Pharmacists considered the protocol complete but felt that not all items should be mentioned/questioned during all conversations. They suggested only subtle modifications to be made prior to delivering a final protocol ready for nationwide distribution. Despite attributing positive effects to having a protocol, no single pharmacist ‘actively’ used it at-the-counter but used it instead as a ‘checklist’ after the encounter. Pharmacists found that the paper-based format of the protocol hindered protocol-based dispensing. Future research is needed to provide evidence on the actual benefits of protocol application, as well as to identify factors influencing the implementation of ECP dispensing using a software-integrated protocol.Community pharmacists in Belgium frequently dispense emergency contraceptive pills (ECPs). However, variable and insufficient counseling practices exist across pharmacies, highlighting the need for standardization and quality improvement strategies. The aim of this project was to develop and test an ECP dispensing protocol for pharmacists. An ‘experience-based’ co-design approach involving academic and practicing pharmacists was applied, followed by a 4-month test period and interviews to assess users’ experiences. In total, eight geographically dispersed pharmacies participated. Pharmacists ( According to the World Health Organization, emergency contraception (EC) refers to “methods of contraception that can be used to prevent pregnancy after sexual intercourse” . The useDespite being less effective as EC , ECPs arUnfortunately, anecdotical reports and preliminary findings have shown that ECP counseling in the Belgian pharmacy setting does not always meet the required quality. In addition, counseling differences across pharmacies exist, underscoring the need for standardization and quality improvement strategies ,8. VaryiTo standardize ECP dispensing and facilitate consistency in the provision of pharmacy-based ECP services, protocols/checklists have been developed in some countries  ,17,18,19Given the increasingly important role of community pharmacists in EC counseling, the potential benefits but current lack of an ECP dispensing protocol, and the suboptimal quality of ECP counseling in Belgium, efforts were needed to pursue and contribute to the standardization, optimization, and quality assurance of EC(P) counseling. Therefore, a project was set-up, in collaboration with the National Pharmacists Association (APB), to develop and pilot test an ECP dispensing protocol for community pharmacists in Belgium.The project consisted of three consecutive parts, i.e., (1) development of an ECP dispensing protocol; (2) pilot testing of the ECP dispensing protocol; and (3) protocol optimization based on users’ experiences. First, an ‘experience-based’ co-design approach involving pharmacy practice researchers and practicing pharmacists employed in community pharmacies in Flanders, Belgium , was used to develop a ‘test’ version of the ECP protocol. Second, this ‘test’ protocol was tested in pharmacy practice by the same set of pilot pharmacies. Third, users’ experiences were collected via semi-structured interviews with pharmacists employed in the pilot pharmacies and subsequently used for optimization purposes to result in a final protocol, ready for nationwide implementation. By adopting this ‘multifaceted’ approach, we aimed to consider the preferences and experiences of practicing pharmacists and to maximize the protocol’s utility and application potential upon implementation.The project took place between October 2020 and March 2021, i.e., during the second wave of the COVID-19 pandemic. The selection of pilot pharmacies was performed via convenience sampling, hence recruiting pharmacists with a large interest to participate. As an inclusion criterion, pilot pharmacies needed to dispense at least 40 boxes of any type or brand of ECP each year, ensuring sufficient experience with the topic of interest and ample testing opportunities during the pilot period. Information on the project was distributed by the national and local professional pharmacy organizations through digital newsletters.All participating pharmacists provided written informed consent prior to study initiation. Ethical approval was obtained from the Ethics Committee Research UZ/KU Leuven .To develop the ‘test’ protocol, an online focus group discussion with pilot pharmacists was organized as a ‘co-design’ event in October 2020. Due to the COVID-19 pandemic, we were obliged to use an ‘online’ format. The group discussion lasted two hours and was moderated by researchers M.C. and V.F. Four students of the Master in Pharmaceutical Care also attended the focus group , as well as representatives of the National Pharmacists Organization (I.D.W.) and Sensoa, the regional expertise center on sexual and reproductive health.The ‘co-design’ event started with a brief presentation by the moderators of some project information, followed by an open-minded discussion with all attendees focusing on two aspects: (1) which questions pharmacists would ask when someone requests EC and (2) which information pharmacists would provide when dispensing ECPs. The moderators invited all attendees to provide input and suggestions on both questions. In the second part of the meeting, a draft version of an ECP protocol, initially created by the researchers based on personal insights, pharmacy experiences, and literature ,17,18, wAs soon as the ‘test’ protocol was available, a four-month test period in the pilot pharmacies commenced . Pilot pharmacists were asked to motivate their team, including pharmacy-technicians (PT), to use the protocol during each conversation on ECP. Pharmacists were also invited to register baseline data after each ECP conversation using a predefined, paper-based registration document. While pilot pharmacists were neither trained by the researchers on the components nor on the actual application of the protocol in practice, some documentation with theoretical concepts on ECPs was available to all pharmacists.At the end of the pilot period, pharmacists were invited to participate in an online, semi-structured interview to gain insight into pharmacy staff’s experiences with using the ‘test’ protocol in practice. It was our goal to interview at least one pharmacist from each pilot pharmacy. Interviews were carried out in March 2021 by a female Master student, E.S., using a topic guide consisting of questions exploring pharmacy staff’s experiences with the content of the protocol  and applying the protocol in daily practice. The obtained insights were used to optimize the ‘test’ protocol and to deliver a final version. The interviews were audio-recorded and transcribed verbatim.The qualitative data obtained during the ‘co-design’ event were descriptively summarized and presented as a narrative text, including representative statements. The interview data were analyzed by two researchers using an inductive, thematic approach in NVivo and Excel and according to the Qualitative Analysis Guide of Leuven (QUAGOL) . The regIn total, eight community pharmacies were included as the pilot pharmacies. These pharmacies were geographically distributed across Flanders, Belgium, with four of the five Dutch speaking regions in Belgium being represented. During the ‘co-design’ event, 15 community pharmacists of different age groups attended (12 women and 3 men).During the ‘co-design’ event, pharmacists agreed that the protocol ideally consisted of four parts and supported pharmacists in four actions, i.e., (1) the ‘intake’ with a list of questions exploring the actual situation; (2) the ‘decision making’ based on the collected/summarized information and explaining this to the patient; (3) the ‘informative’ part, providing patient-specific advice; and (4) asking for feedback  and for questions or concerns.With regard to the ‘intake’, pharmacists agreed that the first/important questions were (1) for whom the ECP was requested and (2) when the (unprotected) sexual intercourse took place. Pharmacists further agreed that upon identification, a clear distinction should be made between women using or not using  contraception. In case of contraception use, pharmacists confirmed it should be questioned which contraceptive the woman is using, what happened with her contraceptive and when she had her last hormone-free interval. If no  contraceptive was used, they found it vital to ask the woman about the timing of her last menstrual period and the average duration of her cycle. Other questions that were considered important by pharmacists related to medication use in the last 4 weeks and previous ECP intake. Depending on the patient’s situation, questions related to breastfeeding and sexually transmitted diseases (STDs) could be used, according to some pharmacists, but were generally not considered pivotal. The ‘open’ question “Why do you think you need EC?” was suggested and supported by some pharmacists, although opinions on appropriateness and preferences to use this question widely varied.Further, pharmacists agreed that after the intake and acquiring essential information on the specific situation/context, the protocol should support pharmacists in outweighing possible choices and discussing these with the patient. For example, the use of EC(P) may or may not be needed, and/or a referral to a medical doctor might be (more) appropriate. Pharmacists felt that this second part of the protocol was ideal for this purpose, including aspects related to the price/reimbursement of ECP and the registration of ECP dispensing in pharmacy software .With regard to the ‘informative’ part, pharmacists totally agreed on the inclusion of the following items in the protocol to support patient counseling: (1) ‘mechanism of action’, i.e., the fact that ECPs postpone ovulation; (2) the ‘advice’ to take the single pill as quickly as possible and to take a new pill in case of vomiting within 3 h after the intake; (3) information on potential side effects, such as earlier or later occurrence of menstruation; and (4) ‘specific information’, including (a) an ECP does not provide protection against upcoming sexual intercourse, (b) how to continue the use of contraception, and (c) the required time to use condoms until hormonal contraception is effective (again). Most pharmacists also agreed to tell patients that ECPs are not 100% effective. In contrast, two items were identified on which pharmacists disagreed about including in the protocol, i.e., (1) to tell patients that an ECP is not an ‘abortion’ pill and (2) that ECPs have no proven effect on women’s future fertility. Pharmacists were hesitant about the necessity to  mention these items when dispensing an ECP. Both items were therefore included in italics in the ‘test’ protocol. Overall, pharmacists stressed the importance to find the right balance between providing sufficient and too much information to make sure that patients remember all relevant details. Pharmacists agreed that written information may be beneficial. They were convinced that providing a patient leaflet at the time of delivery, or referring patients to reliable online sources, would be an added value.During the pilot period, the ‘test’ protocol was used in seven of the eight pilot pharmacies  guideline with corresponding flow chart, patient leaflets, and dispensing protocol), their attention for the protocol was lost).In total, 97 ECP conversations  were registered, with 91 ECPs dispensed. Pharmacists did not always register information for all variables during the ECP conversations  redundant. However, pharmacists confirmed that not all questions should always be asked during ECP conversations. Pharmacists indicated that they prefer to use the protocol and items dynamically and depending on the specific situation. Moreover, opinions on the open question “Why do you think you need EC?” still varied; as it was not clear whether this should be included in the protocol or asked ‘as such’ in practice, this question was finally removed.“The question ‘why do you think you need EC’? Well, not every patient is ‘ready’ to immediately elaborate on the actual situation.” “I prefer the question ‘why do you think you need EC’? instead of asking all items myself, as you may learn a lot about the patient herself. In response to this question, patients often spontaneously tell quite a lot, which makes it easier to respond to their story and ask additional questions if needed.” With regard to the ‘decision’ part, not all pharmacists reported having discussed the potential EC(P) options with patients or having explained their decision(s) about whether or not to deliver EC and, if so, what type of EC(P) was preferred. Nevertheless, pharmacists felt it relevant and justifiable to keep this second part in the final protocol. Moreover, opinions/practices also differed regarding the spontaneous provision of information on the price of ECP prior to payment. Given that such information is indispensable according to some pharmacists, certainly in case of dispensing UPA when LNG is also an option, the item referring to price/reimbursement was kept in the final protocol.“The question from patients about the price of an ECP is a question which actually pops up almost always. Hence, and especially if you want to dispense ulipristal, you should almost always talk about the price of the ECP.” .With regard to the ‘information’ part, pharmacists agreed on the inclusion of protocol items related to the general topics of ‘mechanism of action’, ‘use’, ‘potential side effects’, and ‘information on the use of contraception/condoms’. However, pharmacists did not agree on the necessity to spontaneously mention some specific items during all conversations. This was the case for (no) effect of ECPs on future fertility, an ECP not being an ‘abortion’ pill nor providing protection against STDs, and the advice for STD screening. Since these items could be part of some conversations on EC(P), for example, upon identification of a patient’s distress regarding one of these topics, these items were kept in italics in the final protocol, except for the word ‘abortion’, which was considered inappropriate to use and was changed into ‘not interrupting an ongoing pregnancy’.“I don’t use the word ‘abortion’. Instead, I say that the ECP prevents fertilization but that it does not interrupt an ongoing pregnancy.” .Pharmacists cited that mentioning all items or not may actually depend on the specific patient asking for an ECP. For example, it may be difficult during a conversation with a rushed patient or male customer who is ignorant about the woman’s menstrual cycle or the type of contraception used. Finally, some pharmacists confirmed that patients should not be overwhelmed with too much information, as they probably will not remember everything. Providing a leaflet may be a better alternative for conveying all relevant information.Overall, all pharmacists reported having used the protocol solely after ECP dispensing as a ‘checklist’ to ensure that all items were questioned/discussed. In other words, the ‘test’ protocol was not used at-the-counter during conversations with patients. Pharmacists considered the use of a paper-based protocol during counseling a real barrier. Several factors contributing to this experience were identified, such as (1) hindering the communication/dialogue with patients; (2) making ECP dispensing less spontaneous/more artificial ; (3) appearing unprofessional or ignorant to patients; and (4) giving patients the impression that seeking ECP is a ‘big deal’, which may potentially scare them off. Pharmacists felt that communication with patients in a human way is critical to create trust, which is especially important in case of a ‘sensitive’ topic, such as ECP counseling.“Grabbing a paper at the counter is a bit weird for patients, because then they realize that we are ‘cheating’, but when you look at the protocol on your computer, the patient does not realize it.” .“I find it a real threshold to use the paper-based protocol during the conversation with a patient. By using the paper, it seems like you don’t know the content very well, and it can look like a big deal for a patient, which will scare them off.” .Most pharmacists acknowledged that they prefer a digital protocol rather than a paper-based one. However, if too many pop-ups appear, this would stop pharmacists from using a digital version as well. Pharmacists noted that a balance should be found during counseling between looking at the computer and the interaction (having eye contact) with patients.Several self-reported advantages of having an ECP protocol were identified. Overall, pharmacists felt that ECP conversations/dispensing were more comprehensive, complete, and structured. The observation that conversations with patients lasted longer was not considered negative. Some pharmacists also mentioned that thanks to the availability of the protocol, they more often referred patients to doctors, for example, to discuss the use of contraception. Finally, it was noted that having a protocol created more awareness about the theoretical and practical aspects of EC(P) dispensing in practice. According to pharmacists, using the protocol may be beneficial for patient care and counseling quality and enhance patient involvement and support.“Thanks to the protocol, the conversation with the patient lasted longer. People were longer inside the pharmacy, but it is not a negative aspect. On the contrary, it felt that more questions came from patients themselves. I found this a very positive experience and so did my colleague. She said to me ‘I really think this is an added value’.” .“The advantage is that you certainly question all aspects that you need to know and thus have complete information. You can then make a better decision.” .“We now work in a much more structured way. People get a lot more explanation. In the past, we used to ask ‘the emergency contraceptive pill? Are you taking something of protection? Or what happened?’, but we did not elaborate on it then. Now, with the protocol, we have a guideline for going more into detail.” .This project aimed to develop and test an ECP dispensing protocol for community pharmacists in Belgium. As part of the development phase, an ‘experience-based’ co-design approach involving academic and practicing pharmacists was applied. The protocol was subsequently tested in seven pilot pharmacies for 4 months (with ±100 ECP ‘test’ encounters) and eventually optimized based on users’ experiences collected during interviews.During the development part, pharmacists agreed on the four parts of the ECP protocol , as well as on most individual items to be included in the ‘test’ protocol. After having used this protocol in practice, pharmacists reported that the protocol was complete and that no relevant items were actually missing. Although the items are generally quite similar to the ones included in the ECP protocols abroad ,17,18, tall ECP conversations. Nonetheless, the data collected during the pilot period show that information on some of the critical items was missing in quite a high number of conversations, underlining the need for further quality improvement in counseling. This finding is in line with an Australian study showing poor application of the ECP protocol (items) in practice [Some pharmacists felt that some specific items should not  be spontaneously questioned or mentioned during ECP counseling. Therefore, in the final protocol, these ‘debatable’ items were mentioned in italics see . This obpractice . In contpractice , markingOur ‘final’ protocol became available to all pharmacists in Belgium in Autumn 2021. Since its nationwide distribution, two important considerations with regard to the content of the protocol have been identified and deserve further attention. First, it may be appropriate to modify the order of questions in the ‘intake’. It would make more sense if pharmacists first ‘validate’ the ECP request , before asking about the actual timing of sexual intercourse . Second, a question to find out the patient’s weight/body-mass index (BMI) is missing in the protocol, potentially due to the uncertainty/inconsistency in the available ECP guidelines at the time of development of the dispensing protocol. However, a question on weight/BMI is highly relevant, as weight can affect the recommended dose of LNG (=3 mg)  and shouafter the delivery as a ‘checklist’ to ‘check’ if all items had been discussed, and thus, they did not actively use the protocol at-the-counter to support ECP deliveries. Thus, pharmacists had to rely on their memory during counseling to recall all protocol items, potentially explaining, at least to some extent, the degree of missing data in the registrations obtained during the pilot period. This was confirmed by previous studies on ECP counseling showing that if pharmacists (visibly) used a checklist, high(er) questioning scores were obtained and, eventually, a high(er) likelihood of achieving the appropriate outcome [With regard to the actual utilization of the protocol in practice, pharmacists indicated having used it solely  outcome ,20.The interviews provided preliminary insights into potential reasons explaining why pharmacists did not ‘actively’ use the ECP protocol at-the-counter, impeding its successful implementation in practice. As the most important barrier, it was found that the paper-based format hindered pharmacists. The ‘final’ protocol has meanwhile become available as a pdf version, providing pharmacists the opportunity to save the protocol on their computer (desktop) and use it as such during counseling. Our findings show that protocol-based dispensing (of ECPs) is not yet common practice in the Belgian pharmacy setting. Still, pharmacists attributed several benefits to having an ECP protocol, both in terms of the quality of ECP conversations and patient care. This would be appropriate given the variable practices in ECP counseling in Belgium . As soonOn top of that, it still remains unknown to what extent the application of the protocol will succeed in the standardization of ECP conversations and lead to better ‘outcomes’ in terms of counseling quality  and patient satisfaction with reproductive health pharmacy services. Such assessments are needed in the future ,26, espeThe project has several strengths. First, the co-design approach involving practicing pharmacists in protocol development and optimization may have resulted in the release of a protocol, the content of which is in line with the preferences and views of end users. This co-design approach may also have increased the feasibility, utility, and acceptance of the ECP protocol. Second, the inclusion criterion of dispensing at least 40 boxes of ECPs annually ensured that only pharmacists with experience on the subject could participate. Third, the online focus group facilitated the inclusion of pharmacists employed in geographically diverse regions and  ran very smoothly. This is in line with the findings of recent studies showing the feasibility of online approaches for focus group or consensus methodology ,30,31. FSome limitations can also be addressed. First, only Dutch-speaking pharmacists were enrolled via convenience sampling, recruiting mainly highly motivated colleagues, which may have resulted in selection bias. It remains unknown to what extent the ECP protocol will be accepted by French-speaking pharmacists in Belgium and Dutch-speaking colleagues with less experience with and/or interest in this topic. Second, due to the COVID-19 pandemic and social restriction measures, fewer ECPs were requested/dispensed in the pilot pharmacies during the test period, limiting the possibilities to ‘test’ the protocol. To solve this limitation, the duration of the test period was extended . However, pharmacists acknowledged that not all ECP conversations that happened during the pilot period had been registered. Thus, the 97 registered conversations were without any doubt an underestimation of the actual number of encounters during the pilot period. For some variables, a high number of missing data was observed. It is unknown whether pharmacists did not register this information because of not having collected it during the encounters (due to the lack of protocol application at-the-counter) or whether the information had already been forgotten at the time of registration (which may have occurred after some other patient conversations). The uncertainty concerning the accuracy of recall when completing the registration document should also be considered. Finally, the ‘positive effects’ of using the ‘test’ protocol were collected during interviews and were not objectively observed in real-life, limiting the validity of these findings.An ‘experience-based’ co-design approach involving academic and practicing pharmacists and followed by a four-month test period resulted in a ECP dispensing protocol for community pharmacists in Belgium. Pharmacists considered the protocol complete but felt that not all protocol items should be mentioned/questioned during all ECP conversations. They suggested only subtle modifications to be made after the test period and prior to delivering a final protocol ready for nationwide distribution. Despite attributing positive effects to having a protocol, no single pharmacist ‘actively’ used it at-the-counter but used it instead as a checklist after the encounter. Pharmacists found that the paper-based format of the protocol hindered protocol-based dispensing of ECPs by pharmacy staff. Future research is needed to provide evidence on the actual benefits of ECP protocol application in terms of counseling quality and patient satisfaction, as well as to identify factors influencing the implementation of ECP dispensing using a software-integrated protocol.


At the beginning of the COVID-19 pandemic, people were encouraged to practice social distancing, and schools and leisure venues closed.We aimed to explore the everyday experiences of Norwegian adolescents during COVID-19 restrictions, when in-person contact with peers was severely limited.A total of 622 high-school students (16–18 years of age) replied to an online survey containing open-ended questions about the changes they experienced in everyday life during the first three months of the pandemic.Reflexive thematic analysis resulted in four themes: (a) ‘Everyday life turned upside down – everything is on hold’; (b) ‘Alone with my thoughts – new concerns’; (c) ‘A loss of social life – a fear of wasting important time’; and (d) ‘Gratitude – new perspectives in life’. The results are discussed according to mental-health concerns and psychological developmental challenges during adolescence, such as social exploration of roles with peers, autonomy and identity formation during a crisis.The results underline individual variations and positive experiences among adolescents during the COVID-19 pandemic, despite social restrictions. Still, the lack of in-person contact with friends is related to an increased experience of loneliness and mental-health concerns for many adolescents. The COVID-19 pandemic led to restrictions in many countries, involving social distancing and home schooling, and significant limitations on social contact. Social interaction with others is a basic human need, and engagement with peers plays a special role during adolescence . The outAdolescence is a transitional life period, including cognitive, biological, psychological and social changes . Many meTo date, several cross-sectional studies have found an increase in mental-health problems, such as anxiety and depression, among adults  and adolHowever, these studies do not add to our understanding of adolescents’ subjective experience of their everyday life in the context of the COVID-19 pandemic. Only a handful of qualitative studies have been conducted. Fitzpatrik et al.  found a 25Although there have been a growing number of studies on the pandemic’s impact on adolescents, so far, few have asked adolescents in depth about their own perspectives with open questions. Often, adolescents’ perspectives on mental-health problems or consequences of the crises have been collected with questionnaires with response options. Thus, there is a need for increased knowledge about how adolescents experienced the pandemic more openly. Qualitative methods emphasise an exploration of a phenomenon to find variation and commonalities in the participants’ understandings and meaning making. In this study, we add to the current literature by including qualitative data and an in-depth exploration on adolescents’ experience of everyday life during the pandemic while adapting to social restrictions and new routines. We aimed to examine how adolescents experienced the changes in their everyday lives during the first weeks of the COVID-19 pandemic in order to obtain a more in-depth understanding of how the COVID-19 pandemic was experienced in terms of well-being and mental-health concerns in the early part of the pandemic. The findings are discussed in the context of some of the developmental challenges during adolescence, such as social exploration with peers for evolving autonomy and identity formation at this transforming period of life 1. Even thN=622, 76.8% girls). Participants answered an online questionnaire containing well-known and validated close-ended questions about mental health, social media use and friendship (blinded for review), as well as three qualitative open-ended questions concerning their experience of changes in everyday life after lockdown. Before recruitment started, the survey was piloted among a small group of adolescents (N=10), and a few questions about social media use were adjusted for clarity before recruitment started. Of the 930 adolescents who received a link to the online questionnaire via text message, 709 (77%) completed the questionnaire, 87 of whom were excluded because they were ⩾19 years of age and/or were no longer in high school. The Regional Committee for Medical Research (REK: 124909), and the Data Inspectorate approved the study.Participants were part of a cross-sectional study and were recruited via advertisements on the social media platform Facebook and on 10 high-school webpages in two urban counties. Recruitment was initiated on 1 April 2020, only two weeks after schools and social arenas were closed across Norway  and lastThe present study used the qualitative information from three open questions: (1) What were the biggest changes in your everyday life after the start of the COVID-19 pandemic? (2) What were the biggest negative changes in your everyday life? (3) Are there any changes that have been positive?SD=7 days) after the intrusive restrictions were implemented on 13 March.The participants submitted their responses to the open questions in the Norwegian language , and all participants provided responses to the three open-ended questions, (i.e. there were no missing responses). The survey captured the first wave of the COVID-19 crisis in Norway and was conducted in a period with a low rate of infection in society. On average, participants answered the survey 30 days  ,35 was cThe data analysis consisted of six steps ,35. FirsSecond, the researchers began the coding process by systematically and thoroughly generating initial ‘codes’ or short labels for relevant, interesting and meaningful parts and features of the data material close to the informants’ descriptions of their experience. The second author led the coding process and discussed the codes with the other authors. Thereafter, the first and second authors organised the codes into a general ‘groups of codes’. Some codes were dismissed, while others were grouped together or split apart. All groups of codes with some especially rich quotations were collected into a new working file to provide a condensed overview of the patterns of experience and meaning making throughout the data set. All researchers discussed the analysis, and we noticed that the adolescents described their experiences in a polarised way. What some experienced as challenging and difficult were for others considered a relief or something pleasant or positive.Third, the first and second authors searched for themes by identifying patterns across the groups of codes. Fourth, we generated a hierarchy of sub-themes and encompassing themes, which represented the experiences of change in a thorough and accurate way see . The hieThe analysis of the experience of change among high-school students during the COVID-19 pandemic resulted in four themes: (a) “Everyday life turned upside down – everything is on hold’, (b) ‘Alone in my own thoughts – new concerns’, (c) ‘Loss of social life – a fear of wasting important time’ and (d) ‘Gratitude – new perspectives in life’. In the following, we document and illustrate these four themes with associated sub-themes and selected quotations that are rich in details and capture nuances and divergent points in the data see . To incrThe first theme, ‘Everyday life turned upside down – everything is on hold’, captures the experience of an overwhelming and chaotic change in everyday routines and family life. This theme consists of four sub-themes. The first sub-theme, ‘Lacking the previous variety of everyday life’, highlights how COVID-19 introduced a sudden change from a hectic into a monotonous everyday life for many participants – every day felt ‘the same’. Many of the adolescents experienced the change from normal school to home schooling as challenging and spoke of how difficult it was to separate their school life from their private life when being at home all day: ‘I don’t have any good routines anymore, either with school or with sleeping’. The second sub-theme, ‘Destroyed routines’, underlines how the structures and frames for their everyday life were gone, even broken: ‘I’ve lost my routines, and everyday life is messy’. Some adolescents reported how difficult it was to do all of their schoolwork at home in a new sphere without teachers and classmates. Some even considered school to be an important aspect of everyday life in terms of providing structure to their day and for handling mental-health concerns: ‘I am not able to take part in home school because of my depression and, therefore, I have a lot of spare time’. Their new everyday life seemed to create an experience of having to make new routines to replace the ones they had before the pandemic.The third sub-theme, ‘Family time – for better or worse’, highlights how the students experienced spending more time at home with their family because schools were closed and because of the social restrictions. Some said they had ‘too much time together’ and that being at home so much ‘made them go crazy’ or ‘got on their nerves’. They described more quarrels and disagreements with their family members. Still, some reported that it was nice to spend more time with their family: ‘[I am] maybe more connected to my family, but there’s also more arguing’. Being at home may have created an experience of having little personal space. The fourth sub-theme, ‘Freedom is gone’, highlights the participants’ experience of being prevented from doing what they wanted and from making their own decisions. They could not meet friends and family members due to social distancing: ‘I feel like my freedom is gone. For example, I can’t see my boyfriend. I feel so lonely’. Some participants reported a lack of freedom to do exactly what they wanted when they wanted to do something: ‘I feel I don’t have the right to decide over my own life . . . everything is put on pause’. The first theme highlights how the participants missed their previous everyday routines and felt their life was on hold.The second theme, ‘Alone with my thoughts – new concerns’, conveys how the COVID-19 pandemic brought new thoughts and worries for the participants. This theme consists of four sub-themes. The first sub-theme, ‘Too much time to think’, highlights how several informants reported a sense of suddenly having a lot of time to reflect upon small and big issues in their life: ‘I get more time to think, let the thoughts run wild. Thinking about life and wondering where’s my place and if I didn’t exist would anyone notice’. A few participants thought about where they belonged in the world. The second sub-theme, ‘Concerns for the future’, highlights an increased uncertainty about not knowing what will happen in the future, in both the short and long term: ‘Worrying about when all this is over’. Some reported that it was ‘difficult and scary to think ahead’ and asked themselves ‘what might happen next’, or they said that there was ‘nothing to look forward to’ because of cancelled events.and their fear of infecting others: ‘I am afraid my mother and brother will have COVID-19 because they’re in the high-risk group’. They reported a fear of losing friends and family: ‘Anxiousness, panicking because I’m overthinking what can happen with friends and family’. Several described a sense of fear spreading through society or because of the news about the COVID-19 restrictions: ‘Everyone is in a kind of panic’. In addition, several participants described increased insecurity, difficulties concentrating, being restless, as well as a sense of losing control after the restrictions began. The fourth sub-theme, ‘Haven’t been doing well lately – a return of mental-health concerns’, conveys how some participants experienced symptoms of anxiety, panic attacks, depression, hopelessness, or meaninglessness, or reported that they were afraid they would have a relapse: ‘Since I’m inside a lot and alone, I feel very locked up. Since I can’t go out, I am in my own head a lot. This has led to my depression and anxiety coming back’. A few participants described overthinking because of boredom: ‘Boredom leads to overthinking, and I am afraid I’ll relapse with my mental health and [it will] get bad again’. In sum, the second theme sheds light on how restrictions during the pandemic gave rise to new concerns for many of the adolescents.The third sub-theme, ‘Fear of infection – more anxiety and insecurity’, sheds light on the fear several had of becoming ill with the disease The third theme, ‘A loss of social life – a fear of wasting important time’, emphasises how the participants experienced changes in their social life and habits, and how they tried to adapt to these changes but still felt lonely. This theme consists of three subthemes. The first sub-theme, ‘Miss being with others – now I’m just alone’, conveys several participants’ experience of not being able to spend time with friends, peers and classmates. They described how they missed their friends and had to spend time in their own company, not because they wanted to but because of the restrictions. They described this change as challenging and unfamiliar: ‘I was with people all the time, now I’m only on my own’. Some described a feeling of being trapped at home, while others told stories about parents not allowing them to leave the house or meet up with friends. They underlined a frustration with being alone and left out of ‘ordinary’ social life: ‘[I’m] feeling isolated from social life even though nothing is happening, it bothers me’. They described a fear of wasting important time in their life: ‘I am losing valuable time’.The second sub-theme, ‘Missing in-person contact’, emphasises how many of the participants missed face-to-face encounters with friends. This also included the lack of intimacy and not being able to experience physical contact, such as hugging, with friends on a regular basis: ‘I can no longer see my friends on a daily basis, and therefore I get much less physical contact than usual’. Some had more online contact with friends than usual, while others experienced online contact with friends difficult: ‘Since I’m a girl, I find it harder to keep in touch with friends regularly. That’s because we don’t sit and do gaming like the boys do’.The third sub-theme, ‘The lack of support in friendships’, reflects how a few of the participants described an experience of not being able to be a friend in the way that they used to or wanted to be: ‘My friends are many hours away, and I can’t be there and support them when they really need it’. Some described how they miss getting support from friends and that the social restrictions influenced their mental health: ‘It’s hard for my mental health to not be as social as before, because I’m an extremely social person’. Spending time with friends and engaging in normal social activities, which are a significant part of adolescents’ life, were lost. Seen together, these sub-themes shed light on different aspects of how adolescents’ social life changed. Even though they knew that no one had a lot of social contact, they experienced a fear of missing out on something or wasting an important period in their life.The fourth theme, ‘Gratitude – new perspectives in life’, captures the positive experiences, as well as the learning and growth adolescents experienced during the pandemic, despite the considerable changes and losses that occurred during this difficult time. This theme consists of four sub-themes. The first sub-theme, ‘A break from my usual everyday life’, underlines how the changes and restrictions during the pandemic brought more spare time in their everyday life. Several participants described how the pandemic brought a pause from their usual hectic life. They felt calmer and less stressed: ‘It can be pleasant to have nothing to do. I’m not used to it, and so it’s a little nice sometimes to have time to relax’. Further, several participants described more time to do new things and engage in leisure activities, interesting hobbies or relationships than before: ‘[I have] more time to read borrowed books, be with family, reflect on different things, spend more time out walking’. They had an experience of gaining something, having more time for creativity and more play. A few participants emphasised less pressure on appearance in dressing, hair and make-up when at home: ‘There’s less pressure on things you notice in school and such. As what clothes to wear, if you wear make-up or have spent time in the morning to fix your hair etc. There’s no focus on appearance’. They found it relieving and did not experience the same social demands and strains to ‘fit in’.In general, I have always loved going to school, but I still think I have gained a slightly new perspective on going to school. I miss sitting in classrooms, meeting friends in the hallways, picking up books in the lockers, etc. I even miss taking the bus! So, I think everything that happens now will give me a different perspective and a greater appreciation for everyday things when this is over.The second sub-theme, ‘Grateful for life before COVID-19’, conveys how some missed school:Many longed for common events in their everyday life and appreciated these things now that they no longer had the opportunity to do them.The third sub-theme, ‘Development – exciting to be challenged’, conveyed how the COVID-19 pandemic and social distancing became an opportunity for new experiences. For a few participants, it was exciting to experience coping: ‘More experience of coping with mental challenges. It’s fun to cope with a new and different situation’. It was exciting to discover their own strengths. Some participants described more time to find out what they want in life and more time to think about wishes for the future, career choices and new activities: ‘I feel I have more time for myself and to find out what is actually important in this life’. A time of struggle and hardship along with more time for reflection during the pandemic brought an opportunity for finding a direction in life. The shutdown caused by COVID-19 seemed to slow the pace of everyday life and create an opportunity for growth and new perspectives.In the current study, we examined how adolescents experienced changes in their life after the first lockdown due to the COVID-19 pandemic. The main findings show that adolescents experienced their everyday life being turned upside down. They felt less freedom and alone with their thoughts, and they experienced a loss of social life during an important period of their life. Still, many also felt gratitude and gained new perspectives in life.Previous findings from studies on adolescents’ mental health during the pandemic are mixed. Some studies report increased loneliness, anxiety or depression among adolescents , and othSome quantitative studies –17 and qDuring the COVID-19 pandemic, a whole generation of adolescents experienced changes in their everyday life. In our study, they described everything being turned upside down, a lack of freedom and life being on hold. The changes included less activity, less structure and routines, no borders between school and home and, for some, social isolation. During adolescence, a developmental challenge is to find your own solutions and to trust your own choices towards increased independency and separation . Social Moreover, adolescents live in a social context, and the restrictions may have influenced adolescents in different ways according to individual and contextual risk factors, as well as protective factors. For example, those who had a hard time at school with bullying and social problems with peers before the pandemic could possibly have felt relief at being able to spend more time at home and to have more time with parents and siblings. Maybe they felt less challenged and safer. Others who struggled with mental-health concerns or problems at home before the pandemic may have missed the structure provided at school. Not being seen by a teacher and the lack of contact with friends could potentially have increased mental-health concerns. In sum, the findings highlight the variety in adolescents’ experiences of change during the pandemic: some enjoyed more time at home with their family, but others felt the physical and social restrictions as hindering their exploration and freedom.Our study further underlines how adolescents described an achievement of new perspectives in life caused by the pandemic. The break from their usual everyday life may have enabled a pause and some time for reflection, and the chance to notice and be grateful for the good things in their everyday life, which are otherwise easy to take for granted. Some expressed that the challenges were exciting. Thus, some adolescents may adjust to a new context quite quickly. One study showed that adolescents’ perceptions of change in their relationship quality during the pandemic were heterogenous, and higher perceived change and instability were associated with poorer psychosocial functioning . The varFor long periods during the pandemic, adolescents were at home all day, with their only social contact with peers being through digital channels and arenas. Increased experiences of loneliness and social isolation among adolescents during the pandemic have been reported in several studies ,30. In oThe implication of our findings suggests that closing schools and other social areas should be limited to a shorter period for adolescents. Digital health services, such as open chat functions with school social workers and health nurses, could be important to limit the mental-health burden during adolescence. Schools should increase social platforms for adolescents to interact and socialise during future pandemics.One strength of this study is that the data collection was conducted just two to three weeks after the government closed schools and other social arenas. The adolescents were asked about their own perspective and feelings in this situation. Thus, the results of this survey may present a picture of the situation and illuminate adolescents’ experiences from a here-and-now perspective. It must nevertheless be emphasised that the results are presented as an image of a certain state during a time of urgency. Further data collection may be able to show longitudinal changes in adolescents’ experiences or long-term effects of social distancing and lockdown. Even though the sample size does not outweigh the quality of the data, the rather large sample may allow for the reporting of patterns across the data set .how the participants experienced those changes. Further, the third question asked whether there had been any positive changes. This wording may have caused the participants to think about either positive or negative consequences and not openly describe their experiences. Still, the variety in experience of their everyday life was the overall focus of the analysis.The themes identified in this study are the result of an analysis of questions in the survey that focused on changes in everyday life and, in this way, presumed that there had been changes in everyday life. However, it is still very likely that the vast majority experienced changes to some degree, and this study explores We used a convenience sample, and information about the family and socio-economic background of the participants was not collected. Also, girls were overrepresented in our sample, which may limit how well the results represent young men’s experiences during the COVID-19 pandemic. It is possible that this reflects our recruitment method (via Facebook), as girls use social media (i.e. Facebook) more than boys in general . HoweverReflexive thematic analysis is an appropriate method for analysis seeking to understand experiences ,35. HoweThis study explored adolescents’ experience of changes during the first COVID-19 wave . Reflexi


A meta-analysis is used to explore the relationship of sleep quality and duration with the risk of diabetic retinopathy (DR).Cochrane Library, PubMed, Embase, and other databases are searched from their establishment to April 2022. Literature on the relationship of sleep quality and duration with DR risk published in various databases is collected, and two researchers independently screen the literature, extract data, and evaluate the quality of the included articles. The meta-analysis is performed with Review Manage 5.4.1 software.A total of 7 articles are selected, including 4,626 subjects. The results show a strong correlation between sleep quality and DR risk. When comparing the sleep quality scores of “DR”  and “NO DR” (control group), the Pittsburgh sleep quality index(PSQI) score of the DR group is significantly higher than that of the NO DR group , while the ESS score of the DR group is also significantly higher than that of the NO DR group , so the sleep quality score of the DR group is higher than that of the NO DR group in both the PSQI and ESS scores, which confirms that low sleep quality is a risk factor for DR. Long sleep duration is also associated with the risk of developing DR; the number of adverse events  is higher for “long sleep duration” than “normal sleep duration” , suggesting that long sleep duration can cause increased DR risk. Short sleep duration is also associated with the occurrence of DR  and can increase DR risk.Sleep quality and duration (including long and short sleep duration) are significantly associated with DR. To reduce DR risk, sleep intervention should be actively carried out, lifestyle changes should be made, and attention should be paid to the role of DR management. Diabetes mellitus is one of the most common and frequently-occurring diseases in the world, and its rapidly rising prevalence has become a global public health problem. According to the International Diabetes Federation , there wCochrane Library, PubMed, Embase, and other databases were searched by computer from their establishment to April 2022. English search terms included “sleep quality”, “sleep wake disorders”, “sleep score”, “Pittsburgh sleep quality index”, “PSQI”, “Epworth Sleepiness Scale”, “ESS”, “sleep time”, “sleep duration”, “sleep amount”, and “diabetic retinopathy”.Inclusion criteria: ① The subjects of the study were diabetic patients. ② The study was a cohort study, case-control study, or cross-sectional study. ③ The exposure factors were sleep quality score and sleep duration, wherein sleep quality score included the Pittsburgh sleep quality index(PSQI) and Epworth Sleepiness Scale (ESS) scores, and sleep duration included long sleep duration and short sleep duration. ④ The outcome indicators included mean difference (MD), odds ratio (OR), and 95% confidence interval (CI) after multivariate adjustment. ⑤ Based on different reports on the same research population, the studies with the largest sample sizes were included.Exclusion criteria: ① Languages other than English. ② Studies for which the effect sizes could not be extracted or calculated. ③ Studies for which the original author did not respond or could not provide meta-analysis data.Two researchers independently searched, selected, and screened the literature, then checked each other’s work and provided articles with differences to a third researcher for analysis to decide whether they should be included. The evaluation was performed using the “Risk of Bias Assessment” tool recommended by the Cochrane Collaboration, which is divided into three levels: low risk, unclear, and high risk. The contents are: whether it is randomly assigned; whether to carry out allocation concealment; whether to use blinding; whether the outcome data is complete; whether the research results are selectively reported; and whether there is any other risk of bias. The extracted data included the first author, study area, publication time, study type, sample size, age, PSQI, ESS, sleep duration assessment method, sleep duration grouping, outcome measures, and adjustment for confounders.The sleep quality scores of the research subjects were obtained by the PSQI and ESS questionnaires, and sleep duration was obtained by survey visits or questionnaires. DR was diagnosed by ophthalmologists through the analysis of fundus photos or conducting indirect ophthalmoscopy. In the included studies, DR included mild, moderate, severe, and any DR. The PSQI and ESS scoring standards of the sleep quality score were fixed and consistent, while the grouping and definition of sleep duration were not completely consistent. Long sleep duration was defined as > 8–9h, normal sleep duration as 6–8h, and short sleep duration as < 5–6h, all at night and within a 24h period.2 statistic test and Q test. When I2 < 50% and P > 0.1, this indicated that there was no significant heterogeneity among the studies; when I2 > 50% and P < 0.1, this indicated that there was statistical heterogeneity among the studies. If there was still heterogeneity, a random effect model was used, and if there was no obvious heterogeneity, a fixed effect model was used. Sensitivity analysis was used to judge the stability and reliability of the combined results. P < 0.05 indicated that the difference was statistically significant.Statistical analysis was performed using Review Manage 5.4.1 software. MD and OR values were used for effect evaluation, and 95%CI was calculated. The heterogeneity of the studies was analyzed using the IA total of 513 articles were retrieved. A total of 437 papers were obtained after deduplication, and a total of 266 papers were excluded by reading the titles and abstracts. After reading the full texts, 7 papers were finally included , any articles that had no significant effect on the combined effect size of the remaining literature were removed to confirm the stability of the results; for the ESS score study, only two articles were included, and the sensitivity analysis was not carried out for two studies, so the results of the ESS score analysis were unstable.The results of the sensitivity analysis showed that for DR risk in diabetic patients, all included studies had I2 = 0%), so the fixed effect model was used. The results of the meta-analysis showed that the PSQI score of the diabetic population in the DR group  was significantly higher than that in the NO DR group (control group), and the difference was statistically significant , suggesting that the PSQI score is associated with DR risk and is a risk factor for DR. (2 = 0%), so the fixed effect model was also used. The results of the meta-analysis showed that the ESS score of the diabetic population in the DR group  was significantly higher than that in the NO DR group (control group), and the difference was statistically significant , suggesting that the ESS score is associated with DR risk and is also a risk factor for DR , so the fixed effect model was used. The meta-analysis results showed that the fixed effect model was , suggesting that compared with patients with normal sleep duration, the prevalence of DR in diabetic patients with long sleep duration was significantly higher , so the fixed effect model was used. The meta-analysis results showed that the fixed effect model was , P = 0.003), suggesting that compared with patients with normal sleep duration, the prevalence of DR in diabetic patients with short sleep duration was significantly higher .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Afghan refugees and asylum seekers constitute one of the largest groups that live in camp settings in Greece. While they experience psychological distress, they are facing significant barriers in accessing appropriate mental health care. Explanatory Models (EMs) provide a context-sensitive framework for understanding the differences between health professionals, refugees and NGOs that operate on the field. This study aims at further understanding how Afghan refugees perceive and explain depression and largely psychological distress, and how this influences their choices for coping strategies and help-seeking.N = 19, 12 female and 7 male) residing largely in camp settings in Northern Greece. The vignette describes a fictional person with symptoms of depression in line with DSM-5 and ICD-10 criteria. The interviews were recorded, transcribed, and analysed through template analysis.This qualitative study included six vignette-based semi-structured focus-group discussions with Afghan refugees and asylum-seekers  and Post-migration Living Difficulties (PMLD) relating to camp settings. Female participants identified gender-based and domestic violence as contributing to psychological distress while males highlighted conflict and persecution. Life in the camp with associated inactivity, and uncertainty for the future, was perceived as a significant risk factor for psychological distress among females and males. In terms of coping strategies, females tended to focus on mobilizing collective resources within the camp , while males advocated for self-empowerment and solution-oriented coping. The value of engagement in peer helper-roles was highlighted.The results highlight the potential value of community-based psychosocial approaches to support and promote mental health within camp settings. Additionally, they may inform policies and practices regarding access to appropriate mental health care for Afghan refugees. Further research is needed to establish the efficiency of such interventions in this context.The online version contains supplementary material available at 10.1186/s12888-023-04613-2. In April 2021 there were around 6,6 million forcibly displaced people living in refugee camps worldwide –6. AragoHealth systems in camps must manage a wide range of mental, neurological and substance use problems . While aNearly 6 million Afghans have been displaced from their homes, with nearly half of those fleeing to other countries . High ilStudies on EMs among Afghans in exile show that in addition to exposure to war and pre-migration trauma, perceived causes of stress include PMLD such as, acculturation, financial concerns, fractured social networks, negative social control, uncertainty about the future, and unemployment , 18–21. Arrival at a camp implies a slow adjustment process to a new and unfamiliar setting . Dire liSince 2014, more than 1.2 million refugees have crossed into Greece , with alThe Hellenic Ministry of Migration & Asylum  reports “either sufficient or suitable food” migrate”, and “when I was in school studying, in Iran and the head mistress came into the classroom, she would open the door and say: “Afghani, come out”. When we were doing the daily prayers, they would ask the Afghani to go to the back of the class. They did not count us as human beings”. s”. Several participants had crossed into Iran with their families, where they faced further struggles and discrimination:“When we were on the boat we fell in the water, and we were in the water for half an hour. And […] we are not very well mentally. So, my other kids are fine, but the one 6-year-old I have now… I think it’s because of the water incident… she is kind of not well. And I am also not well psychologically. I think maybe the shock that was given to her, you know, during falling in the water, has made her this way”. ”. Others recalled life threatening situations during on the way to Europe:Females acknowledged feeling safer in the camp than in Afghanistan. Yet, living in the camp involved other stressors such as uncertainty and inactivity. One commented: “It’s a really difficult situation that we are living in the camp. Of course, you get depression in this situation” . AnotheUncertainty is widely prevalent in camp settings. In our study, uncertainty for the future was emphasized as a major source of distress. One commented, “We don’t know about our own future, what will happen to us. What can we recommend to her? [the vignette character]” . AnotheTalking about causes of mental health problems, participants stressed the restrictive refugee policies and many expressed hopelessness about the future:“Everyone kept telling us that the people who had been rejected once, would definitely be rejected again for the second time. And we were very hopeless. And the fact is that yes, we also got rejected the second time. I was crying all the time. I was completely hopeless. I was worrying about my children. I also gave a third interview, but I did not have any hope at all.”. .”. Rejection of the asylum application could potentially cause separation of families: “We have got accepted, [but] one of my children has received a rejection”. .The issue of having nothing to do in the camp was frequently raised among the causes of mental health problems: “Here there is absolutely nothing. No classes, nothing for women” ; “we ar“One day I was coming back from school […] There was a water source and I went to drink some water. I went alone. There I saw a person whose head was cut [off]. I was only ten years old. I saw cut [them] like that [explains how his neck was cut]. After that my family took me. Everyone from my family came to take me. I had my eyes open all the time at the house. After that, for six or seven months, I didn’t get out.” t.” Participants emphasized that the violent conflicts in Afghanistan contributed to the high levels of distress. Several talked about significant distress connected to witnessing violence, murder and atrocities in their childhood and later in life. One recalled,Another recalled, “I am driving the car on the street and you [hear] explosions in this or that area. Always stress, always fighting” .One of the male interviews took place shortly after Taliban returned to power in Afghanistan in August 2021. The two participants discussed how they followed the events of the violent regime change in, closely through social media. Both talked about distress associated with thinking about the aggravated situation of people in their home country. One commented, “Two days ago, the Taliban attacked a boy and killed him because he was wearing headphones and was listening to music. I have the videos” . The saThe camp was often described as a crowded place of confinement, isolation, and unrest: “In a camp, especially in the camp that we are living, with high walls around the camp, [it] is like a prison here. Every night happens something new to the people. So, this is actually bringing stress” . One stLack of meaningful activities and detachment were also discussed as relevant to life in the camp: “Every day it was the same. I didn’t have anything to do. There was no motivation to do something” , while “The situation in the camp; [there is] no good food, you don’t get good money for a living, [while] you have three sons. The sons want a better school, better area, better life, better [inaudible]. The father is always looking at his sons’ faces. If the babies have no good life the father also has no good life.” e.” Feelings of distress were closely linked to concerns about their children in the camp:The discussions related to the vignette focused on his family situation. One suggested “At least for his [the vignette character’s] children, he needs to make life really well. Now they are young, but in 2–3 or 5 years they will grow up and it’s super difficult, but he has to support them” . Many refugees considered Greece as a temporary stop on their way further into Europe. However, the lengthy legal process and the limited opportunities to move on from Greece were associated with increased distress. One explained that “all of them are thinking about one option: positive result from the asylum interview. To be able to leave this country, to go somewhere else and make a new life over there” . Thus, The participants described a vicious cycle of demotivation and social withdrawal. One states, “I was inside. I didn’t go to classes for the languages. I didn’t meet anyone else. For 6 months it was so difficult for me. I couldn’t talk to anyone […] I was depressed” . PerceiThe escape from the war and adversities in Afghanistan also implied leaving important coping resources behind, extended family members, neighbors, religious counseling, village meeting points, and where available, Afghan psychologists. One stated, “In our own country the situation would also be different because we would have our friends, relatives, family that would not let us be in that situation” .Another, relating to Afghans living in Iran, stated, “In Iran you have your parents they can help you, try to understand you and make life easier for you” .Given that distress was seen as a shared experience among refugees in the camp many emphasized coping with the situation collectively: “You feel ‘ok there are more women that have the same problem’. This makes you feel better and stronger to continue” . CommunSeeking support from remaining family inside and outside the camp was emphasized, “When you have family, you kind of feel that you have support. You kind of share the problems with each other” . SocialHope was a central theme across the focus groups. First, they expressed the hope that difficulties are only temporary. One argued: “We say to ourselves: ‘This shall pass’ and ‘Things shall get better’. And since we all have, you know, psychological problems, this is the sentence we use” .Second, hope centred on a better and safer future in Europe, away from the struggles in Afghanistan, e.g., one mentioned: “They understand that here is Europe, women have rights, and everyone knows about the rights. It will get better and better”.: “Just think about Afghanistan, there’s war, there’s no security, at least here we are safe with our children” . A thir“Participant: The women here are, basically all of them, under the psychiatric care here. I am going to the psychologist for three years and one month now […]Interviewer: That’s very good to hear that you have got help and that you…Participant: Yes, there is no other solution”. .Participants prioritized seeking help within their community when experiencing distress. Yet, professional help was also available in the camp and in some cases in cities nearby. Some shared their experience seeing a psychologist when this was considered the only option:However, there seemed to be ambivalence regarding the efficacy of psychological treatment. One stated, “I went to the psychologist for three months, but I did not get anything good out of it”. Later, explaining how she didn’t receive the help she was looking for, she stated “I really don’t know what could have helped me. And the psychologist wasn’t helping me because she kept saying ‘cry, cry’” . The asUsually when living in Afghanistan, participants would seek help from their social and family networks which might not be available in their current situation: “In our own country the situation would also be different because we would have our friends, relatives, family that would not let us be in that situation” . To remTo the participants’ perspective, being a helper could improve meaningfulness in everyday life and contribute to future opportunities: “Like you see a person living in a refugee camp and working as an interpreter. You will see he is improving, doing lots of things and it really helps you. You see the person working, having a life, coming back” .Becoming formally engaged with NGOs in the camps was described as a way to expand social networks and as a possible gateway to employment: “After a while I went to [name of organization] and I met so many refugees. They were my colleagues. Right now, they have left, they have jobs, some of them left to another country” . The saWhile the males considered the burden of family obligations in the setting of camp life a source of distress, they emphasized that the responsibilities that come with fatherhood could also be a coping resource.: “The important thing is that he has to be strong because of the children. The children are going to look up to their father, to what he is doing. They are going to learn, learn from the father” . Since Cognitive mechanisms such as reframing was suggested as an essential way of relieving distress: “If you want to change the way, I mean a change to Adel [vignette character], you have to be strong, you have to give him the motivation to change his mind” . Other Thinking should eventually lead to action through small steps. One said:“I started thinking I cannot continue with this. I have to change my life. I cannot be in my container all the time. I have to move, I have to change my life. If this situation continues, then I cannot enjoy my life. But step by step, I am happy I did it”. t”. Another participant suggested that “he [the vignette character] can start slowly, slowly to do some activities, to do something better, to feel better” . PractiThus, the males emphasized that the main responsibility lies on themselves to improve their situation. Interestingly, participants emphasized that even God would not solve their problems for you: “Well naturally when people have no other option, they try to refer themselves to God. Now I want to share my personal belief that God will never interfere with peoples’ life. I mean if you pray now for tomorrow, God will not do anything for you if you do not move for yourself.” .Participants did not seem hesitant to seek professional help. For example, they advised the vignette character to talk to a psychologist and a lawyer involved in procedures around asylum seeking. One stated, “the solution for this person is twofold; Having a psychologist and having a lawyer to inform him daily for the procedure and his documents. These two are the solution to his problems.” .In line with previous studies , 23, 44,Consistent with coping literature , the datThere were some noticeable differences between females and males. Females tended to attribute the symptoms of the vignette character more often to gender-based and domestic violence. They highlighted their experience of marrying and giving birth at young ages, and of physical abuse within the family. That is congruent with their long experience of adversities, even while in exile in neighbouring countries, such as Iran . Males tWomen used cognitive restructuring to facilitate hope during their stay in the camps. Hope for themselves, meant hope for their children as well. Braun-Lewensohn, Abu-Kaf  argue thParticipants sought help through different sources. In line with previous research  the inteThe EMs of these Afghan refugees, then, were context-sensitive and flexible in their character, reflecting objective socio-political factors and economic and social constraints and facilitating factors such as the availability of coping resources within the camps, as much as underlying subjective cultural models , 71. WhiLiving in a confined state, due to the structure of the camp as well as the geographic remoteness, offering poor stimuli and increasing the sense of exclusion from society can be associated with a sense of apathy and loss of motivation in what was termed as “institutionalism” by Wing . In thisNotably, religion or spiritual explanations were hardly discussed. While this may partly be due to a lack of willingness to discuss these aspects with European researchers with possible prejudices against Islam , the participants emphasized that although they may find consolation in prayer, even God will not solve their problems. This is congruent to the Islamic emphasis on individual responsibility and self-determination , 78.The study has limitations. First, Afghan body language and culturally relevant expressions might not always be understood to their full extent by the researchers due to language and cultural barriers. A short discussion between the interviewers and interpreter followed the interviews to clarify potential misconceptions. Two Afghan language experts were also consulted to provide insight into the collected material. Second, there may be a gender dimension at play in the interview situation in the two focus-groups with female participants moderated only by a male researcher. To remedy this, the last female focus group was conducted with a female researcher participating alongside a female interpreter and a male researcher. Third, the gender of the interpreter and the translation, might contribute to further misunderstanding and inaccuracies. For that reason, in several instances, we employed an external translator to make sure that data was accurately translated. Additionally to gender, a bias could be attributed to the Iranian origin of one of the interpreters who also was a humanitarian aid worker. The choice to work with this interpreter was made, based on her trust relationships with the population and the fact that she was not working directly with them anymore at the time of the interview. Finally, Covid-19 crisis might have exacerbated the feeling of isolation for these refugees and is likely to have influenced the study results. The pandemic also resulted in variations in how the interviews were conducted, online, hybrid, or face-to-face. While this flexibility facilitated the inclusion of participants, it might have resulted in variability in the report between researchers and participants, access to non-verbal cues, and interaction between participants. Also, the researchers had less control over the location of the hybrid and digital interviews . It shouAn important finding from this study is the view of the refugees that mental health problems are normal and common reactions to extreme experiences and expected to improve through social and emotional support. If individuals do not view common mental health problems as medical issues, they may be less likely to seek care through formal health services and more likely to turn towards informal psychosocial supports within the community . This isThere are significant recommendations that can be derived through this study. First, psychoeducation in appropriate language can help refugees understand and cope with distressing thoughts, emotions, and psychosomatic symptoms. Providing brief and practical information can further reduce barriers of mental health service utilization. Second, there is a growing body of evidence that competence-building activities initiated by the refugees themselves  or engagConclusively, scaling up mental health care in such ways, involving collaboration between different actors on the field, will increase access to culturally appropriate mental health care for refugees facing adversity.However, to establish best practices, more longitudinal studies are needed. Researchers and mental health care providers should recognize possible gender differences in experiences and coping resources within the Afghan refugee population and that trauma among females might be closely related to domestic violence.Additional file 1.