Background: Haiti’s 2010 earthquake devastated social, health, and economic infrastructure and left 2 million persons homeless. Over 6 years later 61,000 people remain displaced, most lacking protection, services, and durable solutions. Structural contexts elevate risks of gender-based violence (GBV) targeting internally displaced (ID) girls and women.Objective: We used an intersectionality framework to explore lived experiences and understanding of violence among ID young men and women in Leogane, Haiti.Methods: We conducted six focus groups, three with ID young women (n = 30) and three with ID young men (n = 30) aged 18–24 years, and 11 in-depth individual interviews with frontline workers in Leogane. Focus groups and interviews were conducted in Kreyol, transcribed verbatim, translated into English, and analyzed using narrative thematic techniques.Results: Findings revealed violence experienced by ID youth was (re)produced at the intersection of gender, poverty, displacement, and age. Multi-level forms of violence included structural (e.g. poverty), community  dimensions. Coping strategies spanned intrapersonal (hope), community , and structural (employment/education) dimensions.Conclusions: Interventions to reduce violence should be tailored to address the social inequities that emerge at the intersection of youth, poverty, displacement, and hegemonic gender norms. Haiti’s 12 January 2010 earthquake led to the collapse of the country’s social, economic, and health infrastructure, resulting in the breakdown of community networks, increased poverty, and sexual violence . One yeaResearch across the globe highlights the relationship between gender-based sexual violence (GBSV), conflict, and precarious living conditions among internally displaced persons. Research with youth ,5 has exInadequate housing in the months and years after Haiti’s earthquake has produced additional survival challenges. The lack of housing after the earthquake resulted in young women exchanging sex for shelter ,7. Lack Intersecting factors increase gender inequities among internally displaced women in Haiti, including poverty, unemployment, insecure housing, and gender norms grounded in hegemonic masculinity ,10. FurtStructural violence is a framework that has been applied to understand how social and structural contexts contribute to health inequalities and unequal life chances in Haiti ,18. ThesGibbs, Sikweyiya, and Jewkes  discuss The study objective is to explore lived experiences and understanding of violence with internally displaced young men and women in Leogane, Haiti.The study was conducted in Leogane, approximately 30 km from Port-au-Prince. Leogane was the epicenter of Haiti’s 2010 earthquake, and 80–90% of its buildings were destroyed, and one-quarter of its 120,000 population died, in the earthquake . This waEligibility criteria for FG participation included persons: aged 18–24 years, self-identified as internally displaced , and residing in Leogane or contiguous areas. We conducted 6 FG with a total of 60 internally displaced youth. This included 3 FG with internally displaced young men  and 3 FG with internally displaced young women . All participants were given an honorarium of $7.00 (USD) for their time and their transportation costs reimbursed. We hired six peer researcher assistants who were internally displaced youth; they included three young men  and three young women . We used peer-driven sampling methods ,31, wherWe conducted 11 KI in-depth individual interviews (IDII). KI were purposively selected for their knowledge of internally displaced youth, and included the peer research assistants described above (n = 6), three internally displaced community health workers working with NEGES, one community youth worker, and one research project coordinator.FG typically lasted 60–75 minutes and IDII typically lasted 60 minutes; both were conducted in private rooms at NEGES in Kreyol and facilitated by study investigators  and a research assistant fluent in English and Kreyol who was also a translator. FG and IDII questions were informed by a semi-structured interview guide and sought to understand the lived experiences of violence among internally displaced youth in Leogane. FG and KI interview questions included: ‘We have heard a lot about violence, especially since the earthquake. What kind of things have you heard about violence targeting women? What are some causes of violence in your community?’Research ethics approval was granted by Women’s College Hospital, University of Toronto, Toronto, Canada and Adelphi University, New York, USA. The informed consent was read aloud to all participants, participants provided written consent in Kreyol, and were offered a copy of the consent form.All FG and interviews were digitally recorded in Kreyol, transcribed verbatim, and then translated into English. Field notes were made after the FG. KI were consulted to clarify transcript data, and findings were presented back to participants at youth community forums. Thematic analysis, a method used to identify, analyze, and report themes in the data, was employed to review the transcripts ,33. Two Participant narratives articulated experiences of violence that were shaped by the intersection of social inequities associated with intersecting social identities of gender, poverty, displacement, and age. Violence was discussed at multiple levels: structural , community , and interpersonal . Strategies for coping included intrapersonal (hope), community , and structural (employment and education opportunities) dimensions.I want to tell the story of the life of people living under tents. Life under the tent is not safe, especially for young women. There was a young woman living under a tent alone, when three young men came in and violated her. After this happened, she wanted to take it to the police, however she was scared that they may come back and kill her. She was also discouraged because no one felt that the police would take charge. (FG young women aged 18–19)Following the earthquake, most people in Leogane were displaced and lived in informal tent cities. Insecure tent housing was discussed as a site of violence. Participants reported many young women viewed insecure housing conditions as unsafe and making them easy targets of sexual violence. Most women expressed feelings of helplessness and being in a constant state of hypervigilance against sexual violence. Despite the presence of local authorities, participants noted sexual violence was commonplace and women were reluctant to report their assaults, as local authorities were believed to be ineffective at addressing these crimes. As one participant explained:In the tent site the vagabonds do whatever they want. You may be sleeping here and your tent is getting unzipped. When you ask who he is, they pull a gun on you and you can’t do anything. A key informant noted the precariousness of living in tents that increases exposure to GBSV:Lack of money is the cause of the violence. A group of men can break into a house to steal, but when they get there they find women, they automatically add rape to their list of crimes, just because. Now the problem with housing. And now they are forced to sleep somewhere that is unsafe. (FG young women aged 20–21)Participants discussed how violence was a result of desperation from high rates of poverty and unemployment. Poverty and GBSV intersected as women discussed men may intend to conduct a robbery and, if women were present, may also perpetrate sexual violence:When the earthquake just happened, all the time they are raping somebody or commit a violent act. Because there is no security in the tents. You may be in a tent and they set it on fire. There are no jobs. It is due to high unemployment rates. (CHW 3)A key informant noted unemployment and insecure housing converged with a lack of law enforcement to produce GBSV:I know a 17-year-old guy by my house that raped a 5-year-old. When the child’s mother came home she found her child covered in blood. The 17-year-old was at his house for 2 days, no one said anything and on the second day he saw the police outside his door ready to come get him. He spent 4 months in jail. He was in Leogane and then Ti Guave and after that you know, ‘deux cabrit maigre pas cuite’ (two skinny goats can’t cook), which means the 17-year old’s parents have a lot of contacts. The little girl’s parents don’t have any contacts. So with all these big heads involved, they simply have to shake the judge’s hand and ask him for what they want and need. So now this little girl’s life is taking a turn for the worse. (FG young men aged 20–21)Persons living in poverty experiencing GBSV were discussed as less likely to receive justice:I think it’s mainly a relationship of power. Generally, the woman, even though they love someone, they will look for the person that can provide them security, food, housing. I think the insecurity here, it’s such a big deal, people, in general, but mostly women, since, in the culture it’s still the man that will provide everything for the family. The man is the one that works, gets the money. The women stay at home with the kids. There are a lot of women that get beaten up and they won’t tell anything because they don’t want the man to leave. It’s the same for the young people. (KI 1)In addition to strangers perpetrating GBSV, participants also discussed how women’s poverty reduced their relationship power and enhanced vulnerability to IPV:In Leogane the young men do not respect women. There is economic hardship. There is no work and young girls do not go to school. She decides to sell her body so that she can eat or to make money to go to school. The men who have money want young girls. Because she is in need, whether she was interested in him or not she sleeps with him. (FG young women aged 20–21)Poverty contributed to young women’s engagement in survival sex work, including sex work for money, food, and/or education. A FG participant articulated:There could be something that the young people want but the parents don’t have the means to provide it, especially for the women. There could be a job posting and you go to an interview. You may have the skills to get the job but the boss says no, you must sleep with him first before he gives you the job. More men work than women. Now the women don’t have the possibilities. And they get abused in various ways. The above narrative elucidates the intersection of inequitable gender norms (‘the young men do not respect women’) and poverty that results in women and girls’ involvement in survival sex work. A youth peer leader further explained gender discrimination in the workforce that could lead to women’s sexual exploitation:Well it’s something that I can tell you that all Haitians already know. The major problem is hunger. Hunger. Once there is hunger in a country, the country will not function properly. The more a child doesn’t eat properly…. Sometimes, someone doesn’t need to know the person to offer him or her food. And just that can cause them to do things they don’t want to do, like have sex without condoms. And they could then catch HIV. (FG young men aged 20–21)A male FG participant discussed survival sex in the context of food insecurity:because you are not in a good economic situation, if the person does something for you, you are forced to sleep with him even if you did not want to. This is another type of violence because you did it, but did not do it voluntarily. (FG young women aged 22–24)Another FG participant discussed survival sex work as a form of violence:In my opinion, just because I gave a girl something I wouldn’t expect her to ‘pay me back’ by sleeping with me. And I also think that I could be in need and that the girl is the one that gets me out of trouble. If that was the case I wouldn’t feel required to do anything either. Some girls are like that. She will come by you with a problem and say she needs $50 for hair products or something. But the fact that she asked you, if you don’t do anything she’ll say that you’re gay. (FG young men aged 22–24)A male participant explained that gender norms around masculinity may contribute to men asking for sex as payment for gifts to women:I’ve heard of stories like that, young girls, that their own parents, their own father, will just ask them … not even ask them, just say, you do that, you’re going to sell your body so we can have some money. But the fact that there’s still a separation between what women can do and what men can do, and their role in the society, so that’s why, I think, you see that there are more girls that are selling their bodies or their services, as opposed to men, that will go work at more respectable jobs. They will risk themselves and health to help their family. (KI 2)This narrative also highlights a double standard, where a boy receiving a girl’s help will not be expected to repay the favor with sex. A key informant discussed family members’ involvement in having girls engage in survival sex to support the family:This narrative also highlights the gender inequities in society that constrain women’s employment opportunities and converge with women’s gender role expectations as caregivers.Participants discussed multi-level coping strategies, including hope, social support, and education and employment opportunities.People are people but not everyone has the same objective. I want to accomplish something so I can help my entire family. I have always said that I will get in a relationship when I am ready, when I have accomplished certain things. I have a job then I can have a relationship. But there are young ladies who don’t see it like that, if a guy is talking to them, they answer. (FG young women aged 18–19)Participants discussed hope as a motivator for working towards goals. A young woman discussed how her hope helped her to prioritize a job over a relationship:I will like to have the possibilities. In the same manner some older people used to help me and guide, I will like to do the same to the younger people. My hope comes from the way I live, the way that I understand life, the way I find people who give advice. My hope is someday I will help the young girls so maybe they will be able to change some aspects of their lives. (FG young women aged 22–24)Another participant discussed hope as a motivation for helping other young girls:This is an ox that I have and that I love a lot. Because the way you see it now, he is how I will be earning some money tomorrow. All of my hope lies in him. I already told you that when I need to pay for school or school materials, it’s this little ox that makes it possible. (FG young men aged 18–19)A young man discussed how his animal, representing his livelihood, helped to give him hope in reaching his goals for the future:Participants discussed how community support and reciprocity helped with coping and maintaining hope. A community health worker discussed the idea of reciprocity, being helped by others and helping others in return: ‘What really gives me hope? I always find people that encourage me. When I have, I share. I do good deeds. I help. While I am helping, I find those who also help me too’ (CHW 4).I can also help my community. I don’t exactly need to be a mayor to help my community; there are many other ways that I can help. I am an orphan living with people. That is why today I am proud. All these people, all the family welcomes me and appreciates me. A male youth leader also expressed the impact of community support on his life and willingness to help his community:Participants expressed that education and employment were central to improving their lives and providing hope. A CHW situated their hope within access to education, employment, as well as faith: ‘School, work, and God give me hope. All that!’ (CHW 3). A FG participant discussed wanting HIV education to be shared with others, as well as the need for employment: ‘I would like to see what we learned here to be shared with others, I would like to see jobs’ (FG young women aged 22–24). Another youth leader discussed how support with her education helped her strive for her dreams: ‘I have hope because I believe in it first of all. I go to school and I have people who want to support me with my dreams’ .Structural , community , and interpersonal  dimensions of violence are represented as social ecological levels that connect with – and provide the context for – intersecting identities of youth, poverty, gender, and displacement. The overlapping circles for the identities reflect one of the central tenets of intersectionality, which is the interdependent and mutually constitutive nature of social identities [A conceptual framework of intersectional violence that integrates the themes in our analyses is presented in entities ,24,25. Tentities , and theOur study’s exploration of violence reveals that violence is situated at the intersection of gender dynamics, poverty, young age, and displacement for internally displaced young men and women in Haiti. Violence was discussed as complex and multi-level, operating across structural, community, and interpersonal levels. Our findings suggest that poverty is a significant underlying factor in contributing to violence; both young men and young women described desperation and unemployment as root causes of men’s involvement in GBV. Displacement resulted in precarious housing in tents; this increased young women’s exposure to GBSV. Extreme poverty and a lack of employment opportunities converged with gendered expectations for girls to support their family, and for girls to repay any assistance received from boys with sex: the urgent need to meet basic survival needs intersected with these gendered expectations to contribute to girls’ involvement in transactional sex.direct  and indirect (e.g. housing insecurity); these converged to produce latent violence, the pervasive feeling that danger and conflict could emerge at any time . Narratives also highlighted psychological violence [A lack of educational and employment opportunities constrained youths’ ability to realize their potential: this reflects Galtung’s  conceptuviolence , or violOur findings corroborate literature that elucidates how social processes that (re)produce gender hierarchies are complicated by intersecting social positions such as poverty and age . Young mResearch conducted before Haiti’s 2010 earthquake highlighted that men’s perpetration of IPV was associated with men’s unemployment, neighborhood poverty, and men’s endorsement of traditional gender roles, including a man’s right to beat his wife ,35. We fThere are study limitations. We separated FG by gender to reduce the influence of hegemonic gender norms  on partiOur findings have implications for multi-level interventions to reduce GBV among internally displaced youth. The Internal Displacement Monitoring Centre recommends that strategies with internally displaced people should focus on employment and income generation, as well as how displacement impacts social and psychological worlds . Shelter


N = 357) were explicitly asked to describe a memory they had of an everyday ‘experience which involved nature,’ as well as an everyday ‘experience which involved shopping.’ The open-ended responses to these questions were analyzed both quantitatively and qualitatively. Nature experiences were generally found to be more positive than shopping experiences, and they were more likely to be rated as ‘peaceful’ and ‘active’ compared to shopping experiences. Follow-up analyses indicate a significant interaction between experience category (nature or shopping), and the relationship between connectedness to nature and the amount of pleasure associated with that experience: The more strongly connected to nature a respondent was, the larger the disparity between the pleasantness of the shopping experience and that of the experience in nature tended to be.Although a growing volume of empirical research shows that being in nature is important for human wellbeing, the definition of what constitutes an ‘experience in nature,’ and how this is different from other types of experiences, is very often left implied. In this paper we contrast everyday experiences involving nature with a category of everyday experience in which most people regularly partake. We present an exploratory study in which people ( There is a growing volume of empirical research demonstrating that being in nature is important for human wellbeing, as it, for example, facilitates attention restoration  and has Research on these effects has referred to a number of different representations of nature, ranging from static representations such as pictures  to imagiWe conceptualize everyday experiences here as a person-environment relationship using the perspective of the “lived day of an individual” . In broaa priori assumptions about the valence of an experience, but contrast two types of experiences that, in principle, could be both either recreational or part of an everyday chore , and that could both be perceived as either pleasant or unpleasant . We investigate neither practices nor social representations . Thirty-five percent of all participants had children, and 57% had completed a university-level qualification. The majority, namely 271 of these participants, were recruited via an on-line survey described as an “everyday experiences questionnaire,” and the remaining 86 participants were approached in public places in the city center of Aberdeen, United Kingdom, and asked to fill in a paper-version of the questionnaire. The reason for adding the face-to-face sample was to maximize the variability of responses to the shopping question (because people approached in the city center were very likely to have been shopping recently). Exploratory analysis of the differences between the two samples found that as expected, the face-to-face sample tended to rate the shopping experience as more pleasant and peaceful when compared with the online sample. Given the exploratory nature of this study, we therefore decided that the additional variation in the range of responses added by the face-to-face sample justified the data being included in the overall data set. Due to anonymity and the convenience nature of the sample, we do not have sufficient information about the respondent’s place of residence. However, from the descriptions of experiences, we can infer that the majority were based in the north east of Scotland.A convenience sample was recruited consisting of 357 participants . The mean age of participants was 39 (Please describe a recent experience you have had which you would describe as:” followed by (1) “An experience which involved nature” and (2) “An experience which involved shopping.” The order of question presentation was not counterbalanced, so participants always answered the question about nature first. Participants were asked to write a few sentences describing the experience that came to mind. Following this, participants were asked to rate their self-elicited experience on eight 7-point semantic differential scales: ‘familiar – unfamiliar’, ‘pleasant – unpleasant,’ ‘active – passive,’ ‘arousing – not arousing,’ ‘simple – complex,’ ‘peaceful – not peaceful,’ ‘in control – not in control,’ ‘difficult – easy.’We used an autobiographical memory retrieval method similar to that described by I often feel a kinship with animals and plants”) was not included in the paper version of the questionnaire by mistake; therefore, all analyses were done on a 13-item version of the scale, with a Cronbach’s alpha of 0.81.Connectedness to nature was measured using the ‘connectedness to nature scale’ , which aFor both the paper-and-pencil and the on-line version of the questionnaire, participants were provided with a page of information about the study and the wider project of which this study was part, and then given assurances of anonymity, before asking for written confirmation of informed consent. The only notable difference between the on-line and the paper-and-pencil version of the questionnaire was that we added some data-checks to the on-line version to minimize missing data. The question order was the same for both the paper and the on-line questionnaire. The questionnaire took approximately 15 min to complete.a priori theoretical assumptions, but based on structures that emerged from the data. For the qualitative part of the analysis, in line with our objective to explore what ‘an experience that involves nature’ and ‘an experience that involves shopping’ meant to our respondents, this open-ended, exploratory approach seemed the most appropriate. In a first step, we explored the data to identify recurrent themes as well as striking arguments and patterns. These related to several different dimensions of the experiences described by our interviewees, including the places where the experience took place, the activities involved, the description of sensations and feelings, and social factors. In the nature-related experiences, encounters with non-human beings or particular features of nature were important part of the descriptions, whereas for the shopping experiences, the purpose of the activity  played an important role in these accounts. Based on these themes, we then formed coding categories which constitute the backbone of the presentation of findings in the first two parts of the results section. These aim to provide an overview of the range of experiences that together constituted the two categories.For the qualitative analysis of the responses to the open-ended questions that asked for a description of experiences with nature and shopping, we used a grounded, data-driven approach, chiefly guided by The questionnaire items were designed to elicit discrete ordered ratings on each of the semantic differential. Consequently, we use median values to describe them because they are more appropriate measures of central tendency for ordered data than mean values. We compare the scores on each individual semantic differential between experience categories using a Wilcoxon Signed-Ranks test, and in the regression model we focus on the semantic differential ‘pleasant–unpleasant,’ and model the response variable as ordinal.Figure 1.Prior to constructing the ordinal regression model (see below), in order to aid interpretation, we created a binned variable for connectedness to nature by dividing the distribution of CNS scores into terciles (with cutpoints at scores 3.38 and 3.9), ranging from ‘1’ representing low connectedness to ‘3’ representing high levels of connectedness. The raw data distribution (prior to binning) can be seen in We then examined the relationship between people’s connectedness to nature and their ratings of how pleasant their experiences were for both categories (nature and shopping) via a cumulative logit model  in whichIn order to find a simplified model with the best possible fit, we tested the proportional odds assumption of equal slopes across the response categories. The assumption did not hold for our data; therefore, the final model specification is that of a partial proportional odds model where the assumption is relaxed for the categorical variable  experience.Additionally, the cumulative logit model takes into account that, by definition, the rating scale for the pleasantness variable is symmetric . Cumulative logit models rely on the concept of thresholds on a continuous latent scale, which are cut-points defining the categories of the ordinal response variable. The threshold coefficients are parameters that allow us to calculate the points in the latent scale where responses might be predicted into a higher category and the corresponding slopes . The relevance of these coefficients and one of the strengths of an ordinal model (versus a linear regression model) is that they allow us to calculate response category probabilities if required .All statistical analyses were carried out in R , and theexperience which involved nature” referred to direct, unmediated experiences – except for single statements, describing browsing through a nature book and composing a piece made out of birdsong, respectively – and nature outdoors – except for single contributions referring to the tending of indoor plants, and one on a visit to a zoo.All responses to our request to describe a recent “Being atop Bennachie  in a snow storm, the realization of how close to death I was truly opened my eyes.”In the vast majority of cases, respondents described indeed – as framed by the questionnaire heading “Everyday experiences” – moments or activities that were part of their everyday life, such as dog walking, running or gardening. Only very few statements referred to experiences in an everyday environment that constituted extreme occasions: “This is difficult for me to think about because I feel that I do not experience nature very often. I guess to some extent watching my chameleon climbing around in its tank could be an experience of nature but like most other things its artificial and man made. Even when we think [they] are natural they are not really.”Overall, this suggested that respondents felt that they had indeed something to say about ‘ordinary’ (as opposed to ‘spectacular’) nature experiences. Only very few respondents explicitly struggled with the question: “I was watching some baby starlings being fed when I noticed one was sitting down and not moving. They all flew off together, including the seated one, only to return minutes later. The seated one again just flopped down and I realized it had either no legs or leg damage and therefore could not stand up. As the mother was feeding those which mobbed her and not the seated one, I am assuming that while he was in the nest, his chances were the same as the others, the problem arose once he left the nest. Felt quite sad after that.”Many responses referred to physical activities, such as running, hiking, going for a walk, or walking the dog. Others described experiences made in their own garden or allotment, but also local woodlands, beaches and urban parks were mentioned repeatedly. Strikingly, many statements mentioned sensations such as views, sounds, smells or the feeling of sun, grass or wind on one’s skin. Of particular relevance seemed to be sunshine and warm, dry weather. Seeing colors (such as a “wonderful fresh green”), trees, flowers, landscape (features) and animals were another very important element of our respondents’ sensory experiences. Most prominently, respondents described seeing and observing animals as their experience of nature – such sights could be fleeting  or targeted and over a longer period of time: “Watching a Thrush break a snail shell on a stone in my garden, it was completely absorbed with the task and totally unaware of me even though I came upon it in quite a noisy fashion.”Typically, such observations took place in the respondent’s garden: “Driving near home and spotting a red kite flying over the field right by us. It was brilliant to see this magnificent bird for its own sake, and also because I know they have only recently been reintroduced to this area.”And often, sensory experiences were seen to gain in meaning because of the respondent’s knowledge about its context: “Successfully, after 5 years, teaching a blackbird to whistle the opening bars of Beethoven’s 5th Symphony, and also imitate me calling the cats, wolf-whistling. This happened a few years ago but to my mind is my greatest achievement!”It seemed that respondents described experiences of interaction with animals in a particularly fond way: “I found a small frog in my cellar yesterday which I was very pleased to be able to release into my garden.”This was particularly the case where this interaction involved the rescue of an animal: “Being out for a walk with my dog and looking at the trees and wildlife that surrounded me. I find it stimulating to be out in the fresh air and relaxing when I’m in the fields and woods that surround my house. I appreciate the green vibrant landscape and it makes me feel connected with the earth and all that has to offer.”In some cases, these feelings, as well as the sensory aspects of the experiences, triggered more abstract, situation-transcendent thoughts (as in the example of the snowstorm above) that tended to be positive and happiness-inducing: “At the weekend I took my son and his friend to Drum castle so we could walk the dog. The boys spent a lot of time playing at the pond, clearing leaves and watching the water flow while I sat in the sunshine and the dog ran around exploring.”Many statements emphasized that being with friends or family was an essential part of the experience of nature, while others particularly valued solitude and the absence of other people (maybe apart from one’s companion). Several respondents described how they found solitude in an otherwise crowded (maybe peri-urban) environment by enjoying nature, for example, in the early morning, when no other people were around. For some parents, their children almost seemed to be proxies of their own nature experience: “My friend visited me in Aberdeen and we walked along the beach, appreciating the scenery. It was very enjoyable. The oil tankers were out and it was sunny so it was very picturesque!”Only a few responses referred exclusively to inanimate nature, such as the sun. Interestingly, several respondents did not strictly distinguish between the ‘natural’ and human-made environment: “Overall, it seemed that nature experiences were often described in very warm and fond terms. Even where experiences were negative, they were portrayed as sad  or as a challenge  rather than as outright unpleasant. In the majority of cases, gardens – as one’s own private, sheltered space – and parks, as well as other locations in the vicinity of the respondents were mentioned as the place where nature experiences took place. Such experiences were usually not intentional, but coincidental, occurring, for example, while going for a run or walk, and had very strong sensory components.Responses to our request to describe an experience that involved shopping fell usually into one of three categories – the purchase of groceries in a supermarket, the purchase of groceries in a smaller shop, and the purchase of non-food items such as clothes. Of this last category several referred to experiences in other countries – however, being set in known types of environments such as malls, these were not necessarily portrayed as special or unique. Others described an online shopping experience, and a small number of participants chose to narrate an event which happened while they were shopping, but that in itself did not constitute an act of shopping, such as singing a love song to strangers in a supermarket, or observing a shoplifter. Interestingly, a large part of the responses focused on an unsuccessful search for an item that was wanted or needed.Searching for a dress to wear for a party”; “I went to buy shoes on Thursday after work and the shop was closed – it doesn’t open late on Thursdays”). However, among those that included an assessment of the experience, many portrayed shopping as an admittedly necessary but frustrating and stressful “chore.” Many participants considered time spent on shopping as time wasted, and reducing the time needed for a shopping trip was regarded as an achievement. In line with this, shopping environments were typically described as busy and noisy places that triggered feelings of boredom, stress and time pressure. The phrase “I hate shopping” was repeatedly used, and terms such as “hurry,” “grab,” and “whizz” illustrated the prevalent perception of shopping taking up too much of one’s life time. Statements that described positive experiences often noted their surprise at a positive atmosphere which made the experience enjoyable: “…and strangely it was very quiet and stress free. Even the staff were cheery.”Overall, a large part of the statements under this category did – as in the category of nature-related experiences – not include an evaluation , very few participants were outright negative about their shopping companions. Others described how knowing other customers and the staff of a shop made their shopping experience more pleasurable, and several participants mentioned how shopping helped them to bond with their teenage children – usually daughters: “Overall, experiences that involved shopping were thus described as more stressful and oppressing than experiences that involved nature, which were generally characterized as restorative. This might have been partly due to the perception of shopping as a duty, necessity or chore, whereas being in nature – at least among our study participants – was usually by choice. In both cases, social aspects played an important role, and while crowded environments were often referred to as stress-inducing, being with friends and family usually enhanced an experience and made it pleasant. This seemed especially important for the relationship between teenage daughter and parent in the case of shopping, whereas comments on experiences in nature usually referred to younger children.Figure 2). When filling in the semantic differential scales immediately after providing their experience description, a Wilcoxon Signed-Ranks test indicated that on average participants reported their recollected ‘nature’ experiences as being significantly more pleasant (Mdn = 1) than their recollected ‘shopping’ experiences (Mdn = 4), Z = -12.77, p < 0.01, r = -0.68. Participants also reported ‘nature experiences’ as being significantly more peaceful (Mdn = 1) than shopping experiences (Mdn = 5), Z = -14.76, p < 0.01, r = -0.78. On average, participants found their recalled ‘nature’ experiences to be more arousing (Mdn = 3) than their ‘shopping’ experiences (Mdn = 6), Z = -9.34, p < 0.01, r = -0.49, and more active (Mdn = 2) than their shopping experiences (Mdn = 3), Z = -3.3, p < 0.01, r = -0.17. Participants also experienced nature experiences as simpler (Mdn = 2) than shopping experiences (Mdn = 4), Z = -8.56, p < 0.01, r = -0.45, and ‘easier’ Mdn = 6) than shopping experiences (Mdn = 4), Z = -8.47, p < 0.01, r = -0.45.Overall, experiences with nature tended to be perceived significantly differently from shopping experiences , with people with higher scores on CNS rating nature experiences as more pleasant.There was a statistically significant association (at 5% significance level) between CNS and the rating of pleasantness of the recalled nature experience (Table 1) showed that there was a statistically significant interaction between connectedness to nature and experience category (shopping versus nature), both when comparing medium to low, and high to low levels of CNS. Essentially this means that people who scored high on connectedness to nature were likely to feel more pleasure when experiencing nature, and less pleasure when shopping. Similarly, people with low scores on connectedness to nature were likely to report higher levels of pleasure from shopping experiences, and lower pleasure with nature experiences. However, in absolute terms, nature experiences were for all three groups more pleasurable than shopping experiences.As noted in the approach to analysis section, in order to aid interpretation of the ordinal model, we created a binned variable for connectedness to nature by dividing the distribution into terciles. The cumulative logit model  and the relationship between connectedness to nature and the rated pleasantness of the recalled experience. The finding that higher levels of nature connectedness are associated with greater levels of pleasantness in recalled nature-related experiences is what we would expect from the literature on connectedness, as this is implied by the link to psychological wellbeing in much of the writings on this topic  might also have led to a self-selection of nature-interested respondents, so any follow-up study should randomize the category order to enable any such effects to be ruled out.In relation to the issue of question order, it is of course possible that the recollection of nature-related experiences in the first part of the questionnaire acted as a prime for later responses in the questionnaire on the connectedness to nature scale. One area of research that may benefit from considering the findings presented here is the study of pro-environmental behavior. Studies have reported findings showing a positive association between connectedness to nature and pro-environmental behavior . Other sThis study has explored the variation of responses to two common categories of everyday experience – namely nature and shopping. Experiences involving nature are often drawn on as a given category in environmental psychology (often in opposition to the built environment). Here we go beyond this and provide insights into the variability of remembered experiences associated with both ‘nature’ and ‘shopping.’ Although nature experiences were generally found to be more pleasant and to bring to mind more positive memories compared to shopping experiences, the results were far from clear-cut.More research is needed here, but this study has demonstrated that the two categories studied here, nature and shopping, provide an interesting point of comparison when examining people’s responses to different categories of everyday experience.The wider project of which this study was part (RES-355-25-0012) underwent ethical review, and the study was carried out in accordance with the recommendations of the ethics committee of the project coordinator with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. At the time that the research was carried out, The James Hutton Institute did not have its own research ethics committee, but the protocol for the core questionnaire used across the wider project was approved by the research ethics committee of the project coordinator, and this study did not deviate from this protocol.TC was the principal investigator for this study. He conceived and designed the study and led the writing of the paper. AF contributed to the early discussions of the study design, analyzed the qualitative data, and contributed to the preparation of the manuscript. AL-A carried out important parts of the statistical analysis, and contributed to the preparation of the manuscript.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.


As a high school student in Salinas, California, Irene Vera was part of the Youth Community Council, a project of the University of California, Berkeley, Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS). This project aims to train local youth as environmental health leaders through research, education, and advocacy, and it was through the Youth Community Council that Vera learned about potential endocrine-disrupting chemicals in personal care products. She and fellow council members worked with Kim Harley, an environmental health scientist at UC Berkeley, to study how teen girls are exposed to these chemicals and steps they can take to lower their exposures.hermosa means “beautiful” in Spanish). These compounds have shown endocrine activity in animal and cell studies.,,,The HERMOSA  study measured the exposure of Latina teens to certain phthalates, parabens, triclosan, and benzophenone-3 in makeup and other personal care products (Women are disproportionately exposed to phthalates and parabens because they use more personal care products on average than men.What remains unclear, however, is whether these exposures actually harm people. “We don’t know if there are long-term health effects of [these] chemicals, but we have reasons to be concerned about exposure to teenage girls, who often use a lot of these products during a time of rapid reproductive development,” Harley says.It is also unclear how much of a person’s total exposure comes specifically from personal care products. Parabens, phthalates, benzophenone-3, and triclosan are widely used, says Ruthann Rudel, director of research at the Silent Spring Institute. “With chemicals that are so common,” she says, “it’s hard to know which sources influence exposure the most.” Rudel was not involved in the study.Vera and the other teens on the Youth Community Council were involved with every aspect of the study, from recruiting participants to analyzing data. The students enrolled friends and classmates for a final sample size of 100 Latina adolescents from around the Salinas area. All the girls were educated on the potential risks of endocrine disruptors as a way to motivate both participation and compliance with the study protocol.Girls who agreed to participate were provided with replacement personal care products and instructed to use these alternatives for 3 days. The replacement products were chosen on the basis of whether their ingredient lists included triclosan, BP-3, or parabens. Phthalates are not listed on ingredient lists, but they are often found in scented products. So the researchers avoided products that listed “fragrance” as an ingredient unless they were specifically labeled as phthalate free.Urine samples were collected at the beginning and end of the 3-day period. Analyses of urine samples showed that more than 90% of the HERMOSA participants had detectible levels of phthalates, parabens, and benzophenone-3 before they started using the replacement products, with most levels higher than average concentrations estimated for teens in the general U.S. population.After using the alternative products for 3 days, however, urinary concentrations of methyl and propyl paraben decreased by 43.9% and 45.4%, respectively, mono-ethyl phthalate decreased by 27.4%, and triclosan decreased by 35.7%. On the other hand, there were increases in concentrations of butyl and ethyl paraben, which were detected in about half the girls. The authors suggest that these chemicals might have been unintentional contaminants or unlabeled ingredients in replacement products, which they acknowledge they were unable to ensure were paraben free.These results indicate that consumer choices can affect exposures to the study compounds. “We were really pleased to see that after three days, [most] levels decreased by twenty-five to forty-five percent, on average,” Harley says. “When we started the project, we hadn’t seen any other studies that showed changing your personal care products and makeup would lower your levels of these [chemicals].”Sheela Sathyanarayana, an environmental health scientist at the University of Washington, has high praise for how the study was carried out. “It was a very well-conducted study and an incredibly savvy approach to involve the study participants in their own research project. This only adds to the quality of the work,” says Sathyanarayana, who was not involved with the study.Vera, now a sophomore at UC Santa Cruz, says the project sparked a desire to pursue a career in environmental law and policy. It also influenced her thinking on the personal care products she chooses. “I had never heard of these chemicals or looked at the labels on my personal care products until this project,” she says. But now, she adds, “I’ve switched out face, hair, and body products for … low-chemical replacements as a result of this work.”


The practicality of applying evidence to healthcare systems with the aim of implementing change is an ongoing challenge for practitioners, policy makers, and academics. Shared decision- making (SDM), a method of medical decision-making that allows a balanced relationship between patients, physicians, and other key players in the medical decision process, is purported to improve patient and system outcomes. Despite the oft-mentioned benefits, there are gaps in the current literature between theory and implementation that would benefit from a realist approach given the value of this methodology to analyze complex interventions. In this protocol, we outline a study that will explore: “In which situations, how, why, and for whom does SDM between patients and health care providers contribute to improved decision making?”A seven step iterative process will be described including preliminary theory development, establishment of a search strategy, selection and appraisal of literature, data extraction, analysis and synthesis of extracted results from literature, and formation of a revised program theory with the input of patients, physicians, nurse navigators, and policy makers from a stakeholder session.The goal of the realist review will be to identify and refine a program theory for SDM through the identification of mechanisms which shape the characteristics of when, how, and why SDM will, and will not, work.CRD42017062609PROSPERO The online version of this article (doi:10.1186/s13643-017-0508-5) contains supplementary material, which is available to authorized users. Shared decision-making (SDM) is a model of decision-making that focuses on a balanced relationship between patients and physicians in order to make a mutually agreed upon medical treatment decision , 2. SDM SDM effectiveness has been extensively assessed; however, there is variable evidence that SDM improves the quality of care for a given patient , 13. DurA particularly well-cited model of SDM, the interprofessional shared decision-making model (IP-SDM) –18, focuDespite extensive research in the field of SDM, there is little systematic integration of SDM into clinical practice –22. EvidAs a consequence of the current state of literature, there is a lack of testable hypotheses of how, why, and in which contexts SDM is successful. To bridge this gap, we intend to conduct a realist review that draws on both primary and secondary data sources. Embedded in realist philosophy is the acknowledgement that the world is “real” but is perceived, interpreted, and responded to through human processes such as language and culture. Realist methodology accounts for both “reality” and human responses to reality in how outcomes are understood . OriginaThe use of realist review makes program theory explicit by developing testable hypotheses about how, for whom, and in which contexts a given intervention or program is thought to work –33. RealThe proposed realist review will allow the formation of testable hypotheses to assist in forming a stronger understanding of SDM. The results of the review will identify hypotheses for subsequent realist evaluations using the following configuration: a context (C) that triggers a mechanism (M) leading to an outcome (O) –33. ContIn realist research, CMO configurations represent a type of middle-range theory. Middle-range theory is a level of theory abstraction that describes uniformities of social behavior that can be expanded to form testable hypotheses by configuring features of an intervention together . Middle-Our team will use realist review methodology to conduct a theory-driven knowledge synthesis. This will enable the development of a program theory that is testable at the intervention level and provide the foundation for testable hypotheses applicable across a range of health care contexts. For example, testable hypotheses will be derived for different clinical subgroups, such as oncology and mental illness. Oncology offers a good example of complex decision-making given the nature of the disease and the multiple, time-constrained decisions that need to be made , 39, heiWhat mechanisms facilitate or hinder engagement in the SDM process?What contexts impact the expression of the identified mechanisms?When do contexts and mechanisms form specific outcomes?As realist review methodology is complex and still evolving, this protocol outlines a detailed process to add to the evolution of this research methodology. Depicting the process will ensure that this review follows a literature informed and consistent methodology. The purpose of the study described in this protocol is to develop a program theory of SDM using realist review methodology. Throughout this process, we intend to iteratively focus our review, guided by any middle-range theories that exist in the SDM literature that we will reformulate into CMO configurations. By employing realist methodology, we will address the following question: “In which situations, how, why, and for whom does SDM between patients and health care providers contribute to improved engagement in the shared decision - making process?” Improved engagement in the shared decision-making process will be specifically related to having a decision that is patient-centered and patient-informed. To address these issues, we will explore:As a team of clinicians, content specialists, a health science librarian, and other researchers, we will approach SDM literature with the intention of developing a program theory. Adapting Molnar’s process for realist reviews , 40, we The preliminary program theory will be derived from the preliminary results of our completed scoping review . Our resOur next step will be a purposive examination of the SDM literature, performed by two team members, beginning with a search using Medline and Google Scholar as it is believed this will provide the most relevant documents. This search is purposive as it is targeting articles focused on shared decision-making and looking for those that provide the most valuable information. Search terms will include: “shared,” “collaborative,” “decision making,” “informed,” “oncology,” “cancer,” “treatment,” “patient(s),” “physician(s),” “clinician(s),” “theory,” “development,” “model(s),” and “framework(s).” The literature on decision-making in cancer will be targeted as an example of complex decision-making, where short timeframes and urgent circumstances exist. However, literature outside of cancer care will also be considered. These search terms were identified by the authors during the scoping review. This preliminary search strategy will be refined as necessary, at the discretion of the two researchers in relation to the relevance of articles returning. An example of the search strategy for Medline can be found in Fig. Using snowball sampling, our team will perform reference searches from the key articles, determined by articles highly cited throughout the SDM field. We will also examine additional publications by influential authors determined by amount of citations, such as France Légaré and Dawn Stacey. Following realist review methodology, that acknowledges non-academic sources as valid, our team will additionally search the gray literature. The use of gray literature often delves into the innermost processes of interventions in greater, more pragmatic detail , especiaOnce we have performed our initial search, we will determine if a secondary search will be performed. The research team will determine necessity based on the depth and extensiveness of literature collected. If the research team members conclude further searching is necessary, two team members, along with the librarian, will expand search terms and utilize other databases, such as EMBASE.To reduce selection bias, two members of our team will independently screen reference and information resources using the following inclusion criteria: (1) exchange between a patient and/or patient’s family and a health care provider, (2) a clinical situation where the patient is legally competent to make their own decision, (3) adult patients (18 years or older) making decisions about their own medical situation, (4) sources from 1980 to present, (5) English-language sources only (due to the language constraints of our team). We will exclude studies on that focus on surrogate decision-making, when patients are unable to be involved . Reviewers will also use Pawson’s criteria of relevance (the applicability of the study to the theory in question) and rigor  to assess each source . Rigor wScreening will be iterative, beginning with all abstracts followed by gray literature and full-text review of identified abstracts. When two members cannot agree on the inclusion of a source, a third member will assess the source to recommend its inclusion or exclusion. Any additional sources that arise from potential additional searches will be reviewed using the same strategy.x” occurs, then “y” will be the result) propositions [To extract data from the sources, two research team members will independently read each source in full to identify the primary and relevant outcomes from each source. Explanatory accounts (EA) will be extracted in the form of “if-then” . Hidden mechanisms will be inferred from the content and clinical expertise within our team. Our team will isolate identified mechanisms and determine how they interact within the procedural steps of IP-SDM, outlined by Légaré [Following extraction and consolidation of our findings into themed EA statements, our research team will synthesize the data into CMO configurations . As EA sy Légaré . This wiCMO configurations will collectively shape our program theory. Guided by literature, our research team of content specialists will then identify which mechanisms are thought to be the “key” in the SDM process. These key mechanisms, anticipated to be processes such as patient anxiety, will be those believed to have a strong impact, either positively and negatively, on the implementation of SDM within medical decision-making. These key mechanisms will be used to revise our preliminary program theory, which will explain how varying contexts may change how these key mechanisms facilitate, or hinder, gradient outcomes (that is facilitate/hinder at varying strengths).Once our revised program theory has been developed, our team will first consult experts within the fields of SDM and realist research, Dr. France Légaré, Dr. Gill Westhorp. Dr. Légaré is currently the Canadian Chair of shared decision-making, and the research team has made contact with her and her team in this regard. We will present the program theory to both expert groups in separate consultations to gather their insights on SDM and realist review. Content experts will be asked if the program theory reflects their understanding of the SDM literature. The methodology expert will ensure that the program theory meets realist review standards. We will document these consultations and use the data from these experts to further confirm, refine, or refute our program theory.We will engage stakeholders who are involved in medical decisions to offer feedback on our program theory. These stakeholders will be physicians, nurse navigators, patients, and policy makers, recruited through the local health region and provincial health ministry. The stakeholder session will be conducted on a single day. All individuals will participate in a single group to further understand the interplay that exists between parties, and how this may impact the identified CMO configurations. Combining participants from an assortment of backgrounds will provide the opportunity to hear from each group that is most directly impact by SDM and afford the participants the opportunity to hear, and react to, the perspectives of others in the SDM process. This session will be semi-structured and audio-recorded. By hosting a stakeholder session with physicians, nurse navigators, patients, and policy makers, we will follow a model developed by Harris and colleagues  for partThis protocol outlines the methodological steps to complete a realist review assessing “In which situations, how, why, and for whom does SDM between patients and health care providers contribute to improved decision making?” The focus of this research is to develop a program theory encompassing the CMOs of when, how, and why SDM is successfully implemented. Using CMO configurations, we will build on IP-SDM to create a more robust understanding of SDM. We will be complying with RAMESES methodological guidelines for realist reviews to produce a sound framework of SDM. Through the identification of mechanisms underlying SDM, implementation of SDM will be more clearly defined, increasing accessibility for knowledge users, such as patients, health care providers and policy makers.Forming a realist-based SDM program theory will contribute to current scholarly knowledge in medical decision-making. Identifying contexts, mechanisms, and outcomes through current literature and key stakeholders, our team will expand the current knowledge of SDM launching further research into SDM implementation within health systems. Study results will be disseminated through peer-reviewed journals, conferences, and as part of a graduate thesis. This research may enhance the uptake and impact of SDM use in medical decision-making. It is anticipated that continued research in this area will improve quality of care for patients and increase efficiency within health care systems.Once the SDM program theory has been developed, the authors intend to conduct realist evaluations in a number of contexts. We plan to examine how the program theory aligns within both fields of mental illness and indigenous health. Further, the program theory will be tested within local cancer centers, to confirm, refine, or refute CMO configurations. It is anticipated that the program theory will continually be revised to identify relevant contexts that impact mechanisms in varying manners.


Associação da Indústria Farmacêutica de Pesquisa , Brazilian counterpart of the Pharmaceutical Research and Manufacturers of America (PhRMA), main lobbying organization of the US pharmaceutical industry, has played a major role in the advocacy of interests of major drug companies. The main goals of Interfarma lobbying activities are: shortening the average time taken by the Brazilian regulatory agency (ANVISA) to approve marketing authorization for a new drug; making the criteria for incorporation of new drugs into SUS  more flexible and speeding up technology incorporation; changing the Country’s ethical clearance system and the ethical requirements for clinical trials to meet the need of the innovative drug industry, and establishing a National Policy for Rare Diseases that allows a prompt incorporation of orphan drugs into SUS. Although lobbying affects community health and well-being, this topic is not in the public health research agenda. The impacts of pharmaceutical lobbying on health policies and health-care costs are of great importance for SUS and deserve to be investigated.In the US, where registration of lobbyists is mandatory, the pharmaceutical industry and private health-care providers spend huge amounts of money seeking to influence health policies and government decisions. In Brazil, where lobbying lacks transparency, there is virtually no data on drug industry expenditure to persuade legislators and government officials of their viewpoints and to influence decision-making according to commercial interests. Since 1990, however, the  The word lobby finds its roots in the Latin term ‘Lobbying as such is not illegal, nor is it necessarily immoral. As long as it is transparent and does not go beyond persuading by argumentation, lobbying is part of the democratic process. Nonetheless, it becomes unethical when lobbyists, in one way or another, provide benefits to legislators and public officials to misdirect decision-making in Congress and government. Under the influence of unethical lobbying, legislators and government officials are prone to favor special private interests instead of serving public interests. In fact, in many cases, it is hard to distinguish unethical lobbying from a thinly veiled bribery and corruption.Advocacy towards the promotion of private interests is generally done by organized groups of people who are paid directly or indirectly by industries, corporations, or associations of companies. In the USA, Canada, Australia, Austria, and some other countries, lobbying is regulated and the registration of professional lobbyists is mandatoryth, 2015) revealed 4,690 documents for the broadest searching term “lobbying”, 129 for “lobbying AND US”, and 10 for “lobbying AND Brazil”. For the alternative search strings “big pharma lobbying”, “pharmaceutical lobbying”, “pharmaceutical lobbying and US”, and “pharmaceutical lobbying AND Brazil”, 4, 106, 9, and 1 documentsAlthough the lobbying done by health-care providers, health insurance companies, and pharmaceutical and health product industries may influence community health and well-being, public health researches have seldom addressed this type of lobbying and its consequences. A search in Medline database Lowering taxes on medicines.Shortening the time taken by the regulatory agency (ANVISA) to approve marketing authorization for a new drug.Removing ‘administrative hurdles’ that prevent a prompt incorporation of new technologies into the Brazilian Unified Healthcare System (SUS).Combating counterfeit medicines, smuggling, and fiscal fraud.Protecting pharmaceutical products from theft and robbery.Lessening ‘bureaucratic constraints’ and redundancies in the ethical clearance system (CEP/CONEP/ANVISA) to speed up study protocol analysis and make the research approval process more flexible.,Interfarma industrious lobby has pressed ANVISA to shorten drug approval time and CONITEC  to be more flexible about cost-effectiveness criteria and to accelerate the incorporation of new drugs and medical technologies into the public health-care system. Interfarma and its affiliated drug companies are also close to achieving one of their greatest victories in Congress. In February 20, 2015, ANVISA published edits that state that, if it does not evaluate applications to conduct phase III trials within 90 days, and the ethical clearance system has approved the study protocol, automatically, applicants are to be considered as being authorized by the agency to initiate the clinical researchopen up the possibility for using placebo-controlled groups even when there is an effective treatment for the medical condition, if a placebo group is necessary “to comply with a justifiable methodological requirement” (Art 27)exempt sponsors from the obligation to ensure post-trial treatment with no charge for patients if there is no risk of death or “clinically relevant worsening” of the disease, and if there is a “satisfactory therapeutic alternative” in the Country for the medical condition (Art 28)allow sponsors to offer money as an incentive for healthy volunteers to take part in phase I trials and drug bio-availability and/or bio-equivalence studies (Art 19 §2)create – in addition to institution ethical committees (CEP) – a new type of ethical committee  that is not linked to a public or private institution;state that a single ethical review clearance by either a CEP or a CI is sufficient to begin a clinical study.,,I, and makes no further remark regarding risks, discomfort, and participants’ will.Another worrisome aspect is that the bill clause that addresses the protection of children and other vulnerable subjects (Art 21)In the last years, Interfarma has lobbied for what it calls a “National Policy for Rare Diseases” (NPRD) in Brazil,,,Like the wolf in sheep’s clothing of Aesop’s fable, pharmaceutical lobbying often hides its real intent under the guise of patients’ or doctors’ claims. It has become a common fact that patients’ organizations are in the forefront of lobbying campaigns for new drug approval and incorporation into SUS. Nonetheless, patients’ organizations generally rely on financial support from pharmaceutical companies, and such relationships are not fully transparent-sponsored “parliamentary study missions on innovation policies” to the US and the UK in 2011 (18 Congress members), 2012 (11 members), 2013 (7 members), and 2015Furthermore, lobbying strategies often disguise drug companies’ real purposes by hiding them under the cover of a general claim of Brazilian society. Examples along this line are the InterfarmaIn conclusion, lobbying as such is not necessarily bad and at times it may be justifiable and needed . For democracy’s sake, however, it must be transparent, and a mandatory lobby register must be setup in the Country. Moreover, impacts of pharmaceutical lobbying on health policies, health-care costs, and clinical research regulation are topics of great importance for the Brazilian Unified Health System and should be included in the public health research agenda.


Evidence indicates traditional medicine is no longer only used for the healthcare of the poor, its prevalence is also increasing in countries where allopathic medicine is predominant in the healthcare system. While these healing practices have been utilized for thousands of years in the Arabian Gulf, only recently has a theoretical model been developed illustrating the linkages and components of such practices articulated as Traditional Arabic & Islamic Medicine (TAIM). Despite previous theoretical work presenting development of the TAIM model, empirical support has been lacking. The objective of this research is to provide empirical support for the TAIM model and illustrate real world applicability.Using an ethnographic approach, we recruited 84 individuals (43 women and 41 men) who were speakers of one of four common languages in Qatar; Arabic, English, Hindi, and Urdu, Through in-depth interviews, we sought confirming and disconfirming evidence of the model components, namely, health practices, beliefs and philosophy to treat, diagnose, and prevent illnesses and/or maintain well-being, as well as patterns of communication about their TAIM practices with their allopathic providers.Based on our analysis, we find empirical support for all elements of the TAIM model. Participants in this research, visitors to major healthcare centers, mentioned using all elements of the TAIM model: herbal medicines, spiritual therapies, dietary practices, mind-body methods, and manual techniques, applied singularly or in combination. Participants had varying levels of comfort sharing information about TAIM practices with allopathic practitioners.These findings confirm an empirical basis for the elements of the TAIM model. Three elements, namely, spiritual healing, herbal medicine, and dietary practices, were most commonly found. Future research should examine the prevalence of TAIM element use, how it differs among various populations, and its impact on health.The online version of this article (doi:10.1186/s12906-017-1639-x) contains supplementary material, which is available to authorized users. Global use of traditional medicine has continued to gain momentum over the last decade . EvidencIt is imperative to note that the terms complementary and alternative medicine refer to “a broad set of health care practices that are not part of the country’s own tradition and are not integrated into the dominant country's health care system” . In somePrevious research illustrates the traditional medicine usage patterns in a variety of countries. Over 80% of the world population depends on herbal medicines , and curA prominent traditional healing system in the world, Traditional Arabic & Islamic Medicine (TAIM), refers to healing practices, beliefs, and philosophy incorporating herbal medicines, spiritual therapies, dietary practices, mind-body practices, and manual techniques, applied singularly or in combination to treat, diagnose, and prevent illnesses and/or maintain well-being . DespiteTAIM reflects an enduring interconnectivity between Islamic medical and Prophetic influences, as well as regional healing practices emerging from specific geographical and cultural origins . This amDespite the previous development of a theoretical TAIM model that unites inter-related and overlapping terminology, empirical support for the model to actual use and motivations for use have yet to be demonstrated. Moreover, little is known about how patients discuss TAIM use with allopathic medicine providers. Hence, the primary objectives in this research are: 1) to provide empirical support for the TAIM conceptual model and illustrate its real world applicability by examining patients’ reports on their use and reasons for using TAIM, and 2) to understand how patient-doctor dynamics impact disclosure of TAIM. A parent investigation conducted in Qatar about comprehensively assessing healthcare quality described previously , provideWe used an ethnographic approach to conduct a qualitative study as one component of a multistage, mixed methods parent study focused on developing a self-administered healthcare quality assessment instrument in the four languages of Arabic, English, Hindi, and Urdu . We usedQatar has a population of approximately 1.9 million people , with thTo attain a minimum of 20 participants per language group for in-depth interviews to ensure data saturation, we targeted the recruitment of approximately 80 subjects. Female research assistants, who can move between the gender segregated waiting rooms, approached patients and/or family members in the outpatient waiting room of the clinic to recruit them. The inclusion criteria were: 1) Speaks as first language the target language – primary language was defined as a language that the participant grew up speaking and/or reading from his or her childhood, or as determined by sociocultural norms, such as work environment of his or her home country 2) Has lived in Qatar for at least 12 months in the past 3 years 3) Provides verbal informed consent. Exclusion criterion was 1) Has a severe debilitating illness precluding participating.Items on the semi-structured interview guide for the parent study on developing a culturally adapted survey on healthcare quality ascertained an individual’s health and illness experiences, health observances amongst other healthcare practices, challenges encountered when receiving healthcare, recommendations for improvement in services, as well as demographic information.The interviews were conducted by research assistant-(RA) pairs, each bilingual in Arabic and English, Hindi and English or Urdu and English, who respectively conducted the Arabic, Hindi and Urdu interviews. The English interviews were conducted by various combinations of RAs depending on recruitment and RA availability. The senior PI on the project, MDF, a qualitative and mixed methods research methodologist, trained the interviewers. As the first interviews were completed, these were reviewed to help further refine the training of the RAs, and to begin the iterative analysis. Transcripts were not returned to participants as this was not really feasible given the high mobility of the engaged population, as many are transient workers, or are private and reserved. Field jottings were recorded in the field, and then expanded into full notes after the interviews. The duration of the interviews was 15–60 min. There were no focus groups. The RAs were trained to record demographic information, context, content and conceptual ideas. Observations were debriefed on a regular conference call held approximately every week. A sample of the interview guide can be found in Additional file Audio-recorded interviews were transcribed in the native language, and a second reviewer checked all transcriptions. Any possible identifying information was modified to protect privacy. Arabic, Urdu, and Hindi transcripts were independently translated into English, compared for similarity, and differences resolved by a third bilingual researcher.To develop preliminary codes for systematic analysis, team members  immersed themselves in the data by independently reading and open coding transcripts. Codes and definitions were routinely reviewed and refined during meetings. Emergent themes were amalgamated into the coding scheme, and coding definitions were developed through general consensus of the team. Two analysts (AK and the research assistant) independently coded two transcripts and compared for calibration, while a third (MF) reconciled any variations. All of the remaining transcripts were coded by the primary analyst (AK), who also consulted with team members each week to resolve emerging concerns. The qualitative analysis software ATLAS.ti  was usedThe major codes, Food/Diet/Drink/Nutrition/Supplements, Religion, and Interpretation of Health & Illness were used to generate an initial summary for review. The search was then refined for output by language and gender. Data collected on the demographics instrument was merged with textual data to provide context for stories and quotes. From the generated outputs, we looked for elements of, and participants’ experiences, with the TAIM conceptual model, including herbal medicine, spiritual healing, dietary practices, mind-body applications, and manual techniques. We looked but found no other traditional healing practices or evidence contradicting the model. Finally, we searched text for examples of participants’ experiences and reflections about discussing their use of these practices with their doctors. We integrated the diverse data sources into a narrative format to address these study purposes.A total of 84 individuals (43 women and 41 men) participated and fell into age categories between 18 and 74 years of age, had varying educational backgrounds from no formal education to primary education only, with religious affiliation of mostly Muslim, but also included Christian, Hindu, and other/not reported. For full details on participant recruitment, see another previously published study . PseudonParticipants discussed traditional healing practices as attributable to Islamic tradition, namely, practices based on Islamic religious texts and worship practices, as well as those outside the scope of Islamic tradition, stemming from cultural or ethnic heritage unique to a geographical area. As previously proposed, empirically, Islamic worship practices and regional healing practices proved to be at the heart of the TAIM conceptual model Fig. , and canhadith, are the textual foundations of the Islamic faith, references to herbs, dietary practices, or other healing practices in the Quran and Prophetic traditions formed the basis of specific healing practices. Islamic religious texts are also the primary source for Islamic worship practices, correspondingly perceived to have healing characteristics. Within Islamic worship practices, a spectrum of therapies related to spiritual healing, herbal medicine, manual techniques, mind-body therapy, and dietary practices can be extrapolated. Our findings reflect the greatest emphasis on spiritual healing, dietary practices, and herbal medicine of the five proposed elements of the model.Many of our participants spoke about Islamic-based practices. As the Quran and Prophetic traditions or Many participants believe that God trusts the individual with good health; God sends down illness and is the One who ultimately relieves it. Muslim participants in particular often described how they use Islamic texts, Holy Quran and Hadith, or Prophetic tradition as primary sources of prayers for healing. These descriptions occurred for both individuals in their approaches for themselves and for treatment of others. For instance, participant Omar states, “if you read translation of the Holy Quran then you will know it is about cure…” This idea is also illustrated by Ali, who said “I had pain here (he pointed towards his chin), then later my father told me to recite Alhumd (first chapter of the Quran) three times, seven times Qulhu walla hu Ahad (chapter 112 of the Quran), and blow, then if God wills then this problem will be gone.” In referencing Hadith, or Prophetic traditions, Mohamed states “there are many Hadith and there are (instructions) in the religion about health.”Spiritual healing practices are also carried out in the manner of religious figures reciting prayer over those who are sick, or over things consumed by those who are sick. In a similar manner, individuals also recite prayers as a form of self-care. Examples include prayers recited over water. Mariam states, “…those verses of cure, I mean, even the prayer for eye-sight. First, I have to believe in this then doctor…so I used to read the healing prayer of eye-sight and used to blow on Zamzam water  and I prayed from my heart and applied it on his eye. All praise to Allah, now his eye is fine.” Specific prayers, or supplications, may also be recited aloud or silently by the ailing over the afflicted body area. Noura states, “…it is like, when you pray, you read something and blow on the palms and rub… where there is pain.” Mona states “…every day I read in the morning and blow on the water. I drink it myself and also give it to the children to drink.”Herbal remedies appear to be mainly used in a culinary manner, and reflect the integration of these practices into the mainstream diet. Nigella sativa (L.), an herbal remedy used by subjects and commonly known as black seed, is referenced in the Prophetic tradition as having healing qualities. Use of black seeds is illustrated by participant Farah who states, “If you use black seeds, probably if you add them in cooking as I do…I must put a little in cooking, with the Sunnah point of view” . A woman, Henna states “I used a little black seeds in food according to the Sunnah, in gravy, I put in everyday food.” Mohamed describes, “what my mother did that she warmed a garlic clove in the oil and as soon as she put, after 2–4 s my pain disappeared.” Sayed explained, “all our life we are using the traditional healing… if someone gets a sun stroke then he gets wrapped with Sin and Itrishia (pelargonium graveolens) and Fliyo (mentha pulegium) just like the rose water and flower water itrishyia (pelargonium graveolens) water, and Fliyo (mentha pulegium) water…”Therapies related to diet are often a form of self-care amongst our participants, and include the use of foods such as honey, also mentioned in both Prophetic tradition as well as the Quran. Ali illustrates use by saying, “if you are taking honey then you will not have any problems.” He goes on to further say, “you know in our Islam, there is so much already; I mean you take proper diet. While eating, drink water before or in the middle not at the end, if you follow these you would be safe from many diseases.” Saif reports, “his way (way of the Prophet Muhammad [peace be upon him]) was to eat while sitting on the floor, it means, should wash hands, start with the name of Allah, and drink water in the beginning, can drink in the middle but it’s better not to drink at the end. The last, it means one should not eat that much, that it puts burden on your abdomen, if it will be (heavy) on your abdomen then it will be on the whole body.” Yet another opinion, Nadia stressed the importance of “drinking Zamzam water.” Faisal discussed the value of dietary practices by saying “traditional food stuff supposed to give you health, ginger, chili, you know those sort of things…supposed to help, garlic…”The ritual prayer, salat, incorporates a specific set of physical postures while reciting specific verses of the Holy Quran, glorifications, supplications, and affirmations to God. Our respondents felt that ritual prayer promoted well-being. Notably, Kashef states, “the (effect) of religion is that in our religion, e.g., there is prayer, if you pray regularly then your health will stay good without fail… it is also a kind of exercise. If you pray five times a day then there are so many units of prayer that one gets good exercise.” The Islamic ritual prayer may also be seen as a type of active meditation, where each posture promotes physical and psychological well-being. Saima illustrates this point stating, “praying five times a day is very important both spiritually and physically as well… it’s a matter of composing your body and making the movements for your prayer…sometimes for example if I am feeling stressed if I pray then everything is relieved for me.”Al-hejamah, the Arabic term for cupping, literally means to reduce in size or to return the body to its natural and harmonious state. The practice of al-hejamah has pervaded the Middle East for thousands of years with citations dating back to the time of Hippocrates. Also taken from Prophetic tradition, this is a method whereby blood is drawn by vacuum from a small skin incision for therapeutic purposes. Ibrahim states, “… it is Sunnah (what Prophet Muhammad [peace be upon him] said or used to do) if someone wants to do” (use cupping). Another participant Hussain states, “I thought about doing cupping soon, as it might be useful to liver diseases…” Ayesha spoke about her perception related to the use of cupping, “certainly cupping I know is quite popular.” Mary notes yet another variation, “…Vapourising…inhaling with hot water… during an illness or for preventive measures.”An additional key finding highlights the dynamic in which patients interact or don’t interact with their doctors as it relates to disclosure of TAIM use. Participants were more likely to use vitamins and herbal therapy if recommended by their doctors. Sanaa states when asked about use of complementary therapies, “not by myself…only when doctor prescribes…because we are not aware of their side effects.” Omar further supports this notion when asked about using non-medical interventions, “No whatever doctor recommends… they usually prescribe B-Complex.” Saima notes, “Whatever doctor recommends… we take things according to that”.For non-Qatari’s, relying on their doctor for guidance is instrumental, as they may lack familiarity with non-allopathic care. Ali states, “there is no system of herbs here… when a person is in his own country, then he uses all the treatments.” When asked about her use of herbs, Isra states, “No, didn’t do because I’m here since the age of 19. I came here right after getting married…there is no system of herbal here.”Participants had varying opinions as to the role their doctor plays in prescribing or informing healthcare choices relating to TAIM. Some participants believed it was the doctor’s responsibility to inquire about any and all matters related to their health and well-being. Ali states, “If doctor would ask then we will tell him that we have taken such treatments,” while Mary also supports this idea, “Doctor should ask about other treatments we are taking.” When asked if her doctor is aware of her intake of foods and drinks to maintain health, Hala notes, “…No the doctor doesn’t know, I mean the doctor didn’t ask me.” Other participants believed use of traditional herbs contrasted from medicine, and if they are perceived as safe, then do not warrant disclosure. Karima states, “herbs and stuff like that is separate, medicinal herbs will relax, these are all beliefs that apply to each individual’s beliefs and customs.” Samiah states, “…natural known herbs… the things that are from our parent’s experiences… since we were young make me to drink it with milk; these are good, I mean they are natural.” Samiah goes on to say that she doesn’t feel its necessary to disclose use of such herbs, “because…there is no harm out of it.”Intuitively and anecdotally, there has been an understanding that various elements of the TAIM model are utilized in the Arabian Gulf. Supporting the study’s first two specific aims, this is the first research report providing empirical support for the TAIM conceptual model and illustrating its real world applicability evidenced by patients’ reports on their use and reasons for using TAIM. Additionally, this research contributed to our understanding of how patient-doctor dynamics impact disclosure of TAIM. Importantly, there is not an equal distribution of the elements of the TAIM model, with more practices grounded in herbal medicine, spiritual healing, and dietary practices.Herbal medicine use stemmed from religious texts, as well as traditional practices unique to a geographical area. Herbs were mostly used in a culinary manner, while traditional herbal preparations including tinctures, teas, or salves were not as prevalent. Non-Qatari’s spoke about purchasing herbal remedies upon returning to their homeland, or asking family members to send via mail, suggesting a possible lack of access to herbal formulations and cost may be a barrier if it is an out of pocket expense. Doctors at HMC prescribed multivitamins, prenatal vitamins, as well as individual vitamins. Thus, if doctors prescribe vitamins or nutrients, then patients’ perception may be that additional herbs are unnecessary. Gerber et al. found among midlife Arab women living in Qatar, nutritional remedies and herbal remedies were the most frequently used types of CAM, followed by physical methods .Prayer , Dhikr or remembrance of Allah, and recitation of the Quran are common examples of spiritual healing practices employed by our participants. Recited prayers and worn amulets contain verses from the Quran, to which curative powers are ascribed as passages of the Quran are believed to have vast healing properties , 27. ForParticipants spoke about dietary practices that derived from both geographical influences, as well as religious texts. Examples of geographical influences include the use of spices, such as ginger and chili, in a culinary manner to aid health and well-being . The HolMany religions and spiritual traditions across the world ascribe beliefs in healing through prayer. The Islamic ritual prayer  involves certain physical postures and can be comparable to active meditation. Prayer is a special form of meditation and may therefore convey all the health benefits that have been associated with meditation  includina drink of honey, a scratch of hijamah and cautery.” [Applied, physical or manual therapies include any practice whereby physical application occurs, and includes such therapies as reflexology, cupping or hijamah, and bone setting. This element was the least prevalent among our subjects, and also influenced by religious and regional forces. Islamic books state that the prophet Mohammed (peace be upon him) referred to three methods in curing an illness: “autery.”  Though tautery.” . While sTraditional medicine practices are “woven into everyday life and belief systems”, and traditional healers are “trusted members of the community” . Thus, tThis research also elucidates the details and motives that affect use of TAIM in this population. Muslim participants are motivated to use traditional practices, as they are believed to stem from religious texts, and consequently for many, an extension of worship practices. Amongst non-Muslim participants, worship practices such as prayer are also believed to have curative properties. Moreover, participants relied on traditional medicine if access to allopathic doctors was limited. This is evident in remote areas where doctors or specialists may not be available . TraditiParticipants spoke of utilizing traditional therapies while visiting their home country; some were not familiar with whether or not an herbal system exists in Qatar and relied on family to supply them with needed herbs or homeopathic formulations. Based on these participants’ conversations, they entrust traditional healing practices as they are deemed in line with their cultural and philosophical belief system, and thus a primary choice for maintaining health and wellness. In one study, the authors report that almost half of the respondents interviewed have used herbal supplements, vitamins and minerals, as well as non-vitamin, non-mineral, and non-herbal supplements, and preferred herbal supplements to conventional medicine for addressing digestive ailments, common respiratory concerns, and weight support .In consideration of our final objective, this research highlights the dynamic in which patients interact or do not interact with their doctors, as it relates to disclosure of TAIM use. Participants were more likely to use traditional therapies if recommended by their doctors, and participants also had varying opinions as to the role their doctor plays in prescribing or informing healthcare choices. Thus, education, life experiences and the economics of a community may impart whether an individual may or may not initiate healthcare seeking behavior . Self-reDoctors at HMC prescribed individual vitamins, multivitamins, as well as prenatal vitamins thus the perceived need of supplementing may be deemed ill-advised or unnecessary. A cross sectional study examining the knowledge, attitudes, and practice of general practitioners towards CAM in Qatar determined that over 39% reported poor knowledge about CAM . AdditioRegarding potential limitation of this research, first, while Qatar is demographically diverse, it is unclear to what extent variation can be generalized to other parts of the Middle East. Ethnographic research is best suited for demonstrating patterns and meanings of use, rather than assessing prevalence of use. This would be an area ripe for future investigation. That said, there are several other countries that rely heavily on expatriate workers, e.g., UAE, Bahrain, and Kuwait where these findings may also apply. To examine fully the prevalence and utilization patterns of TAIM, the future studies should include both private and government healthcare facilities. There is open opportunity for direct research in settings where all forms of TAIM are provided. Second, there is the potential for desirability bias. In this case, the normative basis would be for participants to praise the system, and indeed we found some evidence of individuals who said so. As our interviews asked individuals about their experiences, and not their attitudes, this concern, we believe has minimal impact. Lastly, we were aware of our bias going into the data set, and we looked for disconfirming information, and also evidence for other elements, but these were not identified. All types of treatments that were discussed fall under one of the TAIM components.Based on our findings, we conclude that the TAIM model is theoretically robust, and has an empirical basis for all of the elements in the TAIM conceptual model. These findings further suggest that orthodox medicine practitioners will need to inquire if they want to learn about their patients’ use of TAIM elements. Traditional medicine provides a platform for ensuring that all people have access to care. As traditional medicine is either the foundation of healthcare delivery, or serves as a complement to it, we recommend further exploration into traditional healing practices.


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