiacs to the cultural and social expectations that men must be strong in bed—lasting longer during sex and having above-average manhood size. Hence, interpersonal reasons such as avoiding ridicule by the opposite sex or peers encouraged some people to take aphrodisiacs to address these specific personal needs. As illustrated by a female participant, “Some men take drugs to increase the size of their manhood” . A male participant also supported this view, “A man has to be strong. it’s a disgrace if you’re sexually weak” . Consistent with the need to avoid disgrace and ridicule because of poor sexual performance, some participants felt that the urge to take the aphrodisiacs was because of sheer “wickedness”—having a “punitive” or “revengeful” mindset —among some men. As indicated by some female participants, “Some of the men are wicked. They believe that if their ladies show pain during sex, then they are ‘men’” . Another also suggested that “Some men spend money on girls without being able to have sex with them, so when the girl becomes available, they take the drugs to have their money’s worth” . The above reasons resonate with other facets of community factors. Some participants attributed the rise in aphrodisiac use to decaying societal morals—disregard for social and behavioural norms. They claimed that promiscuity had become a lifestyle in the Ghanaian society, which was one of the underlying factors for aphrodisiac use: “I think fornication and adultery have become rampant. Women want to try different men … so the men fear losing their women. Because of this, the men go for those drugs” . To many participants, the decaying morals were also connected to a rise in advertisements about aphrodisiacs. They intimated that advertisements and peer pressure underpinned the desire of many people to try aphrodisiacs regardless of their condition, as exemplified in the following extract: “Previously, aphrodisiacs were not advertised; people just knew about them. But now, there are adverts on radios and televisions everyday…even if a person is fine [sexually], they’ll be tempted to try because of the adverts…” . A male participant added, “Some also take advice from friends when they [the friends] recommend the drugs to them” .Perceptions and attitudes towards the use of aphrodisiacs differed depending on the gender, marital status, and age of participants. Thus, intrapersonal factors were the primary reasons for people’s attitudes and perceptions. Two groups were identified: one having a more favourable attitude towards such drugs and therapies, while another vehemently opposed them. In general, women, and some men, did not have many favourable perceptions of aphrodisiacs. Some women felt that these drugs were unnecessary for sexual relations as they brought pain instead of pleasure to women. Some of them were even willing to divorce/reject their partners who used aphrodisiacs. For example, one female participant said, “If I see [that a partner is using aphrodisiacs], I’ll leave him the same day…” . A male participant supported this view: “I won’t take it [even if my partner requests aphrodisiacs]. It’ll destroy my sex life in the future…she can leave; I came to this world alone” .Some also disliked aphrodisiacs due to their momentary effect and the economic implications of indulging in them. In one interview, a female participant rhetorically said, “That means you have to take drugs whenever you have sex. So, what happens if you don’t have money for the drugs?” . Even those who held positive attitudes toward aphrodisiacs were concerned about the abnormal physical effects of the drugs. Hence, they were cautious about using aphrodisiacs themselves or encouraging their partners to do so, especially the unapproved ones. At worst, some women suggested that they would instead encourage their partners to see a qualified doctor for help. Some women also believed that the only condition that would make them maintain a relationship with a sexually weak man was if they were married. Otherwise, they were willing to end their relationships. For example, one female participant stated, “…if you last seconds during sex, I will tell you to get a drug but not the one that rapidly increases your performance. … It’s better to see a doctor” . Another added, “…if you’re not my husband, I’ll leave [if a partner is not ready to take aphrodisiacs] because nobody likes a non-performing man” . With regard to men, some perceived it as a sign of affection if their partners suggested aphrodisiacs to them to overcome their sexual weakness: “If she doesn’t love you, she won’t tell you to seek help…. It may be because of something else she wants from you, but a lady who loves you will tell you” .In addition to the intrapersonal factors, community norms, beliefs, practices, and expectations about sexual behaviours and sexual relationships shaped participants’ perceptions and attitudes about aphrodisiacs and all sex-related activities. The participants had conservative attitudes towards sexual acts and topics, even among married people. Some married participants felt that aphrodisiacs were the preserve of single people and expressed abhorrence towards the use of sex enhancement drugs: “All these [use of aphrodisiacs] are done by unmarried men. Married men would never use such a stupid drug” . Additionally, the conservative socio-cultural norms meant that women were hesitant to discuss issues about sexual enhancement drugs with their partners: “…some women think they’ll be divorced/jilted if they discuss sexual performance and those drugs with their partners. They are afraid of being tagged as promiscuous by their spouses” .Participants’ attitudes towards aphrodisiacs were associated with perceptions about what the use of the drugs would do to their health, especially unapproved drugs. Both men and women expressed concerns about the potential long-term effects of aphrodisiacs, including abnormal erection, consequential illness, and even death. As one female participant narrated a friend’s story, “A friend used to take certain tablets before having sex. He’s only 46 years, but he has stroke now. …Another person took tramadol to have sex, and he became very weak …he died later at a hospital” . In their view, the main reason that many people continue to use unapproved substances is a misunderstanding of the potential side effects of some drugs, as well as impatience with periods of low sex drive and performance (we elaborate more on this issue under the next theme): “Some women don’t know that those drugs have side effects; that is why they push their partners to take them. They also have to be patient and understand that a man can’t perform well every time…” .Given these misunderstandings and impatience, some took all kinds of aphrodisiacs regardless of the health implications because they feared being divorced/rejected by their partners. One male participant also shared his friend’s ordeal: “A friend of mine takes it, and his penis will still be erect even after the sex. He says the girl likes it…” . The health concerns also emerged from the misuse of drugs approved for purposes other than improving sexual performance and satisfaction: “Like tramadol…. It has its purpose, but some men buy it for sexual performance” . Moreover, participants who had reservations about the stigma and health implications of aphrodisiacs preferred to use herbal or homemade remedies instead. Such remedies were perceived as safer compared to unapproved imported therapies: “I think the herbal ones are better. The foreign drugs can reduce the size of your penis” . However, there were indications that even the revered herbal drugs, including homemade ones, could have severe adverse effects, as some participants attested: “I know a herbal medicine that someone took and had an erection for about three hours” .Another intrapersonal factor relating to the use of aphrodisiacs had to do with the public’s knowledge, skills, and experience when it comes to such drugs. Some participants felt that the health consequences that people suffered by taking some sexual enhancement drugs were often due to limited knowledge of the substances, particularly regarding the dosage and side effects. For instance, one female participant indicated, “I know about three people who were taken to the hospital after taking tramadol to have sex. Some of them had no idea of what it was when they took it… they only knew it makes them perform better” .The attitudes and stigma attached to certain sexual relations  compelled females, in particular, to be less curious and forthcoming about their sexual desires and preferences, leading to low knowledge of safe sex and sexual needs. As presented earlier, some participants claimed that being open about their sexual desires was considered promiscuous, which discouraged even males from learning about sexual issues, including aphrodisiacs. Apart from the socio-cultural dimensions, participants felt that people indulged in unapproved and unprescribed aphrodisiacs mainly because they had less regard for their health as they prioritised pleasure over healthy lives: “Some people want instant satisfaction, not what will happen to them in the future” . The participants widely acknowledged that low sex education was a major reason for the uptake of “needless” drugs. They alluded to limited knowledge among both men and women on ways to satisfy their partners without the use of drugs as the reason for which people indulge in aphrodisiacs: “…the number of ‘rounds’ [sexual intercourse] doesn’t matter … But many men don’t know this, so they use drugs…” . This was supported by a female participant, who shared that “Many women apply vaginal creams and other drugs because they don’t know how to prepare themselves for sex. …Many men don’t know that a woman’s orgasm is different from a man’s… It all boils down to education” .This study has examined the correlates, perceptions, and implications of aphrodisiac use among men and women in Ghana. The study argues that the prevalence, utilisation, and perceptions about aphrodisiacs are associated with interactive factors located at the micro, meso, and macro levels of society .The findings show that both men and women in Ghana commonly and frequently use aphrodisiacs. Participants attributed the proliferation and increasing use of aphrodisiacs to lapses in current regulations, community norms and practices, and individual behaviours. At the individual and community levels, the proliferation and increasing use of aphrodisiacs can be attributed to changing sexual awareness, curiosity, and overall behaviours among men and women. While the predominant cultural position on sexual relations is considered conservative, the prevalence of these drugs reflects an increased demand for them, as participants in this study asserted, and has been argued elsewhere ,12. AlthAlthough individualised practices and decisions to engage with sexual enhancement drugs remain personal, the extent of such choices depends, to some degree, on the prevailing public policies relating to food and drug production, importation, and advertising. The significance of public policies in regulating the availability and use of sexual drugs is demonstrated by calls for governments to ensure the safety of available therapies proactively . As evidAs revealed by this study, the reasons for using aphrodisiacs do not deviate markedly from those reported in existing studies in Ghana and globally across genders. The reasons include the stimulation of sexual urges, the desire to prolong intercourse, the wherewithal to initiate sex, the need to meet the expectations of partners, to increase the size of genitals (among men), and to enhance satisfaction for the users and their partners ,11,44. HConsistent with the intrapersonal and community aspects of the social–ecological model, women were found to use aphrodisiacs because of perceived benefits to their partners. While such practices and attitudes may be the desire of some women, they are also likely to experience the consequence of long-held notions of patriarchal and legal systems that often dominate women’s sexualities and reproductive issues: “the capacity of African women to control their sexual and reproductive lives and to break free from the chains of domesticity is continually curtailed by law, culture and religion” . This stHowever, women who were employed were less likely to use aphrodisiacs than those who were unemployed. Unemployed women primarily include young adults, who are less likely to be in steady or long-term relationships that may encourage them to try aphrodisiacs. Indeed, young women are less likely to take drugs such as alcohol because of prohibitive religious and socio-cultural issues . An alteA common determinant for both men and women regarding aphrodisiac use from the quantitative analysis was that those with multiple sexual partners were more likely to use aphrodisiacs than those with fewer or single partners. This finding is not surprising considering the recreational “fun” use of aphrodisiacs . People The decision to use and the type of aphrodisiacs that people used were connected to participants’ understanding and knowledge of the effect of aphrodisiac use on their health. While studies in Ghana and other sub-Saharan African countries have shown the benefits of several aphrodisiacs in battling sexual problems such as erectile dysfunction , many paNotwithstanding the public policy and health system weaknesses that encourage access to aphrodisiacs, negative health experiences can be attributed to intrapersonal factors such as inadequate health literacy among the adult population, especially women, as reported in other studies ,48. HealIn our study, participants attributed the need to use aphrodisiacs to poor health, which results from poor diets. Evidence suggests that poor health and chronic diseases are associated with the use of aphrodisiacs to overcome dissatisfaction with sexual performance. This is especially the case among men, as found in China . Such a In contrast, it was found that healthy women were more likely to use aphrodisiacs than unhealthy ones. Women are reluctant to engage in certain sexual conduct when they suspect poor environmental hygiene and personal health in either themselves or their spouses . This inThis study has used qualitative and quantitative data to examine the multi-level factors that influence the use of aphrodisiacs among men and women in Ghana. The study found that different kinds of sexual enhancement drugs were commonly used, especially among men. Analysis of the differences and similarities between men and women provided evidence of individual characteristics  associated with the use of aphrodisiacs from the survey analyses. The qualitative data indicated a critical role of community factors , interpersonal factors , public policy , and organisational/institutional factors  in the use of aphrodisiacs among men and women. Although many participants, particularly women, had used aphrodisiacs, many of them, particularly women, held unfavourable views about the drugs due to perceived and experienced negative health implications for themselves and their partners. We argue that such perceptions and experiences may be influenced by the prevalence of unapproved drugs and inadequate knowledge about the different categories of these drugs and how they work. Cross-national collaborations are needed to eliminate adulterated products to protect the public from undesirable outcomes, particularly among men, as they use aphrodisiacs more frequently than women.Altogether, these findings and the ensuing discussions reiterate the importance of understanding the use of sexual enhancement drugs among men and women from a multi-level perspective. Efforts to educate the public and regulate the production and use of these drugs should involve individual experiences, prevailing social norms, and a review of the health system arrangements and policy guidelines on these drugs. Such multi-level effort can help to improve public knowledge of these drugs and reduce the proliferation and utilisation of unsafe drugs. In the long term, such an approach will contribute to improving the health and well-being of the population.This study used a mixed-method approach to examine the multi-level factors that influence the use of aphrodisiacs among men and women in Ghana. While this study expands on the current knowledge of the topic, some precautions must be observed in the interpretation and application of the findings. First, the study used cross-sectional data, which means that the findings only depict how participants felt at one point in time. Because of this, causal inferences cannot be drawn from the findings. The survey data did not include information about the characteristics of the aphrodisiacs that participants chose to use . Controlling these factors may have yielded different results. However, our qualitative data have addressed some of these limitations by offering insight into why people use these drugs. This justifies the confidence in the overall findings. Indeed, the findings are consistent with and add new perspectives to several existing research works. The study thus contributes to the ongoing discourse on promoting healthy sexual behaviours from multi-level and gender perspectives.


Based on the classic theory of the communication of information, the “5W” communication model, this article aims to build a new model and thus explains the generation and communication of Internet health rumors. (2) Methods: The authors selected 50 Internet health rumors, which were widely spread in widely used websites and social media in China, then grounded theory is used to perform the qualitative analysis of the Internet health rumors. (3) Results: Three Core Concepts are abstracted after qualitative analysis. An internal dynamic mutual assistance mechanism of the communication of rumors is built and illustrated. Based on Lasswell’s “5W” communication model, the authors develop an eight-element communication model for Internet health rumors to illustrate the generation and communication of Internet health rumors. (4) Conclusions: By removing one or several elements of this new model, the chain of the communication of Internet health rumors could be cut off, which is valuable information for the government or websites to manage communication of Internet health rumors. We are surrounded by health rumors. When a pandemic rages, health rumors spread even more rapidly. The COVID-19 pandemic is the most recent example. Compared with traditional rumors, Internet rumors are characterized by faster spreading, wider influence, greater social harm, higher professionalism, greater concealment, and larger temptation. The Internet is gradually becoming an important platform for people to gain health information that is easily made up and spread. Against the backdrop of the “Healthy China” strategy, the governance of Internet health rumors has become one of the difficult problems faced by the Chinese government. The Chinese government has strengthened the governance of Internet rumors, but there are many problems with rumor control.This study focuses on the micro-level of Internet health rumors to profoundly explore the flexibility and applicability of the 5W communication model based on three questions, “How are Internet health rumors generated?” “How are Internet health rumors spread?”, and “How do elements of the generation and communication of Internet health rumors interact with each other?” A new theoretical communication model is constructed to answer the questions about Internet health rumors.As stated in Webster’s Dictionary of the English Language, rumor refers to gossip, talk, or opinion without a discernible source or known authority for its truth. With rumors in Massachusetts as the case, Knapp initially studied the causes, consequences, and control strategies of rumors . The proAmong the Internet rumors, health rumors are the worst. False information spreads significantly farther and faster than true information does . Health The Structure and Function of Communication in Society [The 5W communication model provides a theoretical basis for explaining the propagation mechanism of Internet health rumors. The spread of Internet health rumors is a subdivision of information dissemination. When it comes to information dissemination, it is necessary to mention the well-known “5W communication model”. American sociologist Harold Lasswell officially put forward the “5W model” in his book  Society . The “5W Society . Biagi  Open coding is the initial stage of constant comparative analysis, before delimiting the coding to a core category and its properties . (2) SelIn this study, the coding technology of the grounded theory is applied in two aspects. First of all, open coding is conducted by labeling the content related to the basic theme in the text materials and recording the feelings after reading the text materials. Secondly, selective coding is to sort and classify the labels, refine the key factors of the generation and dissemination of Internet health rumors, and summarize the internal relationships among the key factors.A unified standard improves the validity of qualitative research. The research team formulated a detailed coding guideline through discussion and selected two analysts to code separately by following the coding guideline. The cross-validation shows that 90% of the nodes coded by the two analysts are consistent. Code comparison verifies the reliability of the qualitative study. The coding nodes achieved full coverage of the 50 Internet health rumors from 2014 to 2019, and no new nodes appeared, which indicated high validity of the coding results.After open coding, the text materials are summarized as 55 Primary Concepts see . The gro“Correlation” is the prerequisite for the generation of Internet health rumors. The public’s actual demands for health information have led to the generation of Internet health rumors. Based on the results of open coding, regarding the groups of people that are targeted, Internet health rumors related to children’s health are responded to most frequently, with such rumors being encoded 45 times among the 13 text materials. Regarding the fields of the health issue involved, the highest response frequency was found in Internet health rumors about food safety, with such rumors being encoded 65 times among the 17 text materials . The fre“Credibility” guarantees the generation of Internet health rumors. The Category Concept “Faking real information” is a common trick for generating Internet health rumors, the Category Concept “fuzzy truth” is a necessary condition for generating Internet health rumors, and the Category Concept “Claiming as reliable information” makes Internet health rumors more mysterious. As early as 1947, the generation of rumors was proportional to the importance and fuzziness of events. Credibility directly determines the “quality” of Internet health rumors.The ultimate goal of rumor mongers is to spread Internet health rumors. From the selective coding results, the Core Concept “Communication” involved 49 text materials and is encoded 713 times as the most frequently encoded core category. Moreover, according to the coding frequency of 50 text materials in the core category matrix, except for “Claiming as reliable information”, Core Concepts “Correlation” and “Credibility” highly frequently respond to the concept “Communication” as shown in The spread of Internet health rumors mainly refers to duplication and variation. First of all, duplication needs to attract the attention of the public, with the eye-catching headline being the most representative approach. Secondly, it is necessary to meet psychology of the public. When people are anxious about topics related to themselves, they create and spread rumors . Fear ofCorrelation, Credibility, and Communication are the three key factors of the generation and communication of Internet health rumors. Correlation, as the source power, triggers Credibility if people have great demands for health information but insufficient knowledge about health. Credibility promotes communication. Studies have shown that high credibility increases trust and the intention to share rumors . CredibiThe Internet environment diversifies the elements of the generation and communication of Internet health rumors. Internet health rumors cannot exist independently in Internet environment, and their generation and communication are deeply influenced by the external environment, especially in the era of “new media”.The Structure and Function of Communication in Society. “5W” represents “Who”, “What”, “In Which Channel”, “To Whom”, and “With What Effect” . In addition, mutual confirmation between receivers is another factor that promotes the extensive spread of rumors. Apart from arousing the attention of receivers, Internet health rumors also have to make themselves convincing among the targeted receivers to achieve the purpose of communication. As pointed out by Kapferer, there are three conditions for rumors to be convincing: a) the source of information is reliable, b) the information should be what people expect and want to know, and c) the information should sound real . The Cat“With What Effect” is the effect or result of the generation and communication of Internet health rumors. A specific scenario is that the receiver reads (or does not read), believes (or does not believe), and spreads (or does not spread) the Internet health rumors. Based on the result of this study, Core Concepts are abstracted, namely, Correlation, Credibility, and Communication. Whether people read, believe, and spread an Internet health rumor is based on the three Core Concepts. These three Core Concepts constitute an internal dynamic mutual assistance mechanism for the generation and communication of Internet health rumors, which explains the generation and communication of Internet health rumors.Therefore, Rumor Mongers, Rumor Refuters, Internet Health Rumors, Rumor-Dispelling Information, Hot Events, Media Channels, Receivers, and Effect constitute the eight elements throughout the generation and communication of Internet health rumors as shown in Coupling refers to the phenomenon that two or more systems or two forms of motion influence each other and even unite through interaction . The keyFrom the perspective of the system boundary, the eight-element communication model includes internal and external coupling. The internal coupling refers to the internal dynamic mutual assistance mechanism mentioned above among the three elements, namely correlation, reliability, and communication. Internet health rumors are “time bombs”. Once rumors are contacted by the receivers, the internal dynamic mutual assistance mechanism of Internet health rumors starts to work, and the receivers make the following choices: (a) unrelated → filter, (b) related → unreliable → filter → rumors memo, (c) related → reliable → not to spread → filter → rumors memo, and (d) related → reliable → spread → related. External coupling refers to how the seven elements interact with each other and with an internal mutual dynamic assistance mechanism. Whether people read (or do not read), believe (or do not believe), and spread (or do not spread) is determined by correlation, credibility, and communication, respectively. Therefore, the eight-element communication model is illustrated as follows: (a) rumor mongers → Internet health rumors → receivers → not to read, (b) rumor mongers → Internet health rumors → receivers → read → not to believe ← rumor-dispelling information ← rumor refuters, (c) rumor mongers → Internet health rumors → receivers → read → believe → not to spread ← rumor-dispelling information ← rumor refuters, and (d) rumor mongers → Internet health rumors → receivers → read → believe → spread ← rumor-dispelling information ← rumor refuters. The relationships are shown in From the perspective of the development process, the eight-element coupling model includes the prelude to coupling, the occurrence of coupling, and removing coupling. Prelude to coupling refers to the stage in which the Internet health rumors made up by rumor mongers have not reached the receivers, that is, rumor mongers → Internet health rumors. At this stage, there is no coupling effect among the eight elements. The coupling effect is imminent because they aim at specific populations such as kids, women, or elders. Once rumors reach the receivers, the coupling effect occurs. The occurrence of coupling is the stage in which the Internet health rumors made up by rumor mongers have reached the receivers and produced certain effects, that is, rumor mongers → Internet health rumors → receivers → effect. The coupling effect is manifested as reading, believing, and spreading. According to the influence of the coupling effect, rumor refuters fight against rumor mongers and Internet health rumors by releasing them at different degrees. Removing coupling refers to the rumor-dispelling information. From the perspective of development, the three stages of the eight-element coupling model can be summarized and simplified as rumor mongers → Internet health rumors → receivers → effect ← rumor-dispelling information ← rumor refuters .From the perspective of the number of elements, the eight-element coupling model includes weak coupling, regular coupling, and strong coupling. Weak coupling refers to the coupling phenomenon with incomplete main elements  and the incomplete relationship between elements without intervention elements (hot events and media channels), e.g., rumor mongers → Internet health rumors → receivers → effect. Regular coupling refers to the coupling phenomenon with complete main elements  and complete relationship between elements but without intervention elements (hot events and media channels), e.g., rumor mongers → Internet health rumors → receivers → effect ← rumor-dispelling information ← rumor refuters. Strong coupling refers to the coupling phenomenon with complete main elements , the complete relationship between elements, and intervention elements (hot events and media channels), as shown in In summary, the relationships among this eight-element communication model from three perspectives are illustrated. Based on this, the research team proposed the idea that the approach to the governance of Internet health rumors is to break the relationship among the eight elements.Information source determines the origin of rumors, and also becomes a key factor in evaluating the credibility of Internet health rumors, which has a significant impact on the popularity and duration of Internet rumors of public events. The professionalism of the rumor monger and the authority of the platform for Internet health rumors directly affect whether the Internet health rumors would be read, believed, and spread. Therefore, only by tracking the information source and taking targeted measures can the Internet health rumors be effectively eliminated or reduced. At the same time, the government should pay close attention to hot issues in the health field to avoid or reduce the generating and spreading of health rumors on the Internet. For example, new Internet health rumors have surged since 2020, such as COVID-19, related medicine, and related vaccine. Regarding channels for communication of Internet health rumors, news media, social media, and other platforms should be hold accountable if they have no policy or actions for controlling Internet health rumors. The spread of some Internet health rumors could be cut off by those channels. The government should strictly monitor and control the channels and media for releasing and disseminating Internet health information, establish a regular governance mechanism, and conduct emergency management for the possible wrong and misleading public Internet health information.The government often plays the key role of “rumor refuter” in rumor control, and the credibility of the government is the key to effectively dispel rumors. If the government’s credibility is vulnerable, it may fall into the “Tacitus trap” , in the process of releasing refuting rumors on the Internet. In the field of health information communication, the credibility of the government is mainly reflected in the timeliness and transparency of Internet health information. In order to avoid falling into the “Tacitus trap”, the government should actively build professional Internet-health-rumor-refuting think tanks and platforms to timely and effectively popularize correct health information. It is essential to take advice from professional scientific research institutions and acquire assistance from news media, so that the Internet health information would be professional, authoritative, and timely. Only a combination of multiple ways can prevent the growth and spread of Internet health rumors to the greatest extent.Improving literacy of health information of the public can enhance their immunity to Internet health rumors, so that it would fundamentally reduce the credibility and block dissemination of Internet health rumors.Especially, it is necessary to enhance the scientific communication for vulnerable groups, such as children, women, and the elderly. Additionally, scientific communication should specifically aim at the key health issues, that is, food safety, environment issues, and diseases.In addition, “minority” opinions of Internet health information communication should also be taken into account. The spiral theory of silence holds that when people’s opinions belong to “minority” opinions in the public opinion, they tend to keep silent to avoid isolation. In the field of health information communication, opinions of “minorities”, especially those of professionals, cannot be ignored. How to make professional Internet health information become “dominant opinions” is also a problem worth further consideration.By analyzing 50 text materials of Internet health rumors based on grounded theory, three Core Concepts are abstracted, that is, Correlation, Credibility, and Communication. The internal dynamic mutual assistance mechanism among these three concepts is illustrated. Based on the feature, changes, and trends of the Internet, Lasswell’s 5W communication model needs to be reexamined and expanded. Thus, five elements are expanded to eight elements, namely, rumor mongers, rumor refuters, Internet health rumors, rumor-dispelling information, hot events, media channels, receivers, and effect. The eight elements are combined in different forms. The eight-element communication model is viewed from three perspectives. The relationships among eight elements are explained and illustrated to reveal the complicated process and internal mechanism of the generation and communication of Internet health rumors.Compared with the linear mechanism of the 5W communication model, this model develops the process of generation and communication of Internet health rumors. In addition, it is the application of the 5W communication model at the micro level. The significance of this study is that cutting off the chain among these eight elements may eliminate or weaken the harm and impact of Internet health rumors. Thus, it provides the practical reference value for the government to control Internet health rumors. This article also proposes three strategies for governing Internet health rumors from three perspectives, that is, rumor mongers and the channels, rumor refuters, and rumor receivers. By governing the Internet health rumors from multiple ways, Internet health rumors could be reduced or blocked timely and effectively in the future.


Risk and loss aversion are phenomena with an important influence on decision-making, especially in economic contexts. At present, it remains unclear whether both are related, as well as whether they could have an emotional origin. The objective of this review, following the PRISMA statements, is to find consistencies in the genetic bases of risk and loss aversion with the aim of understanding their nature and shedding light on the above issues. A total of 23 empirical research met the inclusion criteria and were included from PubMed and ScienceDirect. All of them reported genetic measures from human samples and studied risk and loss aversion within an economic framework. The results for risk aversion, although with many limitations, attributed mainly to their heterogeneity and the lack of control in the studies, point to the implication of multiple polymorphisms related to the regulation of the serotonergic and dopaminergic pathways. In general, studies found the highest levels of risk aversion were associated with alleles that are linked to lower (higher) sensitivity or levels of dopamine (serotonin). For loss aversion, the scarcity of results prevents us from drawing clear conclusions, although the limited evidence seems to point in the same direction as for risk aversion. Therefore, it seems that risk aversion could have a stable genetical base which, in turn, is closely linked to emotions, but more research is needed to answer whether this phenomenon is related to loss aversion, as well as if the latter could also have an emotional origin. We also provide recommendations for future studies on genetics and economic behavior. According to classical economics, a rational decision-maker would follow the principle of optimization and should always choose the prospect (decision option) with the highest utility ,2. MatheBernoulli ,6 providAn explanation to this anomaly is that human beings do not always act rationally nor follow the strategic decision-making proposed by the classical models . Many ofThere is still a debate on these issues and many economists are trying to accommodate anomalies within the already established, orthodox model to demonstrate that their statements are valid. However, neuroscience is providing increasing evidence that, in fact, risk aversion, framing effect, and loss aversion are part of the same reality, sharing a neural bases and producing similar physiological responses ,18,19,20Moreover, risk aversion is not exempt from individual variability. This heterogeneity seems to depend on multiple factors such as age, gender or level of education, although these only predict a small fraction of the variance in risk-taking . MultiplThe present study carries out a systematic review covering the published literature on genetics and risk aversion (including framing effect and loss aversion given their possibly close links), with the aim of clarifying the debate between the prospect theory and classical economics by shedding light on the question of whether risk aversion is a behavior that fits within the rationality assumptions or, on the contrary, has an emotional origin connected to loss aversion. Our first hypothesis (hypothesis 1) states that there would be a consistent genetic base for risk aversion. On the other hand, (hypothesis 2) states that risk aversion and loss aversion would have a common genetic origin, with both phenomena being connected. Finally, (hypothesis 3) this origin would be related to our affective system.A systematic review of the genetic bases of risk aversion  has been carried out, following the guidelines of the PRISMA declaration  for the The first searches were conducted in November 2021. To obtain an overview of the available results, as well as to see which terms worked best, Boolean operators AND and OR were used, trying different combinations of the following terms: ‘loss aversion’, ‘losses aversion’, ‘risk aversion’, ‘risk avoidance’, ‘risk seeking’ ‘risk taking’, ‘framing effect’, ‘genetic’, ‘genetics’, ‘genetic bases’, ‘gene’, ‘genes’, and ‘polymorphism’. These searches yielded a considerable number of results, many repeated or of little utility, but provided a preview and allowed for us to check that no previous review had been carried out on the topic. As the results of Scopus were the scarcest and did not provide any new studies, they was removed from the systematic search.The systematic search was conducted again in November 2021, in PubMed and ScienceDirect. The combination of terms that yielded the best results in both search engines was as follows: ((“loss aversion”) OR (“losses aversion”) OR (“risk aversion”) OR (“risk taking”) OR (“risk avoidance”) OR (“risk seeking”) OR (‘framing effect’)) AND (“genetic”). Specifically, 186 results were obtained in PubMed and 2684 in ScienceDirect. Before selecting articles, inclusion and exclusion criteria were defined.−Empirical research and not revisions, single case studies, theoretical frameworks, books or manuals.−That specifically and directly report genetic measures .−That use human samples.−That study risk aversion, framing effect, and loss aversion understood within the economic framework.−That measure risk aversion, framing effect, and loss aversion with economic tasks.−Those that approach risk aversion, framing effect, or loss aversion from a far perspective from economics .−Those who use non-economic tasks or use self-reports of risk preferences .−Those that are studied in twins, or in terms of biological aspects, but do not report specific genetic measures.−Those who study risk aversion with Iowa Gambling Task (IGT) . As recen = 6), for using risk measures far from our theoretical framework (n = 12), for not specifically reporting a genetic measure (n = 11) and for not directly studying the relationship between genetics and risk aversion, framing effect, or loss aversion (n = 4). The remaining 18 articles comply with the criteria described above.According to the established criteria, and after only reading the title, 58 articles were considered as adequate (after eliminating sixteen duplicates between the two databases). The abstract was read and, from the identified group, 40 were discarded: for using IGT . Finally, Google Scholar was used with different combinations of the mentioned search terms to check whether any article could have been left out. These searches did not reveal any new relevant studies.Finally, the systematic review includes a total of 23 empirical articles, all of them written in the English language. Nineteen referring to risk aversion; 2 to both risk aversion and loss aversion, and 3 only to the latter. In addition, most used gambling tasks, investment tasks or similar, with the exception of 4, which used the Balloon Analogue Risk Task (BART) , a task The results are summarized in An article (only for risk aversion) , comprehFinally, to avoid over- or under-representing the role that an allele plays in the relationship between genes and risk or loss aversion, possible confusing variables must be controlled. Some examples could be a certain level of impulsiveness, a sensation-seeking personality or suffering from Reward Deficiency Syndrome (RDS). The health and behavioral profile of the participants was included in the results see . HoweverAccording to Harrati , none ofOne of the most-studied candidate genes in relation to risk aversion was the SLC6A4, the only gene that encodes the serotonin transporters (5-HTT), responsible for the reuptake of serotonin from the synaptic cleft . In the Genotyping 32 healthy participants (23 women), the study by Crişan et al.  found thn = 60).A similar result can be seen in Heitland et al. , where sWith 65 participants (48 women), Kuhnen & Chiao  also shoNeukam et al. , with 57Focusing specifically on framing effect, Roiser et al.  pointed Turning again to Crişan et al. , with thn = 83), using a gambling task; in Anderson et al. )Finally, as can be seen from the heterogeneity of the results, and given that they have been published in journals from very different areas , the results do not seem to be particularly affected by the publication bias that favors the publication of positive results. However, given that our approach to risk and loss aversion is framed in the economic field, we must warn of the presence of a specific bias stemming from this.In line with Gao et al. , since rSufficient samples should be included to ensure that the multiple contrasts required have adequate power. More samples imply more effort, but only then will the studies be valuable.It is necessary to control all possible confusing variables that could alter the genes–behavior relationship. Other behavioral and health measurements should be provided, but it would also be useful to rely on neuroimaging techniques and other means to measure or infer the level of neurotransmitters that is available.It should be checked whether the relationship between genes and risk aversion is affected depending on whether tasks or questionnaires are used.To discriminate between risk and loss aversion, it would be advisable to use only tasks whose risk does not include losses.In order to overcome the present limitations of this review, and improve the quality of future studies, they should follow these recommendations:As far as risk aversion is concerned, the studies are heterogeneous, but most of them highlight the polymorphisms involved in dopaminergic and serotonergic neurotransmission pathways. These polymorphisms are related to higher or lower levels of risk aversion depending on the allele they adopt. This supports previous evidence connecting risk aversion to emotions, since the latter are intimately linked to these dopaminergic and serotoninergic pathways. On the other hand, regarding loss aversion, it is too early to draw conclusions and this review should only be taken as a starting point for future studies investigating the genetic basis of loss aversion and its connection with risk aversion. Those studies should follow the recommendations provided in this study to avoid falling back into the same limitations that prevent us from shedding more light on this study field. Whether risk aversion and loss aversion share a common emotional origin is a question that needs to be answered with further research.