Research examining the interrelated drivers of household violence against women and violence against children is nascent, particularly in humanitarian settings. Gaps remain in understanding how relocation, displacement and ongoing insecurity affect families and may exacerbate household violence.n = 73) in two districts in Colombia from May to August of 2017. Participants were displaced and/or residing in neighborhoods characterized by high levels of insecurity from armed groups.Employing purposive sampling, we used photo elicitation methods to facilitate semi-structured, in-depth interviews with female and male adolescents and adults aged 13–75 (Using inductive thematic analysis and situating the analysis within a feminist socioecological framework, we found several shared drivers of household violence. Intersections among drivers at all socioecological levels occurred among societal gender norms, substance use, attempts to regulate women’s and children’s behavior with violence, and daily stressors associated with numerous community problems. A central theme of relocation was of family compositions that were in continual flux and of family members confronted by economic insecurity and increased access to substances.Findings suggest interventions that systemically consider families’ struggles with relocation and violence with multifaceted attention to socioecological intersections. Over the past decade, women’s and children’s exposure to interpersonal violence has been increasingly recognized as a public health priority –3. This Household violence—defined as “power and/or control perpetrated by one person in the household, with the intention or effect of causing harm to another person in the household’s physical, sexual, or emotional health or well-being” –16—has iColombia is an upper-middle income country that housed the world’s largest number of internally displaced persons in 2016, has experienced decades of civil war between the government and non-state armed groups, and offers a window into the effects of protracted conflict on VAW and VAC , 27. In Given that humanitarian contexts, in particular, present situations of grave concern for women and children with regards to exposure to violence , 32, incRecently, a structured review consolidating evidence concluded that conflict exposure, alcohol and drug use, income/economic status, mental health/coping strategies, and limited social support were shared drivers of violence for both women and children in the home . While tThe study outlined in this paper draws on an adapted version of Brofenbrenner’s socio-ecological framework . This frDrawing upon Bronfenbrenner’s socioecological framework, researchers have written about alcohol use, HIV status, the experience of violence in childhood, and psychological mechanisms  as individual level factors for violence against women and children , 39. ExaOur study, funded by the United States Office of Foreign Disaster Assistance (OFDA), aims to address gaps in knowledge around intersections of violence against women and children in humanitarian contexts. While there has been some progress in examining forms of household violence as interrelated, little work has examined the specific and potentially discrepant ways that shared drivers of VAW and VAC operate at various socioecological levels. Additionally, there is limited understanding of how forced migration and displacement relate to VAW and VAC in the home. As most violence against women and children occurs in the context of the home -- even in humanitarian settings , the homUsing qualitative methods to better understand drivers of household violence in a setting characterized by relocation and displacement, the present study was guided by the following two research questions.  What areThe study was conducted with Spanish-speaking adolescents aged 13–17 and adults aged 18–75 in the Cundinamarca and Córdoba departments of Colombia. These two settings, chosen in consultation with Universidad de los Andes and UNICEF Colombia, had different urban/rural distributions but encompassed neighborhoods characterized by high levels of displacement and/or insecurity with an ongoing presence of armed groups. In Cundinamarca, the urban context was a large informal settlement on the outskirts of Bogotá, in which limited access to basic necessities such as running water and public transport exist alongside armed group activity and distrust of local authority figures, such as police, representing the state , 49. CórWe used photo elicitation methods to facilitate open-ended, in-depth individual interviews on topics related to gender norms, household violence, and wellbeing –55. PhotOur community-based partners purposively selected one member per household for photo elicitation interview activities. Community partners were given information on the desired sample, which aimed to recruit equal numbers of men, women, boys, and girls, and approached members of households who were known to have experienced displacement and/or were living in neighborhoods with large known concentrations of displaced households to invite one person to participate based on the specified criteria. Community leaders were encouraged to use their own discretion and judgment in discussing displacement explicitly. Due to stigma about disclosing displacement status and guidance from community partners in urban areas, displacement status was not used as study eligibility criteria; participants were asked about relocation more broadly during interviews, which provided an opportunity to disclose displacement status. The field team included four Colombian researchers from diverse academic backgrounds, a Colombian field coordinator, and two American field oversight staff. Interviewers  were based in Bogotá and completed a two-week training on qualitative research methods, interview tools, ethics and confidentiality, conceptions of violence, and reflexivity. Local referral mechanisms for survivors of violence were identified in both sites and interviewers followed locally approved referral protocols. All data collection procedures were approved by Institutional Review Boards at both Columbia University (AAAR1039) and Universidad de los Andes, and completed in accordance with World Health Organization ethical guidelines for research (2011).Interviewers obtained consent from adult participants and caregivers and assent from adolescent participants to complete three to four interviews, depending on participant availability, in confidential spaces managed by non-governmental organizations. All consent and interview procedures were completed in Spanish. Consent was also obtained to audio-record interviews, and detailed notes were taken if consent for audio-recording was denied.To protect safety and confidentiality of participants, the study was presented as a family well-being study to community members. After obtaining consent, interviewers introduced the activity and asked participants to elaborate on topics related to the thematic session. Participants who did not possess photo-taking devices were provided a mobile phone with photo-taking capability to use for the duration of the study. Many participants had a mobile phone with photo-taking capabilities, and opted to use their own phone rather than a phone provided by the study team. Participants were instructed to only use the phones if they felt safe doing so, and encouraged to consider taking photos of inanimate objects or other items that they felt were symbolic of the themes and interactions between family members, as opposed to taking photographs of individuals. Additionally, community partners included organizations that conducted various types of sports and arts activities with adults and youth, and this link with community partners may have helped reduce suspicion about use of phones for photo-taking.SD = 1.5) and adults 44.3 years (SD = 13.9). While the numbers of girls and boys in the sample were about equal, 58% of adults in the sample were women.Between May and August 2017, 226 interviews were completed with 73 participants . The average age of adolescents was 15 years  described relocation as a response to experiencing household violence between intimate partners or against children.When we were little, my dad, he drank a lot, so he would come home and hit my mom. So, when we were little, we would see that. So, then when my mom made the choice to leave him, for us it was difficult.– Adolescent Girl, Age 17, SoachaThe experience of relocating from a rural to an urban environment was commonplace. Respondents highlighted several reasons for relocation, though the most commonly cited scenarios relayed experiences with interpersonal violence—either as respondents had experienced or witnessed it in the community or within the household. Some respondents who had relocated from rural areas, for instance, described relocating because of armed conflict and rebel group activities.Respondents described drivers—factors preceding and likely contributing to VAW and VAC—at all levels of the socioecological model. Table I’ve seen, in my home we had that case with my dad, the men always try to rule the women, there’s abuse, hitting, or verbal humiliation. They say “no, you’re a women, you’re good for nothing”.–Adolescent Boy, Age 17, SoachaThe societal gender norms described tended to be associated with attempts to regulate behavior and expectations for male dominance and aggression, especially for male violence against female intimate partners. Adult-perpetrated VAC as a form of behavior regulation also manifested, although perpetrators of VAC tended to be both men and women in examples. Adolescents, especially boys, additionally attempted to use violence to regulate parents’ undesirable behaviors.And plus, my dad did use violence, because my dad hit my mom pretty hard for a while, because he saw that his brothers were telling him, “You have to get her in line. You can’t let her talk back to you, you have to…” That is what my mom told me, right? I mean, my dad was a good boyfriend until he went drinking, for example, with his friends, or with his brothers, or the family. They’d tell him, “You have to give it to your wife every now and then. I mean, give it, hit her like to keep her subjugated, in line,” like they said, so my dad would hit us hard.– Adult Woman, Age 33, SoachaFor women and girls, behavior regulation additionally occurred through the restriction of sexual autonomy, as well as freedom to leave a relationship. As shared by one participant,He starts hitting her so she gives him children, or if not he’ll look for another [woman] and try with her like that.– Adolescent Girl, Age 14, Tierralta.Another woman shared,And that man made a house for her and everything for that girl. And one day he had her killed because she didn’t want to be with him anymore.– Adult Woman, Age 46, SoachaVAW and VAC were repeatedly found in connection to the division of and expectations associated with household responsibilities. With regards to VAW, violence stemmed from men perceiving women not to perform expected gendered responsibilities, such as meal preparation. An adolescent girl, age 14, from Tierralta shared,The woman has to have food ready for him, and if she doesn’t have it, he beats her.A perceived lack of contribution to household responsibilities also drove VAC. In these instances, a range of adult caregivers, including mothers, fathers, and extended family members, perpetrated violence against children. An adolescent boy, age 14, from Tierralta shared,Because, I mean, because sometimes I don’t listen to her. I mean I don’t do the errands or that she tells me to, I leave and I go somewhere else and she scolds me, sometimes she hits me.For children, violence as a form of punishment occurred in response to disobedience, poor school attendance or performance, substance use, and missed curfews. Some respondents normalized VAC as a parenting technique. For example, a woman, age 35, from Tierralta shared,One day I hit him…you have to, because sometimes they’re lost/clueless.The quotation below shows that these parenting practices were often intergenerationally learned parenting techniques to regulate behavior.Because she would get so ma— well, she says that, that’s how they used to teach you before, and she like learned that and copied it, to like teach me, to teach me, because that’s how they used to teach you, before. And she had, I mean, she had that like habit from when they used to hit her, and so she thought, well, I’ll hit my children, too, like they taught me to.– Adolescent Girl, Age 15, SoachaAdolescents also reported attempting to regulate and interrupt male perpetrators’ violent behavior against mothers, which resulted in VAC. Boys were often the targets of VAC in this context.Respondent (R): …He returned after some time to see if his father had changed, but he hadn’t. He was worse. He would come home drunk, when he wanted to hit the mother and things like that. Interviewer (I): Then he would try to defend the mother.R: Since there are children who don’t want anything to happen to their mother. And he would do that, but he would also get hit.– Adolescent Girl, Age 15, TierraltaSituated at the outer level of the socioecological model, societal gender norms markedly shaped relational and individual behavior. While respondents did not describe relocation as having directly influenced gender norms, we provide a brief analysis of these norms due to the fact that they were frequently connected to VAW and VAC, offering a contextual backdrop for relocation and resettlement experiences. First, the experience of household violence reflected inequitable gender and age-related power dynamics: women and children were more likely to experience household conflict or violence than men, according to many respondents.Respondents rarely directly connected the experience of relocation or exposure to conflict with increased household violence, despite relocation reportedly having negatively affected families in several ways. When respondents identified relocation as directly related to VAW and VAC, their narratives revealed pivotal interactions among families, urban community systems, and individual-level problems see Fig. . LinkageSome [families] that I know the woman is single because they killed the husband. They are displaced, and the woman makes the decisions.–Adult Woman, Age 47, Tierralta.First, at the relational level, there emerged the theme of instability through the continual shifting of family structures and composition. While not absolute, shifting family systems often depicted a core family composition of women and their children. As one woman shared,I had to receive [my aunt] because she had no place to go, and she came with two little children and, because her mom and because the cousin that I told you I have here, there’s a daughter of her, and she has two other little ones. So, there are four little children arriving to the house at six in the morning and with another cousin that goes there, her niece and another little boy, like five… it’s a lot of disorder.–Adolescent Boy, Age 19, SoachaAnother adolescent male shared:Because we were used to seeing them [mom and dad] both, so then when they split up, well my nineteen-year-old sister, she left with him, my brother. Well, he started to smoke and was sent to a boarding school, and so we well, stayed with my mom and that’s when she found my stepfather. – Adolescent Girl, Age 17, SoachaThe shifting of family structures was a dynamic process that interacted with the host community environment. Family compositions changed when relocating and continued to shift due to stressors faced in the host community. The need for income generation as well as exposure to community violence were associated with continued instability and separation of family members, as illustrated in this narrative:So they began to give him work, and he was working, and he began to hang out with all those guys, the ‘patos’ [bus driver’s helper]. Some of them are annoying, some of them bother so they say some of those guys were going to kill him because once he saw a thing that they were going to assault a bus in which he was working as a ‘pato’ and they killed the driver. He saw everything. He saw who was the one who killed the driver so they were going to kill him because of that, because he could talk, so that’s why they [his family] took him away from here. – Adolescent Boy, Age 17, SoachaIn addition to losing husbands to conflict, participants described women divorcing or separating from abusive male partners and sometimes later partnering with other men:There are not so many conflicts [in our former home]. Well, there are armed issues, the red zone, but you could live in peace, you can talk, look, you live in peace. But here you don’t. There are many dangers.– Adult Man, Age 34, SoachaPerceptions of and experiences with  community violence affected caregiving practices between adult caregivers and children . Women especially expressed concern about the safety of their children and correspondingly restricted children’s movement outside the home. Lack of community safety also limited leisure opportunities that were outside the home for youth.Now I feel overwhelmed by the level of safety in the neighborhood, mostly because of the safety of my children. Because sometimes when you’re lying down and you don’t know if they’re gonna throw a bomb at you or who knows where. So if my kids go out into the street, and then always they always take ages, so I’m there like “Ah, where are you? What did you do? Where and what did you do? Or maybe you’ve done something. What if something’s happened to you?” You’re there like with that, that silence without them. And your heart is just going. You live through it every day.–Adult Woman, Age 35, SoachaA core component of heightened familial stress was the intensification of economic adversity when relocating from rural to urban environments in part because of a lack of labor skills and qualifications  demanded in an urban environment and also due to relative difficulties of securing food in the respective settings. Occasionally, respondents connected economic adversity, in particular food insecurity , in urban environments to violence and friction in the home between partners and caregivers/children .Yes I have already suffered [after relocation], as my daughter was never taught to endure hunger. When we took her, she was hungry and I did not have food to give her, she would get angry. Then she would make me angry, and I would beat her… That's why I’m saying this—it [living in the rural area] was content. Because in the mountainside you can fish, you kill fish, kill bushmeat. All the children were happy…– Adult Man, Age 58, Tierralta…I live with a lot of stress because of the pace of my life, and because of my financial difficulties and because my, yes over many things, eh, you get stressed. I got stress a lot, a lot, a lot… So that day I don’t know for some reason I got up late, got up in a bad mood, I don’t know, and oh and went and clashed so horribly with my kids, horrible, horrible, yelled at them, punched [name of daughter] over here. She didn’t have breakfast.– Adult Woman, Age 40, SoachaUrban employment exacerbated family vulnerability through more indirect pathways as well. For example, there were reports of exposure to community violence because of employment hours  or location . These problems in the community in turn produced economic difficulties for the family.At the community level, almost all participants described their communities as being unsafe, unprotected, and as posing economic challenges for families. In the following narrative, an adult man draws a distinction between the new urban setting and a former rural setting, perceiving the urban community as more dangerous.The roles changed a lot then because, firstly, I changed husbands, from my children’s father. That was a hard loss that I still haven’t gotten over. I don’t think I’ll ever get over that. Then I was left as a mother and father to my kids. I worked outside the home, and I had to work and come home to see my kids. I used to pay people to look after them for me. I’d pick them up and then the next day carry on the same all over again. And for that same reason, it was so hard for me. – Adult Woman, Age 35, SoachaSubstance use  was a frequently referenced driver of household violence, and participants provided descriptions of the ways in which substance use drove violence in the household. Most often, participants described alcohol use as a precursor to male-perpetrated VAW and VAC in the home and often connected substance use to narratives of male dominance and female subordination.Yes, many times men are always trying to mistreat women when they are drunk or when they are on drugs… Because when he gets drunk, he begins to say that women are easy, that if he wants any woman he would rape them or whatever he wants, because he is a very bad person when he gets in that, when he is with alcohol or in drugs.– Adult Man, Age 19, SoachaThe same participant noted that instances of alcohol use and household violence were not limited to VAW perpetrated by intimate partners, but also by fathers against children and adolescents.In a safe home, alcohol can affect many things because it can break the bonds, the family, over all the problems they can have. In one day, they can even be hurting the woman they have or the children because of the alcohol problem. They can, eh, do a lot of bad things.– Adult Man, Age 19, SoachaTo a lesser degree, substance use by children also appeared to drive conflicts in the home with caregivers. For example, adolescents’ substance use was implicated as a reason for parental beating as another manifestation of behavior regulation. In other instances, drug or alcohol use by children created conflict with parents either through parental disapproval or as a result of substance-induced aggression.Finding and affording childcare presented as another notable adverse experience following relocation. A few respondents offered examples of leaving children with extended family members, representing another way in which the composition of families shifted during the relocation process.But now there aren’t very many conflicts in the countryside because people say there is peace. There’re a lot of soldiers everywhere, so there isn’t very much conflict. But here in the city, we see a lot of conflict because people want to fight all the time. For example, there’re a lot of people who work all the week to drink on Saturday and Sunday. And in those days, unexpected things can happen. For example, there may be problems, or another person who doesn’t bear what the other person is saying to him, and they can fight.– Adult Man, Age 19, SoachaUrban communities additionally presented more opportunities to obtain and engage in substance use, a frequently referenced driver of VAW and VAC. Substance use in turn was described as being associated with increased fighting and problems in the community.To our knowledge, this is the first study to examine household violence—including VAW and VAC from perspectives of both Colombian adolescents and adults in communities with high levels of displacement and ongoing insecurity. Findings illuminated intersections of drivers and gender norms of VAW and VAC across the four levels of the socioecological framework.Numerous participants in our sample had experienced relocation, a main driver of which was exposure to interpersonal violence at the relational  or community levels . Data revealed a pattern of shifting family structures and compositions during the process of relocation, with continued shifts after relocation due to community stressors, economic insecurity and exposure to violence. This finding highlights the contribution of household violence as both a result of and an additional driver of displacement for families already vulnerable in contexts affected by armed conflict. Research in low-income countries and humanitarian settings is needed to better understand familial and community variables’ intersecting effects on wellbeing and cycles of violence.Urban communities presented more availability of and opportunity to abuse substances for relocated families. At the individual level, male alcohol consumption interacted with societal expectations of male aggression against intimate partners and children and was identified as a major driver of VAW and VAC. Substance use has a well-established association with exposure to and perpetration of interpersonal violence , 59. WorOur results highlight the importance of broadening violence-prevention interventions to account for intersecting influences at all levels of the socioecological model, attending especially to intersections between patriarchal gender roles and other local drivers. Multi-pronged interventions that focus on intersecting forms of violence, including polyvictimization, and target families experiencing insecurities related to income, housing, and political conflict, may have more success in reducing violence in the household . While pREAL Fathers Initiative [One Man Can [Parenting for Respectability [SASA! [Social norms interventions to reduce VAC and VAW aim to challenge gender norms, increase advocacy efforts, engage in consciousness-raising actions, involve bystanders and stakeholders, and provide increased access to medical and social services , 67. Whiitiative , One Man Man Can , Parentitability , and SASy [SASA! , have dey [SASA! . While VWhile there are several strengths to this study, the findings should be interpreted with consideration of some limitations. Procedural limitations included variation in number and duration of interview sessions to match participants’ availability. This flexibility allowed for greater participation but may have impacted analysis. To address the limitation of oversampling, a subset of interviews was selected from each participant demographic and analyzed until saturation, which risks overlooking certain data points or qualitative outliers as well as jeopardizing participants’ time and effort. Additionally, limited demographic information was collected for this sample in order to protect participant confidentiality, potentially impeding our ability to draw conclusions delineated by more specified demographic data. Relatedly, given the sample size and design of this study, the hypothesized relationships linking personal and household risks with displacement remain untested. Additional research could usefully help elucidate whether links between the drivers identified in this thematic analysis are causal or merely co-occurring.This study found that drivers of household violence—violence against women and violence against children—manifested at all levels of the socioecological framework and routinely intersected with patriarchal gender norms. The processes of relocation and displacement led to new vulnerabilities and continued instability in family structures, particularly through urban community stressors including safety, economic and food insecurity, and increased access to substances. Collectively, these findings support interventions that systemically consider families’ struggles with relocation and violence, with multifaceted attention to socioecological intersections.


Molecular Biology and Evolution and in this issue of Genome Biology and Evolution suggests that we may have only begun to scratch the surface on the number of variations present in the genetic codes of all living organisms.Crack open a biology textbook and you will find a standard icon of molecular biology: the table summarizing the standard genetic code. This refers to the set of rules by which the cell “decodes” the information contained in DNA and “translates” it into the amino acids that make up proteins. For example, in virtually all organisms, the codon (3-letter DNA sequence) “AGA” tells the translation machinery to add the amino acid asparagine. Although a few deviations in the genetic code used by various organisms are known, research recently published in Molecular Biology and Evolution, a group of researchers including Emmanuel Noutahi, Virginie Calderon, Mathieu Blanchette, Nadia El-Mabrouk, and Bernd Franz Lang from the Universite de Montreal, Institut de Recherches Cliniques de Montreal, and McGill University published an analysis of the mitochondrial genomes of 51 green algae and land plants . Because of this, “Comparative/evolutionary bioinformatics procedures such as CoreTracker are now in a position to not only predict deviations of the genetic code but also provide clues with regard to the underlying mechanism.” Indeed, in light of their results, the researchers proposed that the genetic code deviations in the Sphaeropleales mitochondria actually contributed to their unusual genome organization. Based on this theory, after the migration of some mitochondrial genes to the nuclear genome during the genome reduction process, “UCA”  was reassigned to a termination codon. This would have made it impossible for additional mitochondrial genes to be transferred to the nucleus, resulting in a mitochondrial genome that was intermediate in terms of size.analysis, published in the current issue of Genome Biology and Evolution , and although changes to the tRNA repertoire, structure, and specificity may be inferred to some degree, biochemical confirmation is critically required.” This limitation was also pointed out by Eliáš, who noted that his group plans to employ proteomics methods to verify some of their bioinformatic predictions concerning the various presumably reassigned codons. “Unfortunately,” continues Eliáš, “nonstandard genetic codes are generally found in organisms that are difficult to study by direct biochemical or genetic approaches, so it remains a challenge to get a deeper understanding of the molecular mechanisms behind the observed changes in codon meaning.”Future investigations will almost certainly uncover additional, as-yet-unidentified changes in the genetic code in various organisms. Indeed, notes Eliáš, “We are also analyzing some exciting new cases of genetic code modification in nuclear genomes of certain obscure protists that were uncovered by our survey of publicly available sequence data.” Furthermore, the authors of the Noutahi et al. study point out that, given “how rapidly this field is evolving, due to an ever increasing number of reports on deviations from the standard genetic code—particularly, in eukaryotes and their organelles… the journey to understanding codon evolution with all of its mechanistic implications has just begun.”


Valid understanding of the relationship between cultures and persons requires an adequate conceptualization of the many contexts within which individuals work and live. These contexts include the more distal features of the individual’s birth ecology and ethno-national group history. These features converge more proximally upon individual experience as “process” variables, through the institutional–normative constraints and affordances encountered through socialization into a diverse set of cultural groupings. This enculturation is then revealed in the individual’s response profile of values, beliefs, choices, and behaviors at any given time. Cross-cultural psychologists have typically compared these encultured responses cross-nationally by averaging the scores of equivalent groups of persons across national groups, terming these average differences “cultural differences.” This procedure has generated considerable resistance, primarily due to careless over-generalization of results to all members of a given cultural group. Critics of nation-based characterizations have challenged their methodological and conceptual inadequacies, but we now know better how to address the measurement-related aspects of culture-level “psychological” variables, such as individualism–collectivism. In challenging the accuracy of these measures, critics have also neglected to acknowledge the continuing predictive and discriminant validity of these dimensions of national culture. We here review the utility of more recent measurements. We then show how nation-level comparisons can be used by psychologists to improve our understanding of individual, rather than group, outcomes. Nations are heterogeneous amalgams of ethnicities, social classes, organizations, school systems, and families. Individuals’ socialization into these groups affects their functioning at any given point in life. These enculturations are further dependent on their gender, age, and education. Assessment of culture’s relation with individual functioning requires adequate measurement of both personality and normative aspects of situations in which behavior is enacted. Once this integration of cultural influences is achieved, the logic and methodology for integrating national culture into psychological models of individual behavior can be applied within any nation where research focuses on how within-nation cultural variation affects individual functioning. Culture, conceptualized as normative group constraints, becomes more widely amenable to study, and the hard lessons learned from cross-national research can be used to guide the practice of more locally sensitive research. This requires that we take into account the importance of culture and context in the way that we write our papers and in the types of populations that we sample.”-We argue in this paper that a valid understanding of the relation between persons and cultures requires an adequate conceptualization of the many different contexts within which individuals work and live. In particular, we explore the interrelation between the attributes of large cultural groups and the factors acting upon the specific experiences of individuals located within such groups. Relevant contexts include the more distal features of the individual’s birth ecology and ethno-national group history that are treated as “background” variables in Over the course of this developmental process, the individual becomes less dependent on others for survival and better able to exercise greater agency in choosing his or her proximal cultural groupings and the micro-cultures of relationships within these proximal cultures . This geThis progressive “fitting in” across the life course may thus be construed in terms of a Bronfenbrennerian bio-ecological model of development across the lifespan . This moWhat are these cultural contexts, and how can they best be conceptualized and measured? How are social scientists to deal with the interweaving of cultural contexts at different levels of immediacy to the living person ? How to from one another, and discounting the variation between individuals within each nation. As we shall see, this procedure is not without limitations, but the recognition that in order to study culture and persons we need to differentiate levels of analysis was a critical achievement.In developing a conceptual framework for the study of culture, psychologists have faced a series of problems. Firstly, the traditional focus of psychology has been upon understanding the behavior of individuals, and the behavior of these individuals has mostly been studied in a highly restricted set of national–cultural circumstances . ConsequA second problem that has had to be faced is the question of how culture is to be defined. Everyday observation reveals a diversity of values, attitudes, beliefs, and behaviors between different groups. Each of these attributes has been included in some or all of the more than 300 definitions of culture that have been proposed . A majorTwo perspectives have helped toward a resolution of this conundrum. Firstly, A second helpful perspective is complementary to that of Triandis. Researchers have increasingly sought out variables whose measurement can contribute to the understanding of ways in which cultures evolve over time. These are the “distal” eco-social variables referred to in The classic studies of cultural differences have all focused upon comparisons between national cultures. As we insist, cultural differences can be studied at all levels of analysis. It is for purely pragmatic reasons that national differences have been highlighted: survey data from individuals are frequently summarized by averaging the within-nation individual responses to produce nation-level indices, and other forms of data, such as indices of wealth and inequality, are also readily available for use as tests of concurrent validity.The three classic studies of cultural dimensions  each empThe question for consideration is what these dimension scores mean. They are based on individual-level scores, but they do not represent individuals. The scores for nations from different studies are drawn from different types of sample and have been collected at different times over the past few decades, but scores on conceptually related dimensions  are nonetheless shown to correlate substantially with one another . Nation-However, this view has become increasingly difficult to sustain. Analyses of the Schwartz database have shown that variation in values between individuals is very much greater than variation between national samples , with na“Societal culture is a latent hypothetical construct. It cannot be observed directly, but can be inferred from its manifestations. The rich complex of meanings, beliefs, practices, symbols, norms and values prevalent among people in a society are among the manifestations of the underlying culture. They are not culture itself.” (p. 6).Thus, nation-level scores can better be considered as an indicator of an underlying structure that will have been molded over time by multiple factors, and which may entail institutional structures, such as family relations, schooling, work organizations, laws, and languages spoken. They do not necessarily require value consensus. The strongest argument for retaining an interest in nation-level dimension scores is that they are found to consistently predict relevant nation-level indices derived from independent sources. The meta-analysis of relevant studies by If we accept the coherence and predictive utility of some of the dimensions identified in the classic cross-national surveys, there remain numerous questions as to whether and how more recent studies can add value to what we already have. We consider first whether researchers have devised better measures and whether these have identified additional dimensions of variance.The dimensions of nation-level variation that have been most fully explored are those that stem from Using a more specifically targeted design, In a related study using the same dataset of adults from 35 nations, should behave, and thus provide a measure of injunctive rather than descriptive norms , i.e., B = f(P.S), for integrating personality factors with situational features in predicting an individual’s behavior. Norms exercise their force upon an individual’s situated behavior by suggesting or specifying the reinforcement contingencies likely to be applied should the individual behave or not behave in a normatively prescribed or proscribed way. So, some situations may be characterized as strong, others as weak depending on the intensity of reward and punishments regarded by the individual as likely to arise given certain behaviors .“… pursuing understandings of human behavior without taking its relationship context into account runs the risk of omitting a central – if not the most central – determinant of that behavior and one that interacts in important ways with other determinants of that behavior  … of all the situational factors that might be considered in helping us to understand psychological phenomena, the relational context in which a person finds him- or herself is not only one of the most important contexts, it is probably These authors proceed to make their case by examining the research data supporting the importance of variations in relationship type, relational character, and the developmental history of a relationship for their impact on a wide range of psychological outcomes – “prosocial behavior, social influence, person perception, self-concept, self-regulation, and judgments of pain, taste, beauty, and risk.” . They conclude their review by claiming that, “… relationship contexts are one of the most powerful and pervasive situational influences fundamentally shaping human behavior.” .in situ and ex situ) can reliably differentiate situations according to 5 … dimensions of interdependence: (a) mutual dependence, (b) power, (c) conflict, (d) future interdependence, and (e) information certainty.” (p. 716).In predicting individual cooperation, Having identified a general line of approach, we can now explore how it could find application to the study of cultural differences. As Mutual dependence: “Degree of how much each person’s outcomes are determined by how each person behaves in that situation.”…Power: “Degree to which an individual determines their own and others’ outcomes, while others do not influence their own outcome.”…Conflict: “Degree to which the behavior that results in the best outcome for one individual results in the worst outcome for the other.”…Future interdependence: “Degree to which own and others’ behavior in the present situation can affect own and others behavior and outcomes in future interactions.”…Information certainty: “Degree to which a person knows their partner’s preferred outcomes and how each person’s actions influence each other’s outcomes.” (p. 718).We suggest that these dimensions of social–interpersonal interdependency can be linked in suggestive ways with the dimensions of variation in national culture that we discussed in preceding sections. For instance, within collectivistic cultural contexts there are likely to be stronger perceptions of mutual dependence, less perceived personal power, and greater perceived future interdependence. Within tight cultures there is likely to be greater perceived information certainty. However, there is no reason to expect that all contexts within a given nation will replicate the characteristics of the nation as a whole. Other dimensions will become relevant, as These speculations on cultural systems and their associated logics for interdependency management need to be tested empirically. They may provide a way to integrate situational analysis into cross-cultural comparisons of social and interpersonal behavior.f(P.S) for explaining individual behaviors across cultural groupings? There are a few points worth considering in this regard: Firstly, whatever effect personality might exercise on the individuals involved in a cross-cultural study of behavior will be dependent upon the specific lens of the personality measure used in that study. These measures vary across a spectrum of dimensionality – from the single, as in general self-esteem  with situation (S) to predict behavior (B) does not specify the way in which P and S, however operationalized, are to be combined – the researcher might specify and test for an additive or an interactive relationship between the two. Both approaches are possible, depending on how narrowly “the situation” is defined and whether there are “layers” of situational influence to consider in the analysis, as elaborated next.f(P.S) to their behavioral response of interest. To do so, they must hypothesize the personality factors involved, the normative considerations related to the situated behavior, and any P.S interactions, and then test their model. The challenge, however, is to specify the norms applicable for the behaviors being examined. The usual procedure in cross-cultural studies is to measure an actor’s typical behaviors, in effect summarizing across the actor’s life to date. In that case, “the situation” in question is absorbed into the personality measure which summarizes the many, varied situations encompassing an actor’s life to date.Considering culture as a normative situational context would enable researchers to proceed in applying the Lewinian formula, B = Such a simplifying process has been the typical approach in cross-national research. But, what if one is doing cross-ethnic, cross-state (or province), cross-organizational, cross-team, or cross-family research across national cultures where variations of ethnicity, provinces or states, organizations, teams, and families are embedded within nations? In this case, cultural influences on social psychological processes would “seep down” to the situational–relational level through many potential layers of culture, varying in their immediacy to the actor. A multi-layered, multi-level model of influence then becomes necessary to disentangle the complexity of possible cultural influences in play.on individuals in a given context.” . If researchers are to use the Lewinian formula for behavior as a guide, then behavior, B, can be the result of variation in individuals’ personality, P, variation in the immediate normative situation, S, and variation in their interaction, (P.S). When researching across cultures, culture then becomes a superordinate construct in which the B = f(P.S) model is embedded, a higher-level summary of the individual’s situations encountered across a lifetime.Our approach outlined above is consistent with A number of possible effects may emerge from this multi-cultural, cross-level analysis:(1)P may exercise a main effect across all cultural groups, positioning the “average behavior” of members from any cultural group differently from that of other cultural groups.(2)S may exercise a main effect across all cultural groups, positioning that average behavior of members from any cultural group differently from that of other cultural groups.(3)The P.S interaction may exercise a main effect across all cultural groups, positioning that average behavior of members from any cultural group differently from that of other cultural groups. These types of analysis require multi-level modeling . We haveAs an example of this approach, consider the work of This study lacked individual-level measures of S, but where these are also included we may anticipate that a variety of cross-level moderation effects will emerge. So, culture, however operationalized, might interact with P, with S, with P.S, or with any combination of factors to influence individual behavior, B. These cross-level moderations are referred to by a priori argument, well grounded in the literature involving this type of cultural grouping – nation, organization, team, family, role dyad – would be needed to provide a persuasive argument for conducting such a study. As always, methodological rigor and statistical appropriateness are required to prove one’s case. Since results do not always support the researcher’s hypotheses, so a sensible, fair-minded interpretation of the findings would provide a necessary conclusion to the research exercise (“Cultural salience effect” is a descriptive phrase only, requiring a persuasive logic for explaining why this way of unpackaging culture results in greater or lesser weight being attached to P, to S, or to P.S in affecting B. An exercise .cross-cultural psychologists.When designed using the Lewinian formula described above, cross-cultural research can improve psychologists’ interpretive power. “When psychologists leverage interpretive power, they can use cultural differences to build theories that explain a greater range of phenomena with greater nuance.” (We have argued that the culture of any type of group may be defined as the norms characterizing that type of group in situated interaction with the personalities of its members to yield each member’s response. This conceptualization of the cross-level relationship between culture and the psychology of its members opens up a host of possibilities for modeling individual behavior. Our vision has been one of a possible future. Few studies exist that have analyzed effects that included individual-level variance in terms of social context other than that defined by nation-level dimensions. We conclude by identifying three studies that indicate the variance that remains to be explored through more detailed investigation.A more recent study did involve direct sample-level measurement of cultural differences. stronger predictor in nations higher in Self-directedness and in Civility. The socialization context for children characterizing one’s national culture thus has relevance to the life satisfaction of individual citizens. However, because this study also reported results nation by nation, they were able to show that trusting one’s ingroup did not predict life satisfaction significantly in all 50 nations, even if those nations were high in either Self-directedness or Civility. In fact, for Ethiopians the relationship was negative, albeit not significantly so. Why?Moving from the national level of analysis to the individual level, Of course, the specific result for Ethiopia may be an anomaly due to measurement error. However, to understand the results obtained more fully, we should need to move closer to the type of research design outlined in the preceding section. Rather than using a measure of generalized trust as the predictor, we should require measures of personality dimensions and measures of the perceived attributes of different interaction contexts. The World Values Survey already includes a very brief measure of personality but measures more akin to those proposed by Here, then are opportunities for a more “nuanced” understanding of the social–psychological phenomenon in question, albeit one that raises provocative questions of generalizability, begging the question of why a variable that predicts life satisfaction in most national cultures does not do so in a few. Such provocation is surely a reason for conducting studies as culturally comprehensive as that of “Everything should be made as simple as possible, but no simpler.”-Albert EinsteinBoth authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Candida albicans and the mammalian host. In this mSphere of Influence article, he reflects on how “Systematic screens of a Candida albicans homozygous deletion library decouple morphogenetic switching and pathogenicity”  provided tools and a blueprint for open-ended genetic screens in an organism that had been a challenge for genetic manipulation.J. Christian Pérez studies the interplay between  Candida albicans homozygous deletion library decouple morphogenetic switching and pathogenicity,” Noble et al. . The article published by Noble et al. was influential to me in two ways. First, it made me realize that this approach could represent a good entry point to investigate other aspects of the biology of C. albicans in the mammalian host. As a newcomer to the field, I had read that this fungus lives almost exclusively associated with a host  and yet only occasionally causes disease. Therefore, I was interested in exploring the broader host-Candida relationship, not only the “pathogen” facet. Indeed, the tools and experimental strategy described by Noble et al. provided a foundation to develop my own research projects on Candida commensalism (Candida gene circuits that shape the interactions between the fungus and its host. At that time, within the Candida field, the paper by Noble et al. was one of a handful (I became aware of the work of Noble et al. as a postdoc when I was starting to do ensalism , 3. A se handful , 5 that


Wearable technologies for health monitoring are becoming increasingly mainstream. However, there is currently limited evidence exploring use from the perspective of healthcare professionals. This study aimed to explore health professionals’ attitudes toward their patients’ use of wearable technologies.A convenience sample of health professionals was recruited to participate in this study. Qualitative semi-structured interviews were carried out either face-to-face, via Skype or telephone. Interviews were recorded using a Dictaphone, transcribed verbatim and analysed using thematic analysis.Four themes emerged from the qualitative findings: ‘opportunities for wearable technology’, ‘usability and understanding’, ‘privacy and surveillance’ and ‘cost’.The findings portray health professionals’ ambivalence to the use of wearable technology, and it was apparent that whilst the participants considered the technology as being beneficial to patients, they still had concerns for its use. Particularly, changes to the patient–doctor relationship is cited as being a primarily positive change based on the use of wearables.6It is being increasingly recognised that wearable technology has the potential to transform healthcare, providing care that is distinct from usual medical practice and health delivery.7 However, despite some theoretical consideration of what factors are necessary for the long-term adoption of these technologies, there is currently no evidence examining health professionals’ views of individuals using these technologies. Most of the studies currently exploring the use of wearables in healthcare focus on patient perceptions, some on carers, but few on health professionals’ views.810 One study explored all three, based on the views of general wearables and a clinically developed wearable used for seizure detection.9 Whilst automatic data showing seizure detection during consultation was preferred to non-digital methods, they were worried about increased workload and confidentiality of data, as well as wearability of users.9Three critical elements of adoption and use have been considered in creating adoption and long-term engagement with wearable technology: habit formation, social motivation and goal reinforcement.Whilst much focus of this literature currently rests with the user’s experiences, there is currently little exploration of health professionals’ views recommending digital technologies to patients. This study aimed to explore health professionals’ attitudes toward their patients’ use of wearable technologies.A qualitative method was employed in which semi-structured interviews were utilised to examine the research aim.A convenience sample of health professionals were recruited to participate in this study. Fliers were sent to general practitioner (GP) surgeries and other health professionals, and personal contacts were informed of the study. Individuals were ineligible to participate only if they were not a practising health professional. A total of 12 health professionals participated in this study, and took part in semi-structured interviews see .The sample consisted of 12 health professionals; four GPs, three junior doctors, one dietician, one personal trainer/pharmaceutical technician, one consultant nurse, one occupational therapist and one physiotherapist . Only two of the health professionals had previous personal experience using their own wearable technology, but neither used it every day: one participant used an activity tracker whilst running, and one participant used wearable technology whilst skiing.This study received ethical approval from Teesside University's ethical review committee.The lead researcher (AW) provided individuals with both verbal and written information about the study, including its purpose and details of their participation. Once individuals had been given this information, had the opportunity to answer any questions, and had provided written consent, an appropriate time was arranged to participate in a semi-structured interview. One-to-one semi-structured interviews were either carried out face-to-face, over the telephone, or by using teleconference facilities ensuring that data collection was convenient for the participants involved and widened the locality of participants throughout the United Kingdom (UK). Before the interview began, an example was provided to confirm participants’ understanding of wearable technology ; however, it was stressed that these were only some examples of wearable technology, and all forms of wearable technology were of importance. AW carried out all semi-structured interviews (each lasting between 30 and 60 min) utilising an interview schedule that was informed by relevant literature see . All sem11 The six steps of conducting Thematic Analysis were followed, in that the data analyst (AW) familiarised themselves with the data by transcribing and re-reading the data before generating initial codes, searching for themes, reviewing themes, defining and naming themes, before finally producing the report. In order to increase methodological rigour, data analysis was discussed with KS, and themes were checked to ensure they remained representative of the data.Data were analysed using inductive Thematic Analysis. Inductive Thematic Analysis aims to extract patterns of data into themes and sub-themes, as they arise from the data.Four themes emerged from the qualitative findings representing health professionals’ attitudes towards patient us of wearable technology, and their perceptions of implications that this can have on the healthcare service and doctor-patient relationship: ‘opportunities for wearable technology’, ‘usability and understanding’, ‘privacy and surveillance’ and ‘cost’. Whilst the first theme describes the positive aspects that wearable technology can have for individuals, the findings illustrate primarily negative opinions, and the final three themes demonstrate this.rely on everyone to sort out the problem’ (P007).‘Having a doctor tell you that everything’s looking ok, that’s an easy way out, it’s not up to us, it’s up to you, I think that’s a very negative thing.’ (P002).There is a sense that health professionals within the sample believe that the public are responsible for looking after themselves and think that they are required only for serious health issues. However, all participants agreed that wearable technologies are a useful tool to promote self-management, enable others to ‘take responsibility of their own health’ (P007) and ‘be more aware of themselves’ (P006).It was clear that some participants generally felt that patients do not take enough responsibility of their own health and ‘dressed up’ (P008) or ‘on a night out’ (P009) if the device was not hidden. Furthermore, participants described usability issues as a potential barrier for use with older adults.‘I think that, yeah it's too technical [for older adults]’ (P008).‘Even those who are used to smartphone use could see it being too complicated’ (P008).However, there was recognition that future generations of older adults will be more au fait with this technology.‘when they go back they didn’t have anything like iPhones or watches or that, whereas, when we are in our eighties we will, so we will be familiar with those things, when our generation get dementia I think stuff like that will be really helpful’ (P012).Evidently, there were judgements as to who may not use these devices due to usability or aesthetics. Usability issues were also of concern, not for the device itself, but for understanding data provided by the technology, and participants felt that patients may unnecessarily worry about their health either due to data being ‘misread’ (P010) or by patients over monitoring the data.‘I don’t know how effective they would be because you can over monitor, people can become, they think they are unwell when they aren’t’ (P011).One participant was anxious that constant monitoring of one’s health may ‘make people more unwell’ (P001). Instead, it was suggested that wearable devices in which data ‘went straight to a health professional’ (P011) would be more useful. Furthermore, wearable devices are only able to provide some data, which in isolation, may not be enough ‘to give the full picture’ (P006) about their overall health.Participants described the importance of usability and of understanding the data recorded by wearable devices. The health professionals had some concerns that some users may not wear the devices due to aesthetics and usability. Namely, there were assumptions that female users may not wear the devices when ‘Participants showed concern that patients may worry more about their health due to constant monitoring, trying to make sense of the data presented to them, or misinterpreting the findings. In essence, there seems to be a need for user education, knowledge and understanding of the devices.‘I don’t know, I suppose it’s kinda ethically, is acceptable to constantly know what someone’s health biometrics are’ (P011).Participants referred to wearable technology as ‘a silent data gathering thing’ (P003) and as ‘big brother’ (P012).Ethical as well as privacy concerns are going to need to be certified and new laws are going to be required. ‘Privacy, sharing of the information, that sort of thing, would be, all that would have to be clarified’ (P004).Concerns of privacy are of obvious worry to participants and are further compounded by both research and policy lagging behind continuously emerging and changing invocations.Privacy is a much-debated aspect of technology use. The importance of suitable and reliable measures in place for individual’s health information is of upmost importance, especially when being used with relation to healthcare services.‘if you can prevent a fall happening, each operation costs £10,000 pounds so if you can prevent an operation happening, you're saving the NHS a lot of money’ (P011).‘You’d save the NHS a lot of money. I think that is a big question, yeah, I think there are things you can do, and most of them are to do with motivation’ (P010).However, whilst some considered long-term cost saving to the NHS to be a result of reduced emergency admission to hospital and improved methods of self-management, some also discussed the barriers to providing patients with these devices over traditional treatments, such as drugs.‘I suppose the issue for the NHS is the cost for these things’ (P011).There were two ways of considering cost of wearable devices: as potentially saving NHS funds in the long-term, but also the short-term cost of the actual devices.The ability to save money is a huge concern for the National Health Service (NHS) and for those that work within it. Participants discussed both the potential long-term cost savings to healthcare systems due to increased autonomy, self-management of long-term conditions, and improved preventative behaviours.This study aimed to explore health professionals’ attitudes toward patients’ use of wearable technologies. Four themes were generated from the interview data collected: opportunities for wearable technology, usability and understanding, privacy and surveillance and cost. The themes illustrate the ambivalent views of health professionals involved in this study, and it was apparent that whilst the participants considered the technology as being beneficial to patients, they still had concerns for its use. The health professionals understood there was a use for wearables but could see a number of limitations that would require to be rectified before mass adoption.5 health professionals felt that wearable technologies could be used as tools to improve illness and disease prevention, and the self-management of long-term conditions.An unexpected discovery from the current study was the realization that those health professionals interviewed did not think the NHS was adequately providing preventive care to avoid illness or disease. Most interviewees agree that the NHS was instrumental at administering life-threatening interventions and ongoing chronic cases; however, they stressed that consultation time was taken up as a result of the lack of focus of preventative care and the self-management of long-term conditions in the NHS. Similar to the developing health policy in the UK,9 The aesthetics of technology are important, and are considered in general models of technology use and user experience and empirical research which evidence the importance of wearability,12 including aesthetics and comfort.1316 Interestingly, within this study, health professionals’ perceptions of the importance of aesthetics impact their recommendation of wearable technology to patients. Furthermore, it is apparent that the health professionals in this study consider age to be a barrier. Although it is important to consider age-related aspects of technology design and usability such as sensory, motor and cognitive functioning,18 evidence has demonstrated many pieces of wearable technology as being suitable for use, and enjoyed, by older adults.20 Some studies focusing on older adults’ experiences of wearable technology, show that preconceptions make individuals more wary of the technology,19 often with older adults considering it to be designed for younger people.21 However, interestingly, older adults within one study specifically stated that promotion of these wearable devices by health professionals would make them more likely to use them.21Barriers to use included gendered and age-related perceptions of aesthetic design, usability and interpretation, which were discussed. All of which have been considered in previous research primarily by the user’s own perspective but also by the perspective of health professionals.22 and this was clearly an important consideration for participants in this study, reflecting previous research.9 Data protection concern has been growing but an area of heated debate is in the medical sphere. This is also an area of considerable concern for the NHS, and is a central point of its digital innovation plans, to ensure ‘every citizen’s data is protected’.23 Furthermore, cost was a concern, and participants not only considered the cost savings but also the cost and sustainability of these devices within NHS budget.Wearables relating to healthcare must be considered with high privacy concerns,This study presents some limitations. Primarily, the sample size was small and consisted of health professionals primarily from one region. Differing usage and experiences may be observed with different groups of health professionals and cultural factors may also play a role. Furthermore, the researcher had previous personal connections with some participants, which may have impacted their participation and response. The study remit was broad, including any wearable technology, and, accordingly, exploring the use of specific wearable technologies may be informative. Future research must build on these findings and provide a more comprehensive evidence base in this area, as policy is promoting the uptake of wearable use for prevention and self-management; however, the importance of adopting wearable technologies also lies with health professionals.


The treatment of multimorbid patients is one crucial task in general practice as multimorbidity is highly prevalent in this setting. However, there is little evidence how to treat these patients and consequently there are but a few guidelines that focus primarily on multimorbidity. Big data analytics are defined as a method that obtains results for high volume data with high variety generated at high velocity. Yet, the explanatory power of these results is not completely understood. Nevertheless, addressing multimorbidity as a complex condition might be a promising field for big data analytics.The aim of this scoping review was to evaluate whether applying big data analytics on patient data does already contribute to the treatment of multimorbid patients in general practice.In January 2018, a review searching the databases PubMed, The Cochrane Library, and Web of Science, using defined search terms for “big data analytics” and “multimorbidity”, supplemented by a search of grey literature with Google Scholar, was conducted. Studies were not filtered by type of study, publication year or language. Validity of studies was evaluated independently by two researchers.In total, 2392 records were identified for screening. After title and abstract screening, six articles were included in the full-text analysis. Of those articles, one reported on a model generated with big data techniques to help caring for one group of multimorbid patients. The other five articles dealt with the analysis of multimorbidity clusters. No article defined big data analytics explicitly.Although the usage of the phrase “Big Data” is growing rapidly, there is nearly no practical use case for big data analysis techniques in the treatment of multimorbidity in general practice yet. Furthermore, in publications addressing big data analytics, the term is rarely defined.However, possible models and algorithms to address multimorbidity in the future are already published.The online version of this article (10.1186/s12875-019-0928-5) contains supplementary material, which is available to authorized users. Patients with more than one chronic disease are commonly defined as multimorbid . MultimoTreating the individual diseases of multimorbid patients in accordance with the specific guidelines for the single disease is the most common way to deliver care . This apLimitations for treating these patients described back in 2005 such as drug interactions or guideline related recommendations that contradict each other are still relevant today . To datevolume of data, the high velocity of data, and the variety of data [The term ehealth describes the general use of electronic devices or systems in medical care. One aspect of ehealth is the application of big data analysis techniques. The term “Big Data” was introduced in 1997 . Commonl of data –16. It i of data .However, there are no cut off values that clearly determine the point at which data starts being big. Still, big data analytics might have the potential to be a useful addition to the treatment of multimorbid patients.The aim of this review was to evaluate to what degree the application of big data analytics could assist general practitioners in treating multimorbid patients.Two of the authors  conducted an organized computerized literature search for studies that utilized big data analytics of patient data in order to treat multimorbid patients. This review followed the guidelines of the PRISMA Extension for Scoping Reviews (PRIMSA-ScR) .In January 2018, the databases PubMed, The Cochrane Library, and Web of Science were searched. In order to detect all areas of Big Data Analytics, a complex search strategy was developed, using the terms “big data”, “health analytics”, “healthcare informatics”, “electronic health records”, “databases”, “data collection system”, “electronic data capture”, “data management system”, “deep learning”, “electronic medical record”, “machine learning”, “medical data”, “huge data”, “electronic patient record”, “datamining”, “data analysis”, “reinforcement learning”, “decision support system”, “predictive analytics”, “reasoning” and “inference”. In order to identify studies dealing with big data analytics in the context of multimorbidity, search terms were combined with the terms “multimorb*” and “multi-morb*”.The terms “general practitioner” or “general practice” were deliberately not included in the search terms to ensure that as many articles as possible on the topic of multimorbidity were included. Relevance to general practice was individually assessed in the screening process.Additionally, a search of grey literature with Google Scholar was conducted. For this search the terms “multimorbidity AND “big data” AND ” were consented within the research group under the advisement of an expert in computer sciences and used to keep the number of results manageable. Patents and citations were excluded. The search in Google Scholar was performed using the “Private-Setting” in order to produce replicable results.www.covidence.org) which was used in the further review process. The complete search strategy is available in the supplemental material  independently screened the titles, abstracts, and subsequently the full-text articles. Discrepancies during the screening process were discussed during regular consensus meetings. A third reviewer (JS) was consulted as needed.The authors are members of the “Center for Open Innovation in Connected Health (COPICOH)” at the University of Lübeck. In this center, computer scientists as well as researchers from a variety of health disciplines are working together. The authors held consensus meetings with this research group in order to define, what articles were to be included. It was decided that studies that used standard statistical methods, e.g. large cohort studies that examined data from electronic health records, were not deemed eligible.After the title and abstract screening, 29 full-texts were screened. Of those full-texts 23 articles were excluded after discussion within the research team because they either did not conduct big data analytics as defined by the authors, did not focus on multimorbidity or were not relevant for general practice.Finally, six articles were included in the data extraction. For better traceability, the entire screening process is visualized using the PRISMA Flow Chart. see Fig. .Fig. 1PRStudies were not filtered by type of study, publication year or language. Validity of studies was evaluated based on the judgement of two independent researchers . The data extraction from the included studies was done by AW and a scientific researcher in the field of computer sciences and consented with all authors.Extracted data was the publication year, the country of origin, the aim of the study, the number of examined datasets, the used method of data analyses, and the outcome. The Results of the data extraction are summarized in Table Of the 220 results in the “grey literature”, none were deemed eligible and consequently were not among the included articles. All of the included articles were published in English. None of these articles used the keyword or term “Big Data”. However, after discussing this within the researcher group, six papers were included. They originated from Greece, Germany, Hungary, the Netherlands, the United States, and Canada –24. The Four of the articles dealt with the analysis of large data sets of multimorbid patients to analyze or find patterns in the combinations of diseases in these samples , 23, 24.Another result of this review was that there were no precise definitions for “Big Data” in the screened articles. Furthermore, there were no defined cut-off values to specify at which point the levels of volume, velocity or variety of data are sufficiently high to clearly define them as “Big”.The aim of this review was to evaluate to what degree big data analytics are already supporting general practitioners in treating multimorbid patients.Altogether, we identified only one article addressing the approach of improving the treatment of multimorbid patients with COPD by using techniques that are related to big data analytics . HoweverThese limitations are in line with other reviews that addressed the benefits of big data analytics for Diabetes type 1 and 2 and Alzheimer’s disease , 26.The other five included articles did not present direct recommendations for the treatment of multimorbid patients. However, they utilized methods and techniques to develop models that could, upon further investigation, shed a better light on the understanding of the underlying patterns for multimorbidity. It would be reasonable to verify these models for the analysis of multimorbidity clusters of other datasets to further the understanding of multimorbidity and then integrate these models into the medical decision framework for treating patients. This missing step of integration is also commonly found in reviews addressing big data analytics in health care –29.Furthermore, we found a lack of clear definitions for the “3 V’s” or the term “Big Data” in general. In other reviews on big data analytics in health care settings, these terms are also only implicitly described, but their definition is usually not included , 28.Although common expectations are, that big data analytics will have a great variety of applications in the field of multimorbid patient treatment in the future , this reThese findings might suggest an interface problem between different scientific disciplines that do research in the field of big data. For the clinician finding reliable evidence for the benefit of applying big data analytics to improve treatment is crucial. However, they usually do not have the competence in validating algorithms. Computer scientists may be more interested in developing algorithms for a more generic problem than to apply an algorithm in a specific clinical setting. Therefore, there may be the need for an academic discipline that focuses on the implementation of algorithms into practice. One example of a future application for big data analytics in health care could be the implementation of big data algorithms into medical apps for mobile devices. There are already a number of studies that investigate the possible benefits of these apps .This is to our knowledge the first review that addresses applying big data analytics in the treatment of multimorbid patients in general practice. Journals commonly included in databases used by health care professionals might not be the ones researcher working in the field of big data analytics are publishing their results in, leading to a bias in our findings.One study was found that presents an approach for treating a group of multimorbid patients using big data techniques. Terms pertaining to big data analytics are not defined in studies applying these methods. Over all, there seems to be a mismatch between the perceived presence and usage of big data in health care and existing literature in databases commonly used by health care professionals. It seems highly relevant to form interdisciplinary research environments in which experts in implementing computer sciences and health care professionals work together to evaluate the benefits of big data analysis techniques for the treatment of patients.Additional file 1:Search Strategy.pdf. Detailed Information on search strategy. Information on search strategy, search results, and exclusion criterias. (PDF 47 kb)