Background: Many parents have difficulty managing childhood asthma. In Hong Kong (HK), while medication is the primary form of treatment, traditional Chinese medicine is another favored option. In addition, HK follows a dual-track healthcare system, which may pose unique experiences for Chinese parents in managing childhood asthma. This qualitative descriptive study aimed to explore the experiences of HK Chinese parents in caring for their children with asthma. Methods: Fourteen HK Chinese mothers of children (aged 3–10) suffering from asthma were purposively sampled to participate in individual, semi-structured interviews. A realist approach following conventional content analysis was used to interpret the interviews. Results: The mothers expressed feelings of uncertainty, fear of asthma crises, and searched for ways to cope. As long as their child’s asthma symptoms recurred, the mothers’ distress continued. Their distress was sometimes exacerbated by self-doubt and worries over whether they would receive adequate support from their family and healthcare professionals. Conclusions: Helping parents to understand their limits may help them be more open to varied aspects of their caregiving experiences, and thus to cope better. Psychological interventions together with traditional educational training may help to alleviate the psychological difficulties of parents. Asthma is the most common chronic respiratory disease, affecting over 235 million people worldwide . The IntManaging childhood asthma can be challenging for many parents. In particular, the unpredictability and life-threatening nature of asthma can impose a heavy psychological burden on parents . During Asthma is regarded as effectively treatable when parents and their children are educated about how to manage the disease and have access to high-quality healthcare services . Yet, evIn HK, the healthcare system runs on a dual-track basis. Children who have been diagnosed with asthma receive asthma-related healthcare services on a fee-for-service basis in private clinics and hospitals, and/or on a subsidized basis in general outpatient clinics and public hospitals run by the HK Hospital Authority . ParentsFollowing the best evidence from the Global Initiative for Asthma, the primary treatment of childhood asthma is medication for controlling asthma symptoms, including inhaled corticosteroids and short-acting bronchodilators . In HK, A qualitative descriptive design was chosen because it is appropriate for examining the experiences of individuals situated in a particular context who have received little attention in the literature . A realiThe study took place at one Ambulatory Care Centre (ACC) under the Department of Pediatric and Adolescent Medicine in a public hospital in Hong Kong. The ACC is a specialist outpatient clinic where children aged 18 years or below with a diagnosis of chronic respiratory disease, such as asthma, allergic rhinitis, pneumonia, and obstructive sleep apnea, can access medical consultation services provided by pediatricians, and receive education from an Advanced Practice Nurse. The majority of children with asthma, who were under the care of the ACC, attended the emergency department at least once due to an asthma attack over the past six months.Parents were eligible to participate in the study if they fulfilled the following criteria: (a) were either a father or a mother (age 18–65 years) who was the primary caregiver of their child, (b) had a child aged three to 12 years who had been diagnosed with asthma by a physician , (c) were HK permanent residents, (d) lived together with their child with asthma, and (e) able to communicate in Cantonese. Parents whose child with asthma had mental and/or congenital problems were excluded. To seek phenomenal variation, we followed the recommendation of Sandelowski, who suggested the use of one kind of purposive sampling, known as criterion sampling . CriteriParents were invited to complete a short survey to indicate their socio-demographic characteristics, personal and family history of asthma, and their children’s clinical characteristics. Next, data were collected through individual face-to-face interviews in Cantonese. A semi-structured interview guide containing the following open-ended questions was used: (a) “I wish you would share your experiences in taking care of a child with asthma. What experiences do you think are most worthy of sharing? Which were the most memorable to you? And how did you feel at the time?” (b) “As a parent of a child with asthma, what do you do to take care of your child?” (c) “What are the most challenging situations you have faced when taking care of a child with asthma?” (d) “What are the issues of most concern to you when taking care of a child with asthma?” This interview guide was designed by the research team and refined after a pilot test involving two parents of children with asthma. Prompts were used where necessary to encourage more detailed responses, such as, “Can you describe this in a bit more detail?” and “Please tell me more about …”Interviews were conducted by the first author, who is a registered nurse with experience in pediatric care and who had no affiliation to any of the participants prior to the study. Interviews were held in a private room of the ACC at a time that was convenient to the participants, and audio-recorded with the participants’ permission. Field notes were taken to capture non-verbal cues within 24 h of each interview. Each interview lasted between 45 to 75 min. Data collection continued until the research team determined that data saturation had been reached after 14 interviews. As suggested by Sandelowski, an adequate sample is not determined by the number of participants, but rather, by the adequacy of the sampling strategy to get “information-rich cases” to achieve saturation of patterns . Indeed,Before the commencement of the study, ethical approval for this study was obtained from the New Territories West Cluster Clinical Research Ethics Committee (reference number: NTWC/CREC/15042) and from the Human Subjects Ethics Application Review System of the Hong Kong Polytechnic University (reference number: HSEARS20150109001). The parents were reassured that their participation would not affect the healthcare services that their children received. Informed, written consent was obtained from all of the participants. Childcare services were provided at the request of the parents, so that they could focus on the interviews. In addition, the parents were informed verbally about the aim of the study and about future publications of the study in the scientific literature. All of the information that was obtained was treated as confidential.The interviews were recorded and transcribed verbatim in Chinese by two trained student assistants. The first author further checked the transcripts against the audio-taped data for accuracy. Conventional content analysis was used to detect manifest and latent meanings from the data ,23. In tInterpretation followed ideas of metaphorical extraction, which means that the codes, subcategories, and categories drew from the direct meaning of the extracted text (denotation) and, more importantly, from the contextual relationship between the text and the context of the whole interview (connotation) . A furthRigor was achieved through a process of reflexivity and by documenting all analytic decisions, leaving an audit trail. The first author (Y.C.) is a registered nurse in HK, who sought the help of the research team  to examine her role and search for possible biases throughout the analysis of the data. Notably, all members of the team were nurses with clinical expertise in child and family health. The lead author (Y.C.) and one of the co-authors (Y.M.) are bilingual in English and Chinese. For credibility, initial codes from the first three interviews were translated from Chinese to English and independently coded by the lead author (Y.C.) and an experienced qualitative researcher who is a native speaker of English (D.L.). The translation was carried out by a bilingual professional and was double-checked by the first author (Y.C.) and another qualitative researcher (Y.M.). To ensure plausibility, this co-author (Y.M.), together with the first author (Y.C.), independently scrutinized the codes and sub-categorizations from all of the translated transcripts. Regular meetings of the entire research team  helped to resolve any differences in coding and to refine the analysis to determine the final categories. Last, transferability was attained by comparing the key findings with existing literature about parents of children with asthma and other similar chronic illnesses. Raw excerpts of the data, which exemplify the interpretations, are presented to allow readers to assess how the results may be transferable to their contexts.Despite attempts to recruit fathers, a total of 14 parents, who were mothers, participated in the interviews. Two fathers, who refused to participate, reported that they were unfamiliar with their child’s health condition and “unable to provide adequate information” related to their caregiving experiences. One mother left during the interview due to health issues related to her pregnancy.All of the participants identified themselves as their child’s primary caregiver. Among the participants (age range = 30 to 54 years), two were working mothers and the rest were housewives. Nearly half of the mothers (number of participants (n) = 6) had a personal history of asthma. Four mothers reported that the child’s father (n = 3) or the child’s older brother and sister (n = 1) also had asthma. The children (age range = 3 to 10 years) were diagnosed with asthma at preschool age (range = 6 months to 5 years). As of the interview period, eight of the children suffered from asthma symptoms at least one day per week see .In this study, the parents’  experiences reflected a five category psycho-social process: (1) uncertainty and fear in controlling asthma when asthma was diagnosed; (2) the reoccurrence of the asthma, leading to a search for ways to endure the condition; (3) working through the challenges of controlling asthma; (4) ongoing emotional distress as the asthma continues; and (5) learning to manage asthma better after accumulating experience. Note that symbols and numbers represent different participants .The doctor said that he (the son) didn’t have asthma, but bronchial hypersensitivity, and just delayed the diagnosis. Then, was the so-called ‘bronchial hypersensitivity’ that my child previously had just in fact the same as asthma? I really don’t know.The participants began to describe the occurrence of asthma attacks when their child was of preschool age (two to three years old) as something that “just happened all of a sudden.” The high-pitched wheezes, which they described as “he he” sounds, together with other flu-like symptoms, recurred with no recognizable patterns. The participants’ uncertainty further intensified when the doctor’s diagnosis was not asthma, as some parents suspected, but “flu” or “bronchial hypersensitivity.” Without a definite diagnosis, the participants found it difficult to make sense of what was happening to their child:She just wheezed so seriously, and her rib cage was just dented in, just like, losing her breath and saying ‘hah mommy, hah mommy…’ when we (she and the child’s father) were holding her. I was definitely in great fear when we arrived at the hospital. I did not dare to release my arms.When children began struggling to breathe, and had difficulty speaking, participants realized that this scenario was a medical emergency. They perceived that their child’s life was in danger:I was staying outside the curtain and watching how the doctors used the suction tubes to suck the phlegm out and he was shouting ‘Mommy! Mommy! Help me! Help me!’ He was crying so intensely; I was sitting in a chair and just could not stop crying myself. The tears, it was. I indeed felt too heartbroken, it’s a kind of feeling of being stabbed by a knife. I felt that I was useless, helpless too.All of the participants reported that their child had visited the emergency department due to an asthma attack at least once during the past six months. Five children required hospitalization for three to five days. According to the hospital’s policy, only one parent, preferably the mother, was allowed to stay with the child during hospital admission. Some of the participants witnessed the efforts of clinicians to control the asthma, such as by administering bronchodilators via aero-chambers or nebulizers, or by using oral suctioning to clear the airway. They reported feeling “heartbroken” and “helpless” when witnessing their child’s struggles. One participant became emotional as she described the scenario:Many participants described the experience of staying overnight in hospital wards without adequate facilities for rest as “the toughest experience to endure.” A few participants perceived that the treatment offered in the hospital, for example inhalation therapy, was something that they could have done themselves at home. As such, they reported reluctance to go to the hospital again unless they perceived that their child “was on the verge of death.”In these three years, when I hear (my child) cough, I will get up at once. I am afraid that he’ll have (an attack) again. The last time (he had an attack), I simply watched my child suffering, and with great fear. He just kept on struggling and crying, so that’s why I have to take care of him for the whole night, and that’s why I cannot sleep well now. Yes, I sleep badly, until now during the night I’ll be in great fear.Given that a child’s asthma attack could recur unpredictably, the suffering that the participants endured continued. In general, when the participants suspected that there was something “different” about the sound of their child’s breathing, they took a series of prompt actions, such as closely monitoring their child’s breathing, giving symptom-relieving medications, and taking him/her to a nearby clinic for immediate medical advice or to a hospital to prevent life-threatening consequences. Their child’s repeated coughing and wheezing prompted some participants to remain awake all night, to monitor their child’s breathing and to administer the inhaler in a timely manner. One participant said that she had not been able to sleep well for years due to her son’s asthma:I was in great psychological distress; (I) wanted to just cry and cry, because why did I give birth to a child to have this (disease)?Searching for the reason why their child suffered from asthma was important, especially for participants with no family history of asthma. Some of the participants did this by comparing their child with his/her siblings, or reflecting on whether they had paid enough attention to their child’s early development. For one participant, the lack of an explanation for her child’s asthma was a source of great distress:Many of the participants gave detailed accounts of what they had done to control the asthma, which was very burdensome.I won’t offer the blue inhaler frequently at one go. First (I’d) try one puff; if he’s okay, then I’d stop. If he’s not that okay, then I’d offer him another puff. I mean, I try to avoid giving too much medication to my child. Then, after one to two minutes, I’d ask him whether he felt that it was easier to breathe.All of the participants could list several asthma triggers: second-hand smoke, burning incense, fluffy toys, dust, perfume, cold air, and cold food and drinks. Some of them monitored these triggers, and others firmly prevented their children from coming into contact with them. Furthermore, many of the participants believed that the “blue inhaler” was a life-saving bronchodilator that had to be administered regularly overnight to prevent nocturnal asthma attacks. A few of them were very vigilant using the “blue inhaler.” One participant shared her strategy:It’s just like doing homework—you’ve got to do it every single day; otherwise, you can’t see the effect on him (the child).A few of the participants explored different kinds of complementary and alternative dietary therapies, such as “boiled crocodile meat soup” ; “boiled gecko soup” (M7); “boiled fritillary bulbs” , and moxibustion therapy (M14) . All of these soups or herbs were considered effective over the long term at strengthening a child’s health to improve his/her asthma. As one participant stated:In the last year I was thinking it should be alright. But then, all of a sudden, it (the asthma) came again not less than a week later, (she) wheezed and was admitted again. Then, (she) had the oral steroids again.Despite the strenuous efforts made by participants to control their child’s asthma, many expressed disappointment when asthma recurred after participants had come to believe that it had “disappeared” (remission of symptoms after a year). Repeated hospital admissions led the participants to lose confidence and to feel powerless. One participant stated:Asthma is something that I can’t control. Why, when he (her child) got an attack, did it come all over again?Another participant reflected that she had “overlooked” the recurrence of asthma:A few of the participants described their concerns as misunderstood by others. This was particularly common, as their children appeared mostly asymptomatic. They often heard others say: “There’s no need to be that nervous” or “It’s only a cough.”I told them (the extended family members), please don’t let him (her child) have any junk food or soft drinks, okay? But sometimes they just let my child drink and say something like, ‘Come on, wouldn’t it be too harsh for a kid to not enjoy cold drinks?’ But I said, ‘It’ll be even harsher for me if you attempt to let the child try it once!’Misunderstandings were more worrisome when they involved family members. For instance, some of the participants would be questioned by their spouse for hastily seeking medical advice for their child’s flu-like symptoms. Some fathers, who were smokers, might not comply with instructions to keep their child away from tobacco smoke. Further, extended family members were expected to comply with house rules to avoid potential asthma triggers, such as avoiding fried snacks or cold drinks. When these rules were broken, conflict ensued. One participant expressed her resentment:When the triage nurses spot that your child’s oxygen saturation is fine, they obviously won’t act fast.When a child suffered from an acute asthma attack, most of the participants immediately sought medical help from the emergency department of a public hospital. However, they stated that this did not guarantee that their child would receive immediate treatment. As one participant recalled:If it’s financially affordable, I’d rather choose a private hospital for my child.On the other hand, some of the participants appreciated the efficiency and comprehensiveness of the medical investigations provided by private hospitals, but were deterred by the cost. One participant stated:In fact it is really difficult for the parents. First, I didn’t know where I should find ; second, who is a good one?In addition, finding a pediatric respiratory specialist in HK was challenging. One participant recalled that it was “by luck” that she met a private practitioner who immediately offered inhalation therapy to her child. She further emphasized:As you didn’t really know how to use it (aero-chamber), this led to the fact that he (the child) couldn’t take in all the medication powder.’ But that was not the case.Deciding on what was “best” was further complicated by differences in the treatment strategies offered by the public and private sectors. For instance, one participant reported inconsistencies in the method of delivering inhaled bronchodilators between the private clinic  and the public hospital (via aero-chambers). She said that a nurse working in a clinic of a public hospital once told her the following:Situations that generated ongoing distress were not at the forefront of the participants’ thoughts, but became prominent as their stories unfolded.Most of the participants expressed worry and concern about the potential negative impact of asthma on their child’s learning and development. Specifically, their child’s frequent absence from school was felt to threaten their child’s academic performance and social interactions with peers. Furthermore, many participants were worried about the potential detrimental side effects of the chronic use of inhaled corticosteroids on their child’s development. These include appetite loss, facial puffiness, and impaired growth . In addition, a few participants  questioned whether their child would develop resistance to antibiotics.If you had this disease, you dare not to try to have your own family, right?Another concern that was worth noting was the participants’ strong desire to not only control, but to “just get rid of it (the asthma),” given that the asthma symptoms had recurred throughout the years. Those participants believed that they possessed the gene for asthma, and perceived asthma as “something that you must carry for the rest of your life, carrying over to their child’s next generation.” One participant stated:Sometimes (I) would project my negative emotions directly to him (the child) and say, ‘Oh! You see, other children are good at all sort of things, but why did this (the asthma) happen to you?Some of the participants described a few critical moments when they encountered feelings of helplessness and a sense of “being trapped,” or feeling as if “everything was just simply offensive to me.” That moment occurred when the child kept wheezing despite attempts to prevent it, and when the child was too small to voice his/her complaints. One participant projected her anger onto her child in the following way:You seem to have no energy every day, but deep in your heart you wish to share everything with others. But you don’t know who you can talk to, as once you share you don’t know how others would regard you.Of the 14 participants, two recounted feelings of hopelessness and overwhelming distress when living with a child suffering from asthma. Both mothers became emotional and occasionally had to pause during the interview. One of them, who found it difficult to ask for support from others, described her feelings of despair in the following way:From the beginning till now, his dad wasn’t involved in anything about the care. (He) simply blamed me for not doing well enough. When she (the child) was two to three years old, she just cried for the entire night. No matter what you did, it just failed. I was not sure what she needed! Every night was the same, and then you definitely had the feeling that (you) wanted to jump from (a) height with the child.The lack of spousal support triggered another participant to contemplate suicide. She recalled:Stressful experiences of childhood asthma care were emphasized by most of the participants. However, some of the participants, who had at least two years of experience caring for a child with asthma, shared positive experiences. These participants became familiar with the nature of the asthma and learned how to differentiate its symptoms from other illnesses. They shared such thoughts as, “I have full confidence now” and “Asthma is not a big deal to me.” In this regard, their emotional distress and the challenges that they faced in caregiving were mitigated by newly formed positive perceptions that came from learning to manage asthma.I felt glad that I have a friend whose son has asthma, as we’re all in the same boat. We chat a lot, and we share (our thoughts and feelings) with each other. It’s a very good way, as we are all up against the (same) difficulty.Multiple sources of support within the hospital, including patient support groups and follow-ups by specialist nurses, were highly valued by the majority of participants. When the responsibility for asthma management was eventually shared with their partners, they expressed relief and were less vigilant about monitoring their children. In addition, peer support helped the participants to ventilate their emotions and concerns. One participant expressed her appreciation of this mutual support:You need to take a long time to understand but once you accept the fact that the child has asthma, face it with an open mind and accept it, you’ll feel much happier.As the children grew older, their asthma symptoms became less severe. The participants described caring for a child with asthma as being “exactly the same as caring for other ordinary children.” One participant with a 10-year-old son remarked:To the best of our knowledge, this is one of a few qualitative studies to reveal the unique experiences of HK Chinese mothers in caring for a child with asthma. It reveals that they experience significant psychological distress managing their children’s asthma, which they do in many different ways. Consistent with the findings of other studies ,25, the In this study, the mothers stated that a lack of support from their partners exacerbated their distress, which is consistent with findings in other studies of HK Chinese families rearing children with chronic and behavioral health problems, such as eczema , autism However, in contrast with the findings of other studies, the distress of the HK Chinese mothers in this study was not necessarily resolved with emergency medical care for their child’s asthma attacks , nor froIn the present study, the mothers applied various strategies to control their child’s asthma, such as searching for the root causes of the asthma; avoiding environmental triggers of the asthma; using a “trial-and-error” approach to find the most appropriate healthcare service, similar to the “doctor shopping” found in many countries ; and maiIn fact, the mothers in the interviews might had gone through the process of excessively evaluating unwanted emotional experiences and making deliberate efforts to control or escape such experiences. This may have led to greater dysfunction  and increased distress. Indeed, self-blame can be regarded as a maladaptive emotional control strategy that allows individuals to avoid difficult thoughts and feelings when a stressful event occurs .This study has several limitations. One of the major limitations was that no fathers could be recruited in our study. In particular, we found that two fathers refused to participate in our interviews because they felt that they were “unable to provide adequate information” related to their caregiving experiences. In this regard, fathers may tend to devalue the importance of their involvement in childcare when compared to mothers . AdditioThe challenge of recruiting fathers to share their caregiving experiences has been discussed in the literature . GoldsteIn Western studies that explored the experiences of parents caring for a child with a long-term condition, fathers remain under-represented . This unIn addition, we acknowledge that the diversity of the parents’ experiences in childhood asthma management in the present study is limited, as the recruitment of participants was conducted in one public hospital in HK. This was to establish a homogeneous group of parents, whose children would have at least one experience of being treated by emergency care services due to a life-threatening asthma attack. Hence, the caregiving experience reported by the mothers in this study may not be transferable to other parents of children with less severe asthma.Despite these limitations, this study adds an empathetic and detailed understanding of the experiences of HK Chinese parents, especially typical mothers, who are caring for a child with asthma. In particular, this study has implications for clinical practice, revealing that healthcare providers should demonstrate more empathy and attention to parents with young asthmatic children. Structured asthma education programs that offer adequate information on asthma treatment and skills training, in addition to the management of symptoms, might be helpful to parents ,45. MoreIn summary, this study highlights the substantial psychological distress experienced by HK Chinese parents, especially typical mothers, in caring for a child suffering from asthma. Such distress was prominent when encountering an asthma crisis or when asthma symptoms recurred; further exacerbating their desire to take control over the asthma. Considering the desire of parents to achieve a cure for their children’s asthma, and the unpredictability of asthmatic crises, helping parents to understand their limits of control may enable them to cope better. The findings of this study suggest that addressing the psychosocial needs of parents may help them to better manage their children’s asthma condition.


Expert scientific knowledge, including medical knowledge, is relevant for the legal profession and can strongly influence rulings and sentencing in criminal law, civil law, and insurance law. The way in which this medical evidence is understood and evaluated thus has an impact both on individuals and on society as a whole. It enters legal procedures in various forms, for example, as expert witness statements and/or as a legal expert's own acquired medical knowledge. On the other hand, a legal expert may be confronted with expert medical opinions that differ in quality or content and thus have to decide which ones to follow. The aim of this qualitative study was to investigate legal experts' perceptions, experiences, and narratives regarding medical knowledge, particularly the skills and general knowledge used in their branch of the legal profession. A total of 51 semi-structured interviews with judges and prosecutors from different courts of law and from the public prosecutor's office in six different German-speaking  and German/French-speaking (Bern) cantons of Switzerland were conducted, coded, and analyzed using Nvivo. We used a comparison thematic approach identifying common and new themes related to the research aims. Our findings suggest that Swiss judges and prosecutors believe that possessing and developing the skills and terminology required for processing medical information is important but complex, and time-consuming for their work. Additionally, several legal experts reported that their understanding of medical evidence was limited or even non-existent. Moreover, the acquisition of skills related to the assessment of medical reports and forensic evidence appeared to be unstructured. Participants reported having no formal instruction in how to evaluate or deal with medical knowledge. The sources they used to answer questions arising appeared to be in part problematic and non-standardized . Medical literature from peer-reviewed journals was used only rarely. The findings from this study suggest that law departments might wish to evaluate whether their graduates are sufficiently equipped with scientific literacy skills and appropriate skills to evaluate medical information for their later careers. At the same time, medical knowledge pertinent to forensics published in local legal journals may be more effective in reaching the legal expert audience than in medical journals. To fulfill their integrating role, they arguably require high-quality evidence. Legal experts and jurors are often faced with cases that need specialized knowledge outside their regular education, such as medical or other scientific information, toxicology, ballistics, or engineering –4. This Medical or scientific knowledge may enter a legal process in various ways, be it in the form of an expert statement, e.g., from the treating physician, an expert hired by one of the parties or an impartial agency like the court , or in tWhilst in insurance law, legal decisions based on medical experts' statements may, for example, influence compensation claims for certain illnesses . The effUnfortunately, conflicting expert testimonies are not a rarity , even amThe nature of the data: how it is collected, for whom it is collected and for what purposes can increase the risks of bias and unreliability. Although studies to further our understanding of biasability and reliability of psychiatric and psychological forensic evidence are important, such efforts are infrequent and methodologically difficult compared to studies in other fields of medical forensic science .Publications addressing the potential for errors in expert testimonies –22 and oThere are different approaches to this problem. One well-known approach comprises defining criteria to help determine the quality of scientific evidence and its admissibility for a legal case –31. ThisWhere admissibility of evidence is not officially regulated by criteria, the other approach is to hope that the usual trial procedures will weed out inadequate testimony . Expert These measures may help narrow the knowledge gap by weeding out unusable evidence and ensuring impartial expert witness statements of high quality. However, as stated above, the problem of conflicting evidence remains. If judges and juries are to avoid delegating too much responsibility to a scientific expert for a legal ruling, then it is important for legal professionals to decide in the face of diverging medical statements which one to follow. This arguably entails possessing a modicum of knowledge of the science in question , 53, sucPrevious studies have investigated different aspects of this topic; for example, how judges deal with expert knowledge focusing on the Daubert criteria , the chaSwitzerland with its four official national languages German (>70%), French (20%), Italian (<5%), and Rhaeto-Romansh (<1%) follows an inquisitorial legal system similar to those in other European, Asian, Latin American, and African countries. Because of Switzerland's federal structure, the organization of the courts as well as the jurisdiction in civil and criminal matters remains with each of its 26 cantons. Thus, the cantons do not just have a considerable degree of law-making authority, but also have the right to regulate the organization of the courts and their procedures. The Swiss court system is thereby divided into civil, criminal, and administrative courts with a Supreme Court on the federal level, located in Lucerne and in Lausanne .“The procedural law applied by the cantonal courts is thus primarily state or cantonal law  while, depending on the area, substantive law can either be federal law  or state law ” . Within Few studies exist regarding legal experts' experiences in obtaining medical knowledge and scientific literacy skills and the resources used. It could be argued that since forensic science exists somewhere between the disciplines of medicine and law, it is well-placed to further knowledge on how to improve the legal system with respect to medical knowledge. Here, we propose to explore these gaps by undertaking a qualitative interview study, which aims, firstly, to describe legal experts' experiences of medical-knowledge gathering and acquisition and attainment of scientific literacy skills for professional purposes. We focus in particular on experiences during and after law school. Secondly, we aim to describe what tools legal experts perceived to be useful for learning and understanding medical terms and assessments.A qualitative study design was considered appropriate for the exploratory nature of the research. Qualitative research is employed across different disciplines, including medicine, in order to understand phenomena, people's experiences, perceptions, attitudes, and the meanings they assign to them . In the A purposive sampling procedure was used for participant selection. “It is typically used in qualitative research to identify and select the information-rich cases for the most proper utilization of available resources. This involves identification and selection of individuals or groups of individuals that are proficient and well-informed with a phenomenon of interest” . To achiThe research team pursued multiple strategies to contact potential participants: (a) Individuals who appeared to be especially “information rich”  were contacted either by phone or in person and asked to participate; (b) A local information session in the canton of Bern and a regional congress in Zurich were used to inform judges and public prosecutors about the study; (c) an opt-in letter (429 words) was sent to the departments of prosecutors and judges in different German- and French-speaking regions of Switzerland, inviting them to participate. Candidates who expressed an interest in the study were approached privately by a team member, via email or telephone, providing them with more details regarding the research and answering their questions. The latter approach was undertaken to broaden the spectrum and thus to include candidates in junior positions and those less likely to participate in medico-legal meetings.Recruitment was ceased after saturation had been reached. Saturation is commonly defined as the point when no new themes arise. The subjects provided additional basic biographical data.We used a self-developed, semi-structured and flexible interview guide to explore themes of knowledge acquisition among legal experts. Before the interviews, participants were notified that: the interviewers had a forensic psychiatry background and the research would address the collaboration between legal and medical experts. Open-ended questions and non-leading probes were used to encourage participants to speak freely and to elaborate on their statements. Paraphrasing the participants' answers helped clarify ambiguous statements. The interviews covered several topics that were beyond the scope of this manuscript but will be reported on subsequently.The interviews were conducted by four researchers  in the following languages: Swiss German in the German-speaking parts of the country, French in the francophone parts of Switzerland and in some cases Standard German. Additionally, field notes were completed for all interviews. All interviewers were psychiatrists  with experience and training in forensic psychiatry and qualitative research. Previous research results employing qualitative methodology can be accessed using Google Scholar . At the Each interview was transcribed verbatim in its original language (German or French), except for those interviews in Swiss-German, as these dialects do not have a written form. For these interviews transcription was completed in standard German. Each interview had a code number assigned and all potentially identifying information was removed. The transcripts were not returned to the interviewees.The same four interviewers undertook the qualitative analysis of the interview data independently. We used a comparison thematic approach, identifying common and new themes related to the research aims. For this research, the interviews were analyzed with QSR NVIVO 11 for Windows, a qualitative data analysis software (QDAS) . This soThe coding process ensured a systematic, comprehensive and detailed reading of each interview transcript. First, the coders familiarized themselves with the transcripts in order to identify the different subjects of interest to the forensic field. After several interviews had been coded, the categories for the study were redefined, reviewed and revised in a consensual manner at regular meetings. When there was disagreement regarding the code or coded material, ML applied the final code. The additional/new themes led, in accordance with qualitative research methodology, to an adaptation of the topic guide and to supplementary telephone interviews in 29 cases. Five interviewees requested that the additional questions be posed in writing and answered by letter. As a result of the coding process and the purpose of this report, four main categories were identified and selected: (a) importance of medical knowledge, (b) medical knowledge acquisition at law school, (c) medical knowledge acquisition after law school and (d) strategies for increasing knowledge. An overview of the categories is shown in To illustrate the categories and for reporting purposes, exemplary coded quotations were chosen by CC and translated from German or French into English. Google translate was used to translate interview quotes in our findings  into English for publication purposes. These were then discussed and improved by a native German speaker and an English native speaker to ensure readability and accuracy.The research aimed to capture all the possible experiences and perceptions which were collected in the textual narratives and opinions of judges and prosecutors. However, in order to orient the reader regarding the prevalence of similar opinions among the interviewees, as perceived by the coder, a summary statement is reported, identifying the number of participants whose interview transcripts referred to the theme discussed. Since the interviews developed differently, reporting a percentage or weighting of certain statements would be potentially misleading. Moreover, statements of implicit agreement were not counted. Nevertheless, in This investigation is reported as having adhered to the 32-item Coreq comprehensive checklist for qualitative research . This chZurich's cantonal ethics committee filed a letter of non-competence, stating no objection. All participants were assured confidentiality, and gave their written informed consent to the study and, specifically, to the digital recordings of the interviews obtained.The research team was in personal contact  with 67 potential participants. Fifteen declined to participate. Barriers to participation were rarely addressed spontaneously. Four possible participants refused on the grounds that they were generally not available for studies. Five declined to participate, citing a lack of time due to high workload. Six gave no reasons. Thus, 52 interviews were conducted. After conclusion of the interviews, one participant withdrew their consent and consequently their interview was removed. One participant unexpectedly died between the personal and phone interviews and could thus not voice his opinion on supplementary questions, however his primary interview was included. In a few instances, potential participants had questions about anonymity or expressed a desire to obtain permission from their supervisor. However, in no case did these concerns lead to non-participation.n = 51) was composed of a slightly higher percentage of judges (53%) than of prosecutors (47%). The sample included assistant-prosecutors, prosecutors, senior-prosecutors, heads of the department of the public prosecutor's office and court clerks, presiding judges of regional/district courts, higher cantonal courts as well as a former member of the federal court. All 51 legal experts reported having experience in criminal law. Further, some reported experience in other legal sectors, such as civil law (n = 12), family law (n = 5), defendant (n = 1), and all law fields (n = 1).In total, 51 subjects provided their written, informed consent and completed the interview. The sample (M = 49.96 years and SD = 11.29) and average years of employment ranged from 5 to 49 years .Of the participants, 29 were identified as holding senior positions, according to our definition. Male legal experts represented 66.7% of the sample, females 33.3%. Their age ranged from 29 to 73 years  expressed in their own words how medical knowledge was important for their work. They referred to medical assessments as being a very important component of cases they judged or represented. In addition, legal experts (38) professed to have a special interest in medical knowledge. Participants (5) recognized that cases requiring medical knowledge were more time-demanding and complex compared to cases requiring only legal knowledge.yes, very important, was an injury life-threatening or not, this is crucial…(VP15)…Well, I am interested, very interested, yes, it's a really important aspect (…) of course the repercussions are considerable, especially for the consequences if criminal behavior is proven, or whether there is a therapy or not, and, yes, there is also the question of culpability, which can be very important… (VP19)…In 10–20% of the cases, yes, there is the core issue… (VP12)…Compared to the other cases, these [dealing with medical information] require much more time, because they are usually more complex… (VP13)…Legal experts (11) expressed awareness of the importance of scientific knowledge, often coupled with the perception of being inadequately prepared to deal with such knowledge. This knowledge gap appeared to one of the legal experts to justify delegating part of the responsibility for legal solutions to scientific experts.I mean, we have so many fields we should know about, you know, if you think about building law, I have to rely on experts there as well, I just can't evaluate this myself, sometimes I don't even understand what the problem is, it just comes in like that and then the experts deal with it and resolve it and it's the same with medicine. It would certainly be great to know a lot about it and the newest scientific results…(VP16)…Legal experts (11) clearly expressed their lack of knowledge in this area.my medical knowledge is like zero, nonexistent…(VP24)…I have relatively little, in fact, I have absolutely no sound medical knowledge… (VP7)None of the participants reported having specifically learned how to evaluate the quality of medical information .A clear majority of participants (37) claimed not to have been specifically taught any medical knowledge or scientific literacy skills during their undergraduate degree.Res.: During your training, or when you were at law school, was the evaluation of medical knowledge ever a topic? Did you learn how to deal with expert testimony or medical knowledge?B: No, not at all. (VP2)Res: Was the evaluation of medical knowledge ever a topic in law school or later, in your postgraduate career?B: I don't know, now, where you are going with this, but I would say no. (VP12)Res.: Did you notice a subject on how to evaluate medical knowledge at law school?T: During law school I attended a course on forensic medicine. Yes, it was very interesting. I was also able to attend a course once about psychiatric diagnosis. In that one, we were confronted with different people, like people with schizophrenia, or as I remember, dependency was also a topic, alcohol, drugs, but not chiefly. These were extracurricular classes, to be attended voluntarily. It was not mandatory. (VP25)Participants (4) who received training in forensic medicine reported having difficulties in assimilating those courses in a useful manner. Instead, they (3) perceived such lessons as exotic or entertaining, rather than practical.I took an optional course about forensic medicine, once for a couple of hours, but no, when I graduated I had no idea that there even was such a subject like forensic psychiatry (laughs)…(VP1)No, in law school, no, I mean there was of course a lecture on forensic medicine, but it was just a marginal subject, really… (VP14)we went to the Institute of Forensic Medicine, they were conducting a clinical autopsy, the way a corpse looks, that's rather, eh, that's nearly a bit like voyeurism… (VP8)…Interviewees (8) considered that the medical knowledge they were taught at law school was insufficient and felt that it had poorly prepared them to deal with it in a professional context. Only one respondent recognized this as a limitation of their training. However, four participants regarded training in scientific literacy skills and skills in reviewing medical knowledge during law school as not relevant at the time.At the time I started, that wasn't important—it wasn‘t an issue…(VP15)…During law school not at all, this was not an issue for me during law school… (VP24)…retrospectively I have to say that this was a shortcoming [during law school]… (VP43)…In hindsight, others (9) regarded their training in medical knowledge at law school as sufficient. They considered it more useful to acquire knowledge in this field at a later stage of their career, particularly after they had acquired some first-hand experience. Participants (3) believed that such knowledge was only necessary in criminal law and because relatively few legal professionals practice this field of law, it was not advantageous to teach it at undergraduate level.I don't think it makes sense either. I believe you need a certain work experience for this matter. At least, you need to have dealt with those people and experienced them, gotten to know them a bit… (VP13)in my opinion it makes sense to acquire it later, in the field, because you also have to see, that there are only a few working in criminal law. If you look at the students at law school, there are only a few that choose criminal law…(VP38)…Participants mentioned attending postgraduate medical-legal courses and conferences. Legal experts (20) described learning medical knowledge “on the job” and from medical expert reports .Therefore, it appears that their knowledge acquisition resulted from self-directed and informal learning. Others explicitly stated they had not attended a postgraduate interdisciplinary course.I didn't learn my medical knowledge anywhere specific. It was just learning by doing. (VP10)One source is certainly that we are confronted with case files in our everyday work that deal with certain topics, so we observe certain case patterns and you can also see them in the medical expert reports, eh, and of course, the more inexperienced you are, the more you pay attention to the terms in the reports, you gather the definitions, eh, this way you accumulate the information, just from these reports. And if you have the occasion to have a medical expert present at court, you use this occasion to ask him additional questions…(VP12)Interviewees did not know whether medical literature was included in their library at work and others stated that their libraries held only a few medical books or none at all (14).Yes, we have the Pschyrembel  maybe, I have one of my own, but otherwise we don't have many about medicine… (VP27)Res.: Can you tell me what medical, forensic, psychological literature there is?P: No, I can't, I never looked. (VP33)Interviewees reported not consulting medical books at all. Those (14) that did, reported using the diagnostic manual, a pharmacological compendium, a medical encyclopedia and sometimes a forensic medicine or psychiatry textbook.I acquired my knowledge, yes, formerly from the Pschyrembel, which was the only manual, so the manual which one consulted before the Internet came up and nowadays from the ICD… (VP20)All judges and legal experts (51) reported researching medical terms using the internet, chiefly Wikipedia. They used websites for basic information related to diagnosis, prognosis, and treatment.I use, I know Google and then I look it up there, and see what comes up… (VP8)I type it in Google and usually Wikipedia comes up with an answer (VP48)Google, of course, it's normal to sometimes look up a term when you are reading an expert report or when I see that a client needs a certain medication. Then I look it up on the internet, to see what it's used for… (VP42)Concerning scientific/medical literature, 41 legal experts stated that they were not familiar with any medical journals. Furthermore, they were unaware of relevant databases such as “Medline,” “PsychINFO” or “Google Scholar” and/or terms associated with “evaluating” scientific contributions based on bibliographical data such as “number of citations” and “impact factor.” Even though references to specific journal articles in expert witness reports are not uncommon, they were unable to access those. Only one respondent spontaneously provided the name of three journals and another appeared to recognize a journal the interviewer had mentioned. Interestingly, open access journals were considered to be of lower quality than subscription journals—a conclusion that may have to do with experience in legal publishing.Res: Do you know the term impact factor?P: I have heard about it, but I couldn't say in what context… (VP46)Res: Do you know Google Scholar?Pubmed?P: No… (VP1) from the name, I know the British Medical Journal, but, so, I don't claim to have ever looked up anything in it; so in this respect it's useless, isn't it?…(VP17)…I don't consult medical literature, because eh, because I can't really read it… are in another language, usually in English and they are probably not the most renowned… (VP39)So, there are American and English sites, the Lancet or the Journal of Medicine or the International Association of Psychiatrists. In principle, these are interesting sources, anyway. (VP51)Participants (4) stressed that they considered themselves ill-prepared to read “proper” medical articles. They acknowledged that medical experts required many years of training and there were limitations as “a layman” in regards to what medical knowledge they could understand.It is relatively useless looking up medical literature without a couple of years of training and knowledge and to say… that is as if you gave a layman a law book and said,” yes, there is something there that fits.” If you have no idea about the system and the context, you should leave it be. Knowing that, I also let it be… (VP17)Instead of journals, specialized medical services (forensic medicine or psychiatry) with ties to the law were identified by 3 interviewees as resources to be consulted regarding simple questions which do not require an expert statement. Additionally, legal experts (19) believed they could approach their acquaintances and relatives with medical training to obtain medical information .I can call your service…(VP51)I can approach my family doctor, with whom I'm on a first-name basis, yes, I could certainly approach him… (VP46)…My wife is a nurse… and she also did psychiatric nursing and she has got medical books, and I can look something up there or ask her. (VP44).…an acquaintance of mine is a general physician, eh, is going to be, and I asked her once…and with another, a psychologist we also once discussed certain topics…(VP41)Participants (3) considered the newspaper a source of medical information.I read as much as possible in my free time, the newspapers and then I like to read sometimes, what they write about forensics, that I would do… (VP1)Some of the interviewees (18) wished for more opportunities to acquire medical knowledge .Several participants (5) advocated changes to the law school curriculum, while others (8) identified short courses and events  as useful ways to learn more about medicine.I think in the context of congresses or conventions, these events already exist, where you truly learn something, where you can perhaps gain new insights…(VP16)Precisely this interface of psychiatry and justice hasn't been sufficiently developed in postgraduate education. We need to do more…(VP24)Case discussions are for me [the best]…people learn with cases. And the jurists, they like to have cases. Even the psychiatrists are similar in this respect. (VP44)That would perhaps be an approach, during law school, to place an increased emphasis on this intersection between medicine and the judiciary. (VP14)I am struggling to get universities to offer the subject, well, as a “serious” major subject with the corresponding credits, uhm so that the training…so further training is promoted in this area…(VP35)Some of those (3) who felt that improving the prospects of learning more was unnecessary, were also of the opinion that there were already plenty of opportunities and resources to gain knowledge—e—if only they were consistently used.I think not. We can get the knowledge, we can recall it. It just has to be done…(VP3)Other participants (3) wished for more informal contact with forensic institutions. Interviewees (4) suggested alternative means of accessing medical knowledge, such as a specialized hotline, web pages or an electronic newsletter with short articles. Easy access and comprehensive information were valued as significant characteristics for the proposed medical information sources.I think something that is really easy to access, on the internet or on an information platform, but it should offer an easy entry into and a good overview of the matter, that's something I imagine might be used when questions arise…(VP17)Actually, the easiest way would be an info-letter, so if it were done by email, done like a newsletter, I think that would be the easiest and most effective way, because lectures [and] conferences, are very focused on a topic, and often go far beyond what we really need to know.… (VP18)Well, precisely the exchange, for me that's what is exciting, that you have the network, that you can check to clarify, or even ask new questions, if you encounter difficulties with an area…(VP41)Perhaps in the form of a journal, that one could then subscribe to and read, but I think those [legal professionals] who are interested, they also read this; or in the form of an email, like a monthly newsletter or something like that, or also… that we would have a text book or something, that could be looked into if interested… (VP10)Time and financial constraints were the most commonly mentioned obstacles to learning medical knowledge among the judges and lawyers (13). In addition, lack of motivation was identified as a barrier to learning by only one participant. While one public prosecutor perceived that courses should be obligatory for all participants, as a means to improve professionalism and preclude a complaint attitude among colleagues.because of the money, the government has not got that much money… (VP23)…Time is also an issue, in practice we have a lot to do and lack the time needed… (VP27)…I am pragmatic, eh, if I had the choice between going to a two day long conference or getting the essence in written form, in two pages to be read, then, eh, I would prefer to read it, because it takes less time and I would still be informed. If we were to be informed in a brief and concise way by newsletter, or by a source where we could also ask questions when we need to. (VP7)I believe, or, if you do it on a voluntary basis, as I do. I am now going to Interlaken. Only those who are interested in this topic will go. And uh… the question is: how do you reach those who always complain about medical reports, but actually need it [medical knowledge]? …Uh, and I believe it is really in the interest of our profession and thus also of the employer, that is, the prosecution, to require that participation in further education is compulsory… (VP8)While reading related medical articles was deemed a good way to access new information, legal experts (8) claimed to only read law journals and were positively disposed toward medical articles in law journals. Furthermore, participants (12) explained that they preferred reading in their native language to reading in English.That would be, if you have any exposure to the Swiss Journal of Criminal Law or Criminology [Journal], etc. , is something I also consider very good. That would also be read by jurists…(VP34)Res.: Do you have any ideas, or wishes, about how we could make it easier for legal experts to access medical knowledge?P: I would do it by publishing and offering further education courses. (VP12)Yes, because the other thing is, I have little time anyway and reading such topics and in a foreign language that really takes up too much time… (VP14)German, definitely. Medical [literature] is a bit time consuming, so it would be preferable in a familiar language. (VP19)As far as we know, this is the first qualitative study to investigate how judges and prosecutors acquire medical knowledge, among other things to help them answer legal questions directly or to better understand and evaluate expert witness statements. As this is not quantitative research, this study is not an investigation of “phenomena via statistical, mathematical or computational techniques” but is, rather, intended “to provide a description and understanding of a situation or behavior” .Out of 67 potential subjects, 51 agreed to participate in this study and findings were drawn from the transcripts of these interviewees. Since fifteen subjects chose not to participate, our findings might reflect a volunteer bias, i.e., that legal professionals with a special interest in the intersection of law and medicine were more likely to participate in this study.In line with the existing literature, our results indicate that legal experts deem medical knowledge to be important for their work and reported depending on outside information, for example, in the form of expert testimony , 70. JudThey were aware that postgraduate courses and lectures dealing with medicine and law were available. The barriers to training that would increase their scientific literacy skills and knowledge of medical terms for legal practice were lack of time and/or financial costs.As was to be expected, the internet played an important role in gathering information and appeared to have superseded the use of books. Participants followed a common trend among internet users reported in the past decades , 74. WikAlthough the internet was identified as a popular and useful source of medical information, two problems with or limitations of its use are identified. Firstly, there is the issue of users' ability to find pertinent information on the internet. Secondly, there are concerns regarding quality, as the information available can be highly heterogenous  and userIt may be that in the Swiss legal system, where expert witnesses are highly trained and are usually paid by the state, and privately retained experts are the exception, the usual practice of referring to only one expert testimony per case misleads the legal expert into believing the expert statement must be correct. A part of the responsibility for the quality of expert evidence is shouldered by the experts themselves, an attitude consistent with the authors' experiences, as expert witnesses. This could explain why legal experts in an inquisitorial system—or at least in the Swiss system—may feel less pressured to learn how to evaluate medical testimonies or to use criteria compared to their professional peers in adversarial system countries, like the USA . This is problematic, because the quality of expert testimony has repeatedly been criticized in the past, despite the special training medical experts receive before acting as expert witnesses , 82–85. Obviously, legal experts are not expected to acquire the same medical knowledge as medical expert witnesses. However, it seems necessary for them to understand medical terms and data to a sufficient degree in order to be able to assess an interpretation, and, preferably, the risks of bias and unreliability in medical forensic evidence. This means having the skills to access and collect pertinent medical knowledge, which in turn includes scientific literacy. Our findings indicate that legal experts acquire and access medical knowledge in an unstructured way, and may also use problematic sources like newspapers, unspecialized medical professionals or non-peer-reviewed sources available on the internet. No participant indicated having formalized, specialized contacts like medical advisors or links to medical forensic specialist associations, despite acknowledging these as potentially useful sources. Respected academic medical journals and books appear to be insufficient means for bridging the interdisciplinary gap between medicine and law. It would appear that forensic articles published in medical journals dealing with interdisciplinary topics of possible interest for legal experts—for example the aforementioned articles about quality problems of expert witness statements—have a negligible chance of actually being read by legal experts.These results need to be considered within the limitations of the investigation. First, because this is an exploratory qualitative study based on a purpose sampling method, the findings cannot be generalized beyond this study sample. Second, there are limitations associated with volunteer bias, to which most studies are also susceptible. The main reason for non-participation stated was time limitation due to lack of time and workload. However, other possible reasons could include lack of interest in the subject matter, or sensitivity regarding the topic. We only interviewed members of two of the three sides of a law case as defending lawyers were not included. Thus, these results may not reflect the attitudes of such experts nor of recently graduated lawyers. As exploratory research, this study was not driven by a theoretical framework. Future studies on this subject could, however, use the insights gained to pursue more focused research.We also recognize that the results may in part be specific to the Swiss legal system. Nevertheless, the literature indicates that similar problems, such as difficulties in evaluating scientific knowledge can be found elsewhere . FurtherThis research extends our understanding of legal experts' perceptions and experiences of the acquisition of medical knowledge and scientific literacy skills for their profession. Findings have shown several different strategies that legal experts undertake when required to understand and assess medical content drawn from expert witness statements. In light of our findings, several practical implications can be drawn. It may be inferred from our results that for medical knowledge to reach legal professionals, it has to be presented in a way that is comprehensible to the layman and, when possible, in their native language. Moreover, it should be presented where they would normally seek information, such as legal or interdisciplinary journals. Many participants professed a need for direct contact with medical professionals, be it their own acquaintances, a speaker at a conference or employees of forensic institutions. As no interviewee reported having formalized specialized contacts with medical institutions, offering easier access to forensic institutions would enable better interdisciplinary cooperation and further the quality of knowledge on which legal experts can base their decisions.Forensic science professionals, legal experts, legal clients and the general public would naturally benefit from legal experts acquiring the necessary tools with which to evaluate medical witness statements. Scrutiny of forensic evidence would be improved if lawyers acquired the scientific literacy skills enabling them to ask pertinent questions regarding the reliability and biases of data and of expert conclusions in medical expert statements. Ultimately, such scrutiny would help legal professionals to better achieve the goal of legal equality and legal certainty.In the light of our findings, law departments might wish to evaluate whether their graduates are sufficiently equipped with scientific literacy skills. In addition, courses on internet use as well as on evaluating internet resources and information are extremely important and teaching those topics formally at undergraduate and postgraduate level should be considered, as well as in specific short courses. Finally, forensic research into the reliability and bias issues of medical forensic evidence should be increased and communicated not only to peers in the field but across disciplines to legal experts.CC: data gathering, evaluation of data, writing, and revisions. AB: conception, development of the topic guide, and writing. AD and CJ: conception and revisions. IP and RN: data gathering. PS: writing and revisions. ML: conception, development of topic guide, obtaining ethical approval, evaluation of data, writing manuscript, and revisions.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.


In recent years, the problem of bullying, existing in sport and arising in athletes’ relationships, is increasingly emphasized. The aim of this research was to reveal the specificity of bullying in athletes’ interrelationships by elaborating on causes of its emergence, nature of actions, and its consequences. To achieve the research aim, a qualitative research paradigm was chosen. The theoretical part of the research was prepared by applying the methods of scientific literature analysis and analogy. The empirical study involved seven organized sports athletes representing individual, duel, and team sports branches, belonging to the young adult age category. The survey was conducted using the semi-structured interview method. Data were analyzed employing the conceptual content analysis. Emic and etic perspectives were used for data processing. Research results revealed that the specificity of manifestation of bullying in sport unfolded through three generalized categories: intolerable perception of behavior, nature of bullying, and bipolarity of consequences. Every category was detailed by sub-categories, highlighting the nature, causes, and consequences of bullying accepted by athletes in the contexts of their emotional state and career. We found that the factors falling into these categories were interrelated and supplemented each other; therefore, they should be analyzed in a complex way, as bullying is determined not by some single factor but by the totality of them, functioning as a kind of well-established flawed tradition supported by the cultures of the sports organization and the sport. Sport has undoubtedly become an integral part of modern society. Over the past decade, the field of sport-for-development, associated with the importance of using sport and in particular the importance of sport for personal and social development outcomes, started to receive considerable attention . This isBullying is a unique but complex and heterogeneous phenomenon, which “directly affects hundreds of millions of people each year”  p. 327)7], whichHowever, it is not easy to define this phenomenon accurately, as due to constant change and development of the society, it cannot remain static . Often tThe topic of bullying in sport has also been increasingly analyzed in the past decade ,18,19,20It should be maintained that such an approach may be partly related to much lower prevalence of bullying in sport, comparing it with other contexts, especially school bullying, stated in research. Research results show that 10–15% of athletes in large part identify themselves as victims of peer bullying. An even smaller share of athletes 8–11%) attribute the role of the bully to themselves % attribu,18. HoweIt is evident that such a situation shows the need for effective intervention and prevention measures. Unfortunately, the latter are often not implemented in a qualitative manner in organizations operating in Lithuania, including sports organizations. This can be due to both imperfect legal acts or non-incorporation of existing ones into the organizational internal regulation legal acts  and the The imparted ideas enabled the following problem questions of the research to be raised: How is the phenomenon of bullying in interpersonal relationships in sport treated by athletes, that is, what can be the causes of the emergence of bullying? What is the specificity of manifestation of bullying in sport? What consequences of bullying are experienced and seen by athletes?The research aim was to reveal the specificity of bullying in athletes’ interpersonal relationships, detailing the causes of its emergence, actions, and consequences.The object of the research was bullying and its consequences in sport. Seeking to comprehensively analyze the research object and to implement the set research aim, the qualitative research paradigm was chosen, which enabled us to reconstruct subjective experience and, disclosing the context, to describe the process in which the concrete practice takes place. The study was grounded on the constructivist-interpretive paradigm , by whicThe sample was obtained using two different types of non-probability sampling techniques: purposive/judgmental and snowball . Using tThe main requirements for participants’ selection were as follows: encounter with the phenomenon of bullying in sport (the victim of bullying in the opinion of other persons); correspondence to the age group of 18–29 years, defined in Lithuania as “youth”; participation in organized sports for at least 5 years. In total, seven informants were recruited to the study and each of them received a code  in the transcribed texts .Research data were collected using semi-structured face-to-face interviews with open-ended questions. The interview guides for athletes were created following guidelines proposed by H.J. Rubin and I.S. Rubin  and had Interviews took place at selected places between January and February of 2019; their average duration was 32 minutes. Dictaphone was used to record all interviews. Interview records constituted the research data, which were transcribed verbatim by one of the authors of this article. After the transcription of the text , the electronic media of interview records were destroyed and the text was sent to informants for information, supplementation, and confirmation of correctness of the text.Data were analyzed employing the conceptual content analysis . After tThe study was ethically approved by the ethics committee of the Lithuanian Sports University. The study was conducted in accordance with the principles of anonymity, confidentiality/participant safety, voluntariness, and authenticity of research data ,34, thatAnalyzing research participants’ statements, it should be noted that answering initial questions, whether they have experienced or observed intolerable behavior in interrelationships, athletes gave negative answers, stating that relationships in the team or among persons training together were “friendly”. It was only in the course of interviews that the provided stories revealed experienced and observed intolerable behavior leading to bullying, with its nature and consequences showing up.The first distinguished category was intolerable perception of behavior in interrelationships between athletes see .Aggression among athletes can be expressed using both psychological pressure and physical force. Psychological type of aggression was revealed in the narratives of representatives of three sports branches, highlighting several interrelated aspects. Answers of representatives of team branches 2S  and 3S  indicated unfair competition, when seeking to gain advantage, in attempting to degrade the competitor in the same team. In the narrative of 2S, one can discern certain subjectively perceived inferiority of the opponent, which was offset by degrading competitors. The explanation of 3S shows the nature of actions in more detail—formation of the negative opinion about team members and degrading their reputation by spreading rumors. The picture of the situation is also supplemented by the clarification provided by 5S (athletics) that sneers are used in direct contact, that is, seeking to cause pain openly. At the same time, it can be noted that such relationships have signs of being permanent in nature, leaving the only choice for the victim being to accept it . No broad generalizations can be made on the basis of these cases, but further research may verify the assumption that team sports may seek to employ group pressure, whereas in individual sports such opportunities remain more limited.Physical aggression became evident in team sport branches . Although 1S only reflected on experience observed from outside, the narrative of 3S shows subjective experience, which, on the one hand, reveals that aggression is used against the physically weaker person, and on the other, sounds like an excuse: “... smaller all the time <...> I couldn’t oppose”, which implicitly suggests the perception that opposition to aggression is only possible if you have “sufficient” physical force. The fact that physical aggression among team members may be frequent was confirmed by the reference to the presence of a person in the team who was especially responsible for “curbing” the team. In addition, it can be envisaged that the team is aware that interpersonal aggression occurs outside the public space (“in the changing room”), which cannot be directly controlled by team management; therefore, the team captain of standing is used for its suppression in this space. In this context, it is significant how athletes themselves assess cases of aggression . Informant 3S, who experienced aggression, perceived this as “character hardening”. Other informants representing team sports treated the use of physical force in interpersonal relationships as a norm  or tended to understate such situations (2S “... not seriously”). In other words, even taking into account subjective negative experiences, this may point to attempts to accept the existing physical aggression, trying to find positive aspects to justify it because no other alternatives are seen.The narratives of team sports informants highlighted a tendency to divide into smaller groups, during workouts or competitions, which identify themselves as different by emphasizing negative comments about persons who do not belong to them (1S). Such identification is based on the time of belonging to the team, when “older” team members feel superior to newcomers (2S), or nationality (3S). In the context of group formation, the topic of team/group rallying after workouts and/or competitions emerges, which, if detailed, enables the distinguishing of subjectively perceived subtleties of adaptation. Narratives of 1S and 2S, expanding each other, suggest that team integrity can be temporary and can manifest itself only during the match, as the true negative nature of relationships become evident outside the court, with this being perceived as the team’s weakness. The narrative of 5S shows off-court competition where competition between generations also takes place (“... ready to eat each other ...”). Fitting in with the team is perceived as the problem of the “fitting in” or “not fitting in” person (3S), who by default should himself/herself fit in with the team, but the team remains passive towards the new player. In this context, the “not fitting in” athlete is isolated (avoidance) by demonstrating reluctance to communicate (2S) and/or demonstrating physical distance .Another sub-category—degrading of others—shows athletes’ reactions to colleagues’ personal features manifesting themselves by a certain attitude to persons labelled as “conceited”. The fact that as many as five out of seven informants representing different sports confirmed the existence of such problem in their teams or groups indicated prevalence of the phenomenon or “label”. On the one hand, contempt and bullying can be felt from those persons who subjectively see themselves as superior to others (5S), and on the other hand, it is not always possible to precisely distinguish cases referred to as “conceited”, that is, the distinction between demonstrated arrogance, contempt, and reactions provoked by competition. For example, 3S referred to “one of the better players” as “conceited”, who “hindered the microclimate”, without explaining how, but was considering whether it would be better for the team without him; however, he added that he failed to compete with the leader. However, judging from informants’ experiences, the person who subjectively singles himself out and demonstrates certain arrogance receives hostile, malevolent reactions , becomes isolated, or the person labelled as “conceited” is dealt with off-court .In the context of competition between athletes, this label is emotionally influential but remains too vague due to subjective perception and therefore is referred to as dangerous because informants’ responses indicate that the decision  can be made by a unified group without the judgment of external arbitrators.Hostile relationships can turn into intentional harm. The narrative of 7S (wrestling) shows hostility and harm taking a refined, hard-to-spot form; when doing physical exercises, obstacles were formed for the colleague (no help in training is provided) “so that the other fails to do that action ...”. This was, namely, silent sabotage of workout rules, which the victim of hostility subjectively felt but could hardly prove.Although there were no separate questions about coaches’ behavior, informants named physical and psychological aggression experienced from coaches. This was narrated by representatives of two sport branches: 6S (equestrian sport) and 7S (wrestling). Although coaches’ behavior was perceived as a legacy of the “Soviet” coaching culture (6S) and personal incontinence (7S), this may also reveal certain attributes of coaching culture, wherein physical and psychological aggression is perceived as an instrument to “stimulate” better achievements of athletes, without looking for other forms of motivation. For example, although 3S did not speak about coaches’ behavior, he implicitly expressed his approval of aggressive behavior existing in their interrelationships, interpreting it positively as “hardening”. Moreover, although he himself had become a victim of aggression, he justified its use. Therefore, as far as training culture is concerned, it would be more accurate to use the term sports culture with entrenched positive assessment of physical and psychological aggression. Therefore, the victim of coach’s aggression (7S) shows that athletes can unleash their anger and emotions only in the private space, as the coach–athlete relationship is one-way, while the feedback is cut off, fearing sanctions. This indicates a depressed state with no opportunity to oppose.The second distinguished category was the nature of bullying in athlete interrelationships and athlete–coach relationships see .On the basis of informants’ answers, the main causes of bullying in the context of sport were distinguished: “jealousy”, “competition”, “appearance (Authors note–body weight)”, “revenge”. Jealousy and competition had commonalities, as hostile behavior was directed against the person’s superior by his/her athletic achievements in order to degrade him/her, harm his/her reputation, hurt him/her and this way affect the dignity, self-confidence, and emotional state of the victim who became the target of attacks, which could affect the match. In this context, the story of 7S is relevant: “...there used to be a lot of bullying, especially mostly because of weight, because anyway, we group by weight category, and the bigger it is, the more it is necessary to bully for being fat, even though you are a Lithuanian champion, still you will stay like this or like that ...”. Duel athletes understand that the fight takes place by weight categories, but stereotypical assessment of appearance prevailing in society is transferred to interpersonal relationships. Such assessments cause psychological pain to the informant, although he/she perceives the cause of bullying only as a reaction to appearance; high achievements mentioned in the story cannot be denied too. Jealousy and competition are permanent in their nature, whereas revenge, on the one hand, is an instantaneous reaction in its nature yet, on the other hand, also exhibits certain lasting approaches because, according to 3S, “older” players take revenge. This suggests that there is a division by age groups, when older athletes subjectively perceive themselves as having “more rights” or privileges than younger ones and claim exceptional conditions for themselves. This way, “taking revenge” can be treated as a tool used to defend privileges subjectively perceived by the members of the “exclusive” group.Informants’ narratives highlighted verbal and physical aggression. In the case of 3S, physical aggression as material harm occurred when certain items belonging to the athlete were taken away and appropriated, although this happened rarely. In cases of verbal aggression, several aspects can be distinguished—when athletes are criticized for personal failures or blame for the team’s failures is attributed to them. In the second case, criticism used is supplemented by as if additional “weight” in the team’s social context, appealing to the fact that the victim cares about his/her contribution to the team’s success and about the team’s opinion of its particular member. This way, by manipulating the team’s “opinion”, the terrorizing person seeks to increase the subjectively perceived responsibility/guilt of the victim. The narrative of 6S shows how over time, the use of vulgar lexis and jeering suggests the state of inferiority. The victim calls this state “burnout” or the feeling of helplessness after trying to resist by proving his/her value through athletic achievements.Informants’ responses indicate that physical aggression and threat to use it are employed as a means of impact for both team members and opponents from other teams. As noted above, competition moves beyond the court (public space), where, in some sense, publicly “invisible” negative, that is, aggressive actions can be used. In this context, it is possible to distinguish aggression experienced from both opponents in the team and competitors. Here, the problem of objective and clearly stated assessment reveals itself. For example, narratives of 3S and 4S show that informants realize that objective decisions are impossible in the process of relationships taking place in a closed space without the disinterested attitude from outside, which is not received. This could lead to reconciliation with inevitability of aggressive behavior, seeking no other ways out.This state of inevitability in the sub-category the athlete’s response to bullying and harassment is outlined by the narrated experiences and considerations of 2S, which revealed hesitation between trying to resist, fight, and reconcile with the situation for fear of further aggressive behavior. This resulted in avoidance (“... I try not to hear ...”) or attempts to justify the experienced feeling of helplessness . Such reactions are also promoted by ambient approaches. For example, the narrative of 3S shows that reporting to the team management about experienced violence is perceived as a reprehensible act that is not tolerated by the team; therefore, the victim imparted to persons who were not related to the team in order to avoid revenge, all the more so because retaliatory violence is considered a certain norm, a sign of psychological and physical “strength” .Experienced states are revealed by the sub-category the athlete’s emotional state. Informants’ experiences highlighted that violators’ pressure is lasting in its nature, undermining the victim’s self-confidence, and that the victim experiences despair, suffering, and shame, and feels “burnout”, exhaustion, and doubts about his/her as athlete’s career prospects.On the one hand (sub-category bullying in different age groups), informants’ narratives reveal how reactions to bullying change, whereas on the other hand, show tense relationships between persons of different ages. For example, informant 2S mentioned that over time, certain reconciliation with the aggression experienced takes place, and on the other hand, 3S believed that in adulthood, encounters between conflicting parties become more open and direct. Furthermore, age is perceived as a kind of “status” that “allows” younger people to be treated more rudely compared with peers. Time spent in the team is also perceived as a kind of “status” providing more privileges (sub-category old-timers vs. newcomers). The “blame” for the team’s failures may be shifted onto the younger player, besides discrimination and the manifestation of bullying. On the other hand, the answers reveal that such discriminatory behavior in sport is regarded as a kind of “norm”, a natural part of athletes’ interrelationships. For example, the nature of narratives of 3S and 4S shows that discriminatory behavior or calling bullying a “joke” are not perceived as negative actions degrading the person’s dignity or causing suffering.Relationships between coaches and athletes (sub-category relationships with the coach) lack openness, for example, when the coach is explaining decisions made, which promotes hostility (2S), interpersonal relationships bear considerable distance (7S). It also becomes clear that the coach can use bullying “instrumentally” as the means of impact on the athlete, seeking “to encourage” him/her (5S and 6S). This demonstrates that, on the one hand, the impact of verbal bullying is perceived, but on the other hand, the narrative of 5S shows the problem of perceiving bullying. In other words, there is a danger that psychological aggression, both used and experienced, may remain unperceived and unidentified. This behavior of coaches in the coach–athlete relationship was generalized and supplemented with the negative impact on the athlete in the narrative of 6S. The problem of the distance between the coach and athlete even more acutely unfolds in the sub-category that we identified as the coach’s position in cases of bullying and harassment. For example, the informant 2S did not dare to tell personal experiences (which can be seen in his narratives discussed above) and conveyed them indirectly by providing the narrative of another athlete who was forced to leave the team. The informant understood that the coach did not know this story because he remained aloof from what was going on outside the court, referred to as “the changing room”. Thus, two territories showed up: one, the public zone encompassing workouts and competitions, where the coach has power, and the other, the non-public zone, where the coach does not interfere, although non-public interpersonal relationships nonetheless influence the way the team functions. Nevertheless, the informant fostered hope that the coach had instruments to solve the problem.The third category, bipolarity of consequences of bullying in athletes’ interrelationships, revealed what, in the athletes’ opinion, could be treated as consequences of bullying in sport .It is noteworthy that informants’ narratives revealed the consequences of bullying for the individual or social group, but athletes believed that they can have two poles, both negative and positive.The sub-category “negative impact on the individual’s activity” revealed the motive for personal failures, manifesting itself as the loss of athletic mastery, negative learning outcomes, or drop out of sport. Particularly striking was the reported aspect of drop out of sport, having encountered bullying. However, such a conclusion was made on the basis of observed bullying situations. It should be noted that this problem is encountered by athletes of various sports branches, independent of whether they represent team, individual or duel sports. As stated by athletes, personally experienced bullying, which clearly proves its existence in sport, can lead to poorer academic achievements (4S) or loss of individual athletic mastery. The latter unfolds in the narratives through the prism of psychological bullying directed to sporting activities. In basketball (3S), this can manifest itself by persistent sneering of team members when no points are scored, which seems to program the person’s further failure, performing the same action again—throwing into the basket. Such situation can also occur in other sports, such as equestrian sport (6S). The constant saying of “... you won’t do it anyway” determines failure in sport. It should also be noted that this type of bullying can be demonstrated by both team members and coaches. The latter, according to athletes, exhibits communicative behavior called “casting aspersions” (3S).Experienced bullying in sport can also cause “negative psychological consequences”. Both continuous physical actions—“pushes” (3S)—and psychological actions—“pressure” (4S)—can form the feeling of lack of self-confidence. This feeling eventually moves to other areas of life, “... that I looked at every new thing in such a way that I would still fail, well, there wouldn’t be anything good still ...” (6S).Bullying in sport can also determine the person’s disassociation from the group, which becomes the individual’s defensive response to various bullying situations. There is no wish to encounter the bully to whom “antipathy” is felt any longer (5S), because memories of bullying do not disappear. However, when bullying behavior in the team or club repeats, the athlete naturally faces the dilemma, “… maybe it’s enough for me, it’s enough to bully me and maybe it’s time to end that career ...“ (5S), which has nothing to do with the wish to engage in sporting activities.These consequences also naturally determine “the negative impact on the social group”, stated by athletes, that is, on the team or club and its results, as not only “personal goals” are sought in sport (1S). It is as if it is understood that there should be no “anger”, “arguments”, “tension”, or “miscommunication” in team members’ relationships, but in reality, these actions lead to the game that “... straightaway worsens ...” (3S), whereas athletes experiencing bullying “... do not help the team at all ...” (5S).However, stating the consequences of bullying, informants do not shy away from taking the observer’s role, and much more willingly remember the persons they saw in the victim’s roles.However, according to respondents, bullying experienced in sport may not always mean negative things. The behavioral pattern “an eye for an eye” is becoming a norm in athlete relationships, whereas persons who have “withstood” it in sport state that they do not attach much importance to bullying. They choose the strategy of “... just reconciliation ...” (7S), which shows that bullying in their personal relationships remains and is transmitted from one generation to another. Most probably, such patterns of communication among athletes and the coach’s behavior with athletes inevitably leads to situations where bullying will be experienced over and over again. Moreover, because there is a strong need to engage in sporting activities, all that remains is the justification of such behavior. This manifests itself by athletes’ opinion that the ability to withstand bullying, not to break, will build a strong character and harden the athlete, “... I’m sort of glad that I have stayed in such medium, because when you stay in such place (of the victim), you realize that other things that earlier looked very terrible are not so terrible, on the contrary, they have kind of grown such skin to me so that it’s easier for me ...” (2S).The conducted research primarily confirmed the statement that bullying does not disappear anywhere over time and that the likelihood that victims will experience bullying in further life remains considerable . AlthougAs a result of the analysis of research results, This study shows several factors promoting bullying in sport, although the lack of research allowing for the comparison of the research findings with the research conducted on bullying in sport in the adult context has also revealed itself. The outcome of this study allows us to distinguish individual and contextual factors determining bullying in interpersonal relationships. The first level includes individual characteristics of conflict participants, as well as the contextual level, a group of factors encompassing established traditions justifying negative behavior. For example, revenge due to failure can be instantaneous, but jealousy is permanent/long-term in its nature. On the other hand, jealousy provoking unfair competition is one of the significant factors, but it is involved in the interaction with other factors. One of such factors is the person’s perceived status in the team, which is characterized by the athlete’s age. This factor was also found by Kerr et al. , howeverSuch behavior of coaches can be directly related to the primary universally raised role of the coach—to help athletes to improve their performance , which iYildiz  states tThis study also revealed different consequences of experienced bullying and demonstrated the specificity of their treatment in sport. If research analyzing consequences of bullying in various contexts states—namely, its negative impact on the person’s psyche, activity, or development—reveals potential problems related to substance, alcohol, or illicit drug use; emerging sleep disorders; headaches or dizziness; stomach aches; or back pain  in the sHowever, it is likely that eventually such “positive” benefit of experienced bullying will become a threat to the person’s mental and physical health. Primarily, becoming a “stronger” athlete can lead to an increased risk of trauma during sports . QualitaAlso, in order to envisage guidelines for future research, we refer to the position imparted by Fields et al. , who staOn the basis of the analysis of the research data, we distinguished three generalized categories: intolerable perception of behavior, the nature of bullying, and bipolarity of consequences. Every category was detailed by sub-categories highlighting the nature, causes, and consequences of bullying, accepted by athletes in the contexts of their emotional state and career. We found that the factors falling into these categories were interrelated and supplementary to each other; therefore, they should be analyzed in a complex way, as bullying is determined not by some single factor but by the totality of them, functioning as a kind of well-established flawed tradition supported by the cultures of the sports organization and the sport.This study broadens our knowledge of causes of bullying in sport and its specificity, pointing out the problems of perception and identification of bullying, due to which both physical and psychological aggression may remain unrecognized by athletes themselves and their coaches, being perceived as some kind of “natural” behavior inherent to sport. Distinguished categories and sub-categories can serve as a basis for further research, both qualitative and quantitative, going deep into the causes of bullying and investigating its prevalence in different branches of sport. There is also a visible need for research into the relationship between hypothetical school bullying and a possible transference on sports practices with the same athletes. There are, however, limitations of the research and guidelines for further research. This study involved athletes representing various sports branches; therefore, no conclusions attributable to a specific sports branch or group of sports branches can be drawn. In the future, it would make sense to conduct research with subjects involved in specific sports branches or groups of sports branches, choosing either young adults or adolescents. The study involved athletes from only one country; therefore, in the future, the situation of athletes involved in the same sports branch or group of sports branches in several countries on the analyzed issue could be compared.