The COVID-19 pandemic has brought about disruptive changes in individuals’ lives, breaking the established systems of meaning worldwide. Indeed, in the first months of the pandemic, with individuals being forced to stay at home for a prolonged time to contain the spread of the virus, the need to build new meanings to understand and face this crisis emerged. Building on this, the present study contributes to the understanding of how sensemaking processes were shaped in the face of COVID-19 collective trauma during the very first months of the pandemic. Hence, 36 Italian young adults aged between 21 and 25 submitted daily diary entries for two weeks , resulting in 504 texts. The stimulus was always “Could you describe your daily experience and feelings?”. The Grounded Theory was used. Thus, 15 categories emerged, grouped into three macro-categories. The core category was sensemaking as adaptation. Indeed, the sensemaking process seemed to be a strategy to adapt to the new circumstances related to the lockdown, facing the emotional, cognitive, and activation reactions such conditions by relying on coping strategies and the redefinition of primary as well as broader social relationships. In the first months of 2020, lots of governments around the world enforced lockdown measures in their countries as an attempt to control the spread of coronavirus disease 2019 (COVID-19) pandemic  We never imagine that what we gave for certain and sure could vanish at any moment, yet it happens. Yet it happened.” I.S., f, 24, t1Overall, in the face of the COVID-19-related lockdown, respondents reckoned how their ways of experiencing the passing of time had changed. Specifically, they mentioned how time had stopped for them—as if it had been frozen—due to the sudden loss of daily activities and routines. They felt like they were waiting for better times to get on with their lives.“In this quarantine it seems that time has stopped, I can hardly distinguish the days that seem to resemble each other more and more unlike before where every single moment, day, hour and minute of our life was marked by work and school commitments, family or moments of simple relaxation.” F.A.T., f, 25, t2In the face of this experience, participants engaged in three different ways of physical activation while complying with the sudden stay-at-home orders: they either engaged in indoor, outdoor, or gardening activities when possible , escaped/self-distracted via digital technologies—which were used not only as a tool to keep in touch with others out of the households, but also as means for personal entertainment —, and became interested in craft activities. These strategies helped individuals in processing their emotions and cognitions as well as in fulfilling their daytime within their houses.“A strange adrenaline pushes me to solve small problems at home.” S.M., f, 23, t2“I had my room clean […] It helps me organize ideas.” E.S., f, 21, t1“Filling in those empty spaces of the day that previously had passed around with friends, in a café, a bookshop, on the streets, etc.” F.P., f, 24, t1Indeed, on the one hand, emotional experiences represent a primitive and transient organization of meaning which can be understood as a complex system of evaluation embodied by individuals ,28,29. E“The bed is where my thoughts and emotions manage to suffocate me.” P.F., f, 22, t1These feelings highlight the processual overload due to the need to engage in activities able to fulfill their body and mind, in order to avoid the sense of stasis in which they were immersed, so much so as to remember drowning. Nevertheless, some breaches of hope and positive thoughts emerged too from participants’ words by metaphors referring to nature, which was the only thing not frozen by stay-at-home orders and that was rather benefitting from them. Overall, this suggests that, along with the thoughts about the pandemic and the related social distancing, participants were also attempting to metabolize the distress linked to the forced as well as needed restructuration of their daily habits.“I envy them [the birds] a little now, but we will fly together again.” C.G., f, 24, t1“And we are all looking out the window, looking for the rainbow as soon as we see that the rain stops falling, because it reminds us that at the end of everything there is always something beautiful that we can get.” B.S., f, 23, t1Further, the feelings of overload made participants feel like time was not enough even now that they were stuck in their houses and the world was somehow frozen, making them often feel exhausted and late. Nevertheless, they acknowledged the paradox intrinsic in such feelings and experiences, which were made even more paradoxical by the perception that days were getting longer in comparison to pre-pandemic times, which was probably due to the lack of activities and frenzy fulfilling daytime during the lockdown.“Paradoxically, I have the feeling that time is always too short, even in this circumstance.” N.L., f, 22, t2However, while often feeling overwhelmed and overloaded, participants also acknowledged the value such experiences could have for them, due to their being forcedly socially distanced rather than “lost” in the frenzy of their daily lives and of the surrounding world.“I wish it would end up returning to normal and I wish it would not end up not getting lost again in the outside world that consumes us.” N.M., f, 22, t2On the other hand, cognitive processes allow to selectively collect and process pertinent pieces of information in order to organize and coordinate action schemes in the face of acknowledged changes within the individuals or in their surrounding environment . This co“I think of the future, of the transformations, of the environmental catastrophes we are destined to.” P.F., f, 22, t1This also includes the experience of continuity of personal identity by keeping one’s habits when possible and by relying on memories, which were felt as a key element in order to preserve the unity of one’s identity and to connect the latter to what is happening and its individual and social foreseen consequences.“I also like to see the potential for positivity given by the possibility of being able to continue our university path with online lessons that gives me back, at least in part, a piece of my identity as a student, of something that belongs to me and that acts as a bridge between before and now.” B.S, f, 23, t1In a downtime where time seemed frozen, the past only constituted memories that seemed far away, and the future was always uncertain. Participants no longer felt able to envision their future selves and lives. However, they detected strategies aimed at keeping track of their plans and meetings for the future in a way that allowed the flexibility needed to sustain those uncertain times, e.g., writing them down but using a pencil.“Anchored to the present and to the past, little projected in the future.” R.A., m, 23, t2“I am writing the next plans and appointments using the pencil, for fear of having to further postpone or cancel them.” F.P., f, 24, t1Consistently, diary activities were detected as a tool able to help in preserving a sense of continuity and detecting the changes they went through during the lockdown too. Participants noticed the opportunities stemming from this activity and expressed appreciation for the latter as a way to keep track of the small changes they went through day by day and of their emotions.“Re-reading myself from the beginning of the first week [referred to the photo-diary] I notice a strong change has been in place.” E.S., f, 22, t2“It has become a reason for me to put pen to paper […] my emotions and thoughts day by day. On the one hand, it allowed me to carve out a moment of my own; on the other hand, to have a trace of it and therefore to re-read myself and perceive the change.” S.M., f, 23, t1In the face of these sudden cognitive, emotional, and physical activations during a time of relative immobility, and tightly connected to these aspects, several adaptive  strategies were put in place by the participants to face these unprecedented circumstances and the emergency broadly speaking. That is, participants referred to several coping strategies they adopted to face these unprecedented stay-at-home orders. Building on Carver’s model , which pSpecifically, participants reported the relief they felt from providing themselves with a better organization about daily activities and tasks, commitments, and obligations. This kind of coping represented an active strategy, that is, focused on doing something about the circumstances one finds oneself in, in order to improve them as far as possible.“During these days, it has been nice and useful to be able to stop and process my emotions, due to this continuously changing phase. It has been a moment to cadence and organize my days.” M.R., f, 23, t2Furthermore, in order to contrast the current immobility and the inability to continue their normal daily life, participants also extended this new attitude to planning things to do after the end of the lockdown, which can be considered an example of planning coping strategies, that is, thinking about the steps to take in present and future times.“I also found myself writing a list of the things I would like to do once the emergency is over.” R.V., f, 23, t2Along with planning current and future activities and commitments, participants endeavored to self-distract, even just temporarily, from the “prison” they were living in and from what was happening out of it by engaging in activities which were still feasible despite the stay-at-home orders. Indeed, self-distraction is a coping strategy aimed at self-engaging in activities and thoughts with the aim of take one’s mind off the stressor .“[Writing] gives me the opportunity to feel me less in a cage and shifts my thought away, even though just for a moment.” D.A., f, 25, t1“Many times, I find refuge in words, in readings, and I try to escape a little from everything and everyone in this way.” S.Z., f, 24, t1They also attempted to self-distract by imagining scenarios different from the current one, that is, characterized by higher rates of freedom, openness, and chances to take a breath.“The game of the week is «Who imagines the most wins» and so I’m trying to put my maximum effort into it. Sometimes it is something I put in place alone, yet sometimes it involves my friends and we imagine together that we are on the rocks in Posillipo —«Who prepares the sandwiches?»—or about to take a plane—«Where are we going?», «What do you think of this hotel?».” M.M., f, 23, t1However, some of the newly set actions and habits also shaped as venting coping strategies—that is, expressing one’s negative feelings via maladaptive behaviors or words—or even behavioral disengagement—that is, giving up the attempt to cope with the stressor and resigning to it.“Stress in my life always increased the food quantity.” P.F., f, 22, t1Participants also attempted to deny what was happening by refusing to think about it and believe it. They took distances from their new reality also by considering it as something “surreal, movie-like”. This attitude may also have been due to the strong uncertainty they felt about their future and to the evolution of the pandemic, which represented an unprecedented event with uncertain developments to them.“Now this is my life, and the moments when I truly think about this new reality of mine are rare.” N.L., f, 22, t2“To date I don’t know how the situation will evolve. Honestly, I also try to think about it as little as possible.” N.M., f, 22, t1Conversely, other participants endeavored to adapt to the newness of lockdown daily life and to the changes that would have been brought about by COVID-19 in their lives even after the lockdown, sometimes even detecting and stressing the positive effects of such changes. These have been respectively coded as acceptance—that is, acknowledging that things have changed and endeavoring to learn how to live with the new ones—and positive reframing—that is, attempting to look at things differently in order to focus on their positive side—coping strategies.“Adapting to the new modality I don’t like, but better than nothing, I’ll accept the bright sides.” C.G., f, 24, t1“I also feel gratitude, because I feel to thank university and the online approaches which granted us to not loose lessons and not be left behind.” A.L., f, 24, t2Participants highlighted the adaptive role of instrumental and emotional support, that is, respectively, getting concrete help and advice, and emotional closeness and understanding from others. On the one hand participants discovered new ways to reciprocally support and share daily activities and habits with their households, while on the other hand they also came up with the discovery of being able to work together and co-operate despite the physical distance, that is, by means of new technologies. Indeed, belonging to a community or other meaningful social groups provides individuals with a sense of meaning and continuity, belonging and safety, affirmation and mattering, even when the connection to such a group is technology-mediated ,39,40,41“With my great surprise, I discovered that working out together is fun even on videocall.” F.F., f, 22, t1“I have more time to help mom around the house, […] I taught grandma how to make videocalls, I started training with my sister.” E.D., f, 23, t1In addition to these intrapersonal processes, changes in interpersonal relationships also happened due to stay-at-home orders . Indeed,“Today I would like all the ordinary things back, the coffee at the bar, a hug from my best friend, the chats with my friends that always turn into long sleepless nights.” M.M., f, 23, t1However, this unexpected break of previous social habits made individuals more aware about the meaning of their significant relationships and the role they played in their lives, up to providing stronger beliefs about how such relationships could be able to overcome forced distances and still provide closeness, warmth, and support.“Today, I think about emotional ties, how important they are in this very difficult moment, and how much the distance can be shortened by the good and the love that one feels for the people dear to us.” A.L., f, 24, t1In the scenario brought about by stay-at-home orders, digital technologies supported relational habits and social contacts by allowing to keep in touch with significant ones out of the households while complying with the needed measures. This was perceived by participants as a way to “shorten the distances” set by COVID-19-related measures.“Technology allows us to shorten distances by making us relive the joy of meeting, confirming that real relationships can be strengthened even more in difficult moments.” M.V.P., f, 23, t1Indeed, social media engaged people in sharing their daily life, in a virtualized self-giving way, helping to tolerate the need for postponing in-person meetings, building a deferred in-person encounter perspective over time, along with a feeble sense of certainty. Overall, they were perceived as valid alternatives to cope with negative feelings and process them.“I feel relieved when I experience moments of melancholy and I know I can video call my friends.” N.M., f, 22, t1“I listened to the voices of my colleagues, of the professors, because the topics we discussed were not trivial; on the contrary, I admit that they helped me to elaborate some emotional block due to worries or anxiety.” C.G., f, 24, t2Nevertheless, while being aware of technologies enabling distant people to keep in touch and maintain their significant relationships, participants were also aware of the sensory limitation of that tool.“Having a screen acting as an intermediary for communications makes everything less immediate and spontaneous.” A.D., f, 23, t1“We have many means at our disposal to communicate with friends, relatives, this is good and helps us, yet nothing (luckily!) can really replace a hug when we are down. Today I would like a hug.” S.M., f, 23, t1With reference to this, they talked about a “bubble feeling”, an expression that recalls what Hall  defined Along with the need to find different ways to keep in touch with significant ones out of the households, participants also experienced another level of relationship, that is the one within the core in which they were locked, which highlighted the need and opportunity to find new ways to live with their households too. Indeed, differently from what happened as to their relationships with their friends and colleagues, in this case they were forced to share house spaces for an amount of hours which were much greater than before COVID-19 outbreak. Nevertheless, this allowed them to detect and experience new activities and hobbies to share in order to enjoy their time together and feel close to each other.“I found myself with my fingers wet with coffee and cocoa and I liked it, I enjoyed it. I did not do it all by myself, my father helped me […]. It was a moment of sharing, something we had not done for years, something that united us even more. I had the opportunity and the pleasure of doing something for the first time, staying at home, and I really didn’t think it was possible.” I.S., f, 24, t1Among these activities and hobbies, cooking ones clearly stemmed. They were perceived as having twofold benefits. On the one hand, participants perceived these activities as expressions of the cohesion of their family, which proved able to huddle and provide closeness and emotional support to its members. On the other hand, reckoning that these activities were common to most Italian families, as they were broadcasted by National and local television news, made participants perceive cooking activities also as a sort of identity element.“Cooking staples, only to discover that many other Italians in this period are also dedicating themselves to cooking pizzas and desserts, to pass the time, heartened me and made me think that in these little things we can see a greater unity in how much nation, how much we would not show in front of the tricolor [Italian flag].” F.P., f, 24, t1This was felt as a way to convey the unity of the nation in a time when it was not possible to do it otherwise. Indeed, under collective emergency circumstances, this perception of a common fate can strengthen the sense of belonging to the community, the identification with it, and the tie to it, ending up in higher social cohesion ,46,47,48As to the repeated measures t-test, the mean scores for T1, that is, during the third week of lockdown, and T2, that is, during the penultimate week before the ease of lockdown measures, and the results of the comparisons are presented in First, as to the arousal, only emotional experiences showed some differences between T1 and T2, with participants referring more to this area in T1. This may suggest that in T1 participants were more focused on their emotional experience because it was more relevant and fuller of meaning due to the newness of the circumstances they were living in. Conversely, it also suggests a twofold path as to T2: indeed, it is possible either that participants did not perceive the approaching end of stay-at-home orders as something new—thus, their emotional activation was lower—or that in the face of the approaching end of stay-at-home orders some other aspects of participants’ experience emerged as more relevant than their emotional activation, drawing their attention and the focus of their diaries.“Today my mind is taciturn, I feel nostalgia and I have every intention of welcoming this emotion. I want to keep it.” M.S., f, 23, t1This also reflects in a twofold connotation they attributed to their houses, which were felt either as weapons to fight against the virus and as prisons where citizens got trapped without notice nor explanation nor expiration date according to the times of writing. This may suggest that in the face of a not-yet-known enemy, such as COVID-19 in the first phase of the emergency, being locked in one’s house seemed like the best defense strategy under the hold of emotions such as fear and bewilderment. Nevertheless, over time, houses ended up being framed as overwhelming constraints more than comfortable refuges in citizens’ experience.“The houses in which we retire are our weapons.” B.S., f, 22, t1“We found ourselves at home, a bit like prisoners, even if they granted us some yard time.” M.R., f, 23, t2Indeed, when the news about the ease of stay-at-home orders was spread , citizens experienced disorientation, confusion, and worry. On the one hand, they got used to a different organization of their work/study and leisure times and activities and going back to in person activities would have required further changes and planning. On the other hand, they reckoned that their war against the virus was not over yet and that others could still represent potential carriers for the virus to reach their houses and families.“4th May is approaching; it is the beginning of a long and worrying coexistence with the virus.” E.D., f, 21, t2Consistently with this, it seems possible to hypothesize that in T2 participants were more focused on how to cope with the fatigue due to the months of lockdown and, at the same time, with the bewilderment due to the ease of such measure. Indeed, as to coping strategies, differences emerged with reference to behavioral disengagement and positive reframing strategies. While the first kind of strategy was more frequently referred to in T2, the second one was more frequent in T1. Overall, these differences suggest that along with other coping strategies, during the third week of lockdown (T1) participants relied more on focusing on the positive consequences of lockdown measures and less on resigning themselves to the latter in order to cope with stay-at-home orders and the changes they had brought about in their daily lives and routines. An example of this attitude among Italian citizens can be detected in them singing together from their balconies, exposing billboards stating “everything will be fine” out of their houses, and valuing more the collective dimensions of belonging to a community, sharing a national identity, and providing reciprocal support as far as it was possible in compliance with the protective measures ,12,49. C“I have to admit I like this peace and the silence that were missing in my previous routines.” G.C., m, 24, t1“I feel almost always alienated in this time, like I could not reach reality anymore, like if I were somewhere else, as if I were living a dream, a film… Could it be because I have never lived an experience like this?” N.M., f, 22, t2Last, as to relationship redefinition, participants wrote about it more frequently in T1. This seems is consistent with the need to redefine the opportunities and ways to keep in touch with others both in and out of one’s house in order to maintain one’s significant relationships despite stay-at-home orders, which implied both a forced co-habitation among households and a forced distance among non-households. Indeed, on the one hand, participants experienced a strong need to negotiate spaces, routines, and times within their houses, in order to find a balance in their forced time with their households—be them relatives or not. On the other hand, they also had to find a new balance in how to keep in touch with their significant others not living with them, since all the opportunities for face-to-face contacts unexpectedly disappeared. Conversely, in T2 this issue got less attention, which makes sense—participants were already used to technology-mediated ways of managing their significant relationships and to a new balance of spaces and times inside their house—yet also suggests that the information about the ease of stay-at-home orders had no effect on them with reference to this topic.“I miss my days full of moving from one part of the city to another, full of faces, words, I miss the chaotic noise of my city, the voices of friends in sync with the movements of their faces, the human warmth.” S.M., f, 23, t1“It is precisely in our homes that distance is opposed by proximity. These are times when we can experience the joy of having our whole family reunited. We can have lunch together, prepare a dessert together, hear the reassuring footsteps of our mother or father upstairs. I was used to staying at home with my grandfather to study while my parents were at work and my brother at school. Now I am used to seeing them in every room, and it is pleasant, comforting, to the point that if my mother goes out shopping, I miss them.” G.B., f, 22, t1What emerged from this study represents sensemaking processes about the unprecedented and unexpected experience in which participants found themselves. Sensemaking is described as a process concerning identity and meaning building with reference to the social context one is embedded into, from which people gather cues and with which they exchange perspectives about ongoing phenomena and circumstances; it provides people with more stability and motives their actions , helping“Such an atypical experience cannot be empty.” A.F., f, 23, t2The first phase of sensemaking processes under these circumstances was characterized by emotional answers, followed by the acceptance of the new lack of aspects that characterized participants’ relational and personal life and routines, and the subsequent activation of cognitive processes and physical activities aimed at redefining what was happening and its consequences in terms of daily life. COVID-19 was compared to an invisible enemy that attacked citizens and communities all around the world and against which the latter were fighting a war . Indeed,“Fear of being altered by an invisible enemy, a collective trauma which will rewrite forever our history.” G.T., f, 22, t1“The news from the front is added, my uncle is a doctor and is working in intensive care.” I.S., f, 24, t1Under stay-at-home orders, participants clung to already-known phenomena and circumstances as an attempt to give meaning to the unprecedented experiences they were living by relying on already-known meaning structures and organizations. Indeed, building individual and shared meanings and reorganizing previous ones represent core dimensions when this process happens under disruptive, emergency circumstances ,51,52, eThis broad redefinition allowed to rediscover and use several coping strategies which relied both on participants’ own characteristics and resources and on their significant social relationships. Indeed, due to the impossibility to go out, citizens could experience an intensive and prolonged cohabitation with the households, which brought about opportunities for a positive reappraisal of family relationships too. These relationships were lived as elusive ones before COVID-19 outbreak, yet due to stay-at-home orders cooperation and active participation for shared aims, as well as reciprocal support and common coping strategies became possible again among households . Further, technology-mediated communications and interactions  also allowed individuals to keep in touch with other significant ones and acquaintances, carrying on social as well as educational experiences. They represented the containers that allowed to keep an extra-family sociability under stay-at-home orders.This study aimed at gaining a better understanding of sensemaking processes during a disruptive and unprecedented event such as the national lockdown that was issued between March and May 2020 as an endeavor to contain COVID-19 pandemic in its very first phase. Specifically, it deepens our understanding of how the familiar elements that represented daily landmarks in pre-COVID-19 routines and daily habits served as reorientation drivers for adaptation and reorientation processes  under thWhat emerged see  suggestsOverall, this suggests that, in its very first phase, the lockdown was characterized as a liminal experience , as indiFurther, the present results suggest that a stronger focus on oneself and on the meanings assumed by one’s own life projects, activities, and relationships, together with the positive reappraisal of primary relationships and social dynamics, represented critical elements to rely on in order to carry on sensemaking processes under prolonged stay-at-home orders. Indeed, relational structures can aid meaning building in sensemaking processes even under social distancing measures by enabling exchanges in the meanings assigned to experiences, providing the opportunity to mobilize inter-individual resources and to face the disaster as a community . Such meThe present study offers an exploration of participants’ experience of COVID-19-related lockdown through their emotions, thoughts, and ideas. However, it is necessary to mention that some other variables  could have played a role as regards their sensemaking processes and efforts. Further, respondents’ reluctancy in repeating their thought or emotions across close entries and their boredom in writing all the required diary entries should be considered too since they may have resulted in lower commitment in the second part of each week or of the whole study. Last, the results stem from a contextualized and age- and condition-  specific experience, which hinders the generalization of these findings to different groups.Despite these limitations, the present research meets transferability criteria  and provIndeed, the pandemic and the subsequent lockdown represented a natural  social  experimeThe crisis brought about by the pandemic caused a break in one’s sense of continuity and life planning, determining the need to plan and act under new, uncertain conditions characterized by the lack of landmarks and temporal perspectives . Thus, tSince the pandemic and the subsequent lockdown represented a natural  social  experime


Visualisation methods, primarily color-coded representation of sequence data, have been a predominant means of representation of DNA data. Algorithmic conversion of DNA sequence data to sound—sonification—represents an alternative means of representation that uses a different range of human sensory perception. We propose that sonification has value for public engagement with DNA sequence information because it has potential to be entertaining as well as informative. We conduct preliminary work to explore the potential of DNA sequence sonification in public engagement with bioinformatics. We apply a simple sonification technique for DNA, in which each DNA base is represented by a specific note. Additionally, a beat may be added to indicate codon boundaries or for musical effect. We report a brief analysis from public engagement events we conducted that featured this method of sonification.We report on use of DNA sequence sonification at two public events. Sonification has potential in public engagement with bioinformatics, both as a means of data representation and as a means to attract audience to a drop-in stand. We also discuss further directions for research on integration of sonification into bioinformatics public engagement and education. As the field of genomics has matured, the need to provide novel tools for representing DNA sequence data has become pressing. This need ranges from comparative investigation of sequence variation across multiple sequences, searches for functional domains across extended sequences, searches for sequences within and between organisms that share homology or are otherwise similar, and capturing and comparing entire genomes. As genomics data and its potential for scientific investigation has grown, so too have methods for representing data. Visual sequence data has been a standard approach, but it has its limitations, especially when long sequences are involved. Algorithmic conversion of DNA sequences to sound—sonification—offers an alternative means of representing DNA sequences that in turn draws upon other human sensory mechanisms. Sonification may have very general value, though the field of bioinformatics sonification is not yet sufficiently mature to support (or reject) this as a broad conclusion.DNA sequence visualisation has a relatively long history in bioinformatics. Even the representation of the four bases as letters in the alphabet—A, C, G and T, with the sequence of one strand of the double helix represented as a string of such letters—is a simple visualisation, with a long tradition in databases and publications involving DNA sequence e.g., , 2). Vis. Vis2]).However, like any representation, visualisation has limits. In a research context, visualisation of large amounts of sequence is constrained by the size of a computer screen, the ability to convey diverse information through colours or symbols, and the attention of the researcher. In the context of public engagement with science, DNA sequence has a monotonous visual appearance, at odds with the “whizz-bang” often expected in such public displays or shows.Although the quantity and apparently random nature of large DNA sequences is engaging for a short time, more detailed examination of DNA sequence or annotation demands a level of focus that is atypically high for a public drop-in event or short activity. At public events we have had success with a wide range of ages using the Phylo game , where aWe aim to help fill this gap by means of sonification of DNA, where the representation of sequence is auditory rather than visual. Since music is widely understood and used for relaxation and entertainment, this may be more attractive to a public audience than a screen full of DNA sequence or associated data. By use of the Sonic Pi program  for soniSonification of scientific data in is not new . More sl-gulonolactone oxidase gene from mouse  wasSubsequently we incorporated sonification into a series of public events as follows.Gulo; (2) a rave version of the Gulo sonification, using the “mod_saw” synthesizer, with a drum roll starting every 4th note for musical effect; and (3) a sonification of part of an intron of the CF transmembrane conductance regulator gene (CFTR) in human, which includes a dinucleotide microsatellite (AT), to highlight the potential research benefit of sonification (using no drums). Tempos were from 60 equal-length notes per minute up to 300 notes per minute, set using a time parameter to the “play_pattern_timed” function. Additionally, a brief tutorial to Sonic Pi including DNA sonification exercises was written and printed out in laminated form, along with the Gulo coding sequence and the start of the intron sequence from CFTR, with the microsatellites highlighted. Doors Open Day 2017 at the Ashworth Laboratories was attended by at least 258 people. During the event, we engaged ~ 30 visitors in a discussion about DNA, mainly by approaching them with the question “Have you ever wondered what DNA would sound like?”. The event was evaluated by means of direct experience and diaries of H.P. and D.B.In preparation for Doors Open Day, a public drop-in event where we were based at the Ashworth Laboratories, King’s Buildings, University of Edinburgh on 23 Sept, 2017 from 10 am to 4 pm [Gulo gene , followOur preliminary study indicates that DNA sonification is highly suitable for public engagement activities, both for short drop-in events and for more focused workshops.Doors Open Day was a large public event, during which people engaged well with the sonification activity. The question “Have you ever wondered what DNA would sound like” was a successful way of starting a discussion about DNA. Everyone who was asked this question stayed to listen to a sample of our sonifications and engaged in a short discussion about DNA. Visitors were guided through prepared sonifications, and given the opportunity to go through the printed sonification tutorial. Visitors found the event creative and inspiring and were either happy to see it as a light distraction, or to discuss scientific applications. Relatively little use was made of the Sonic Pi tutorial. During the event, Minecraft proved a distraction, so we discreetly removed it from the main menu of each Raspberry Pi. Later, Scratch was also some distraction. For the future, we would remove these in advance because they are not part of our display. Restrictions on Web browser access based on Uniform Resource Locator (URL) may also have some value. The Phylo game ran slowly at times on the Raspberry Pi computers (a problem that would be reduced or removed with newer models of the hardware).The sonification workshops during Ada Lovelace Day were well-attended, and the audience appeared engaged. Six participants completed questionnaires. Others did not, due to leaving early for lunch (1 participant) and leaving at short notice to collect their bags from the main activity room (5 participants). When asked what the best thing about the workshop was, participants stated “The opportunity to engage with DNA or Biology from a different perspective. Hearing a sequence made me think of it as an object in a different way.”; “Sonic Pi (amazing!)”; and “Updating me on sequence investigation”. When asked what the worst thing about the workshop was, participants did not have many comments, i.e., “None”, “Nothing”, “not enough time!”. We had difficulty connecting to the University wireless network and used a 4G phone as a hotspot instead. This was resolved before participants arrived and was not noticeable to them. The event was a success. However, H.P. and D.B. thought a little more time to focus on sonification would be helpful for such events in the future.It appears that DNA sonification engages both researchers and the public in thinking about DNA from a different perspective. Further development of DNA sonification for public engagement activities is warranted.Although our preliminary study is sufficient to suggest DNA sonification has potential in public engagement activities, a larger study is required to discover the full limits of its successful application. Our audience for evaluation consisted of adults, mostly staff and students at Edinburgh University. We recommend a larger programme, using qualitative and quantitative analysis, with a diverse range of audiences.We regard our simple sonification technique—using one note per base—as more relevant to public engagement than to research. The limited range of notes makes for a catchy melody but it is difficult to distinguish sequence features, beyond simple examples such as a long dinucleotide repeat. However, for public engagement, it is important to avoid a strong reliance on biological knowledge.For research, future directions involve sonification of more complex bioinformatics data, for example multiple sequence alignments . Multiple alignment depends on biological concepts such as homology and cross-sequence comparison, unlikely to be rapidly comprehensible to the general public. The Phylo multiple alignment game  is a couGulo gene  among DNA symbols. Sonification could help make the frameshift stand out.For public engagement and education, one promising future direction may be to highlight the effect of frameshift mutations. We have developed and apply a workshop for biology students in secondary education  , which In conclusion, sonification has a demonstrated potential for public outreach and engagement. Our methodology was well-received. It is our aspiration to build on these preliminary efforts to use sonification to make DNA sequence information entertaining as well as informative and to increase the nuance and complexity that we convey in public engagement.


Over 60% of the population in sub-Saharan Africa, live in informal settlements (slums) with little or no resources. To be prepared to meet the needs of older people living in slums, it is necessary to know more about their quality of life (QoL). The objective of this review is to identify instruments, which can be used by researchers to assess the QoL of older adults living in African countries, especially those dwelling in slums.A scoping review was performed using the databases Scopus, PubMed, and ISI Web of Science to retrieve studies published from January 2008 – September 2020. Studies were included if they reported generic QoL instruments, focused on adults with a mean age ≥ 50 and were conducted in African countries.In total, 18 studies were included using 7 unique instruments to measure QoL . All instruments could be interviewer-administered and had 5–36 items. However, little is known about their psychometric properties , time-investment and cultural sensitivity of the domains included in the instruments.Even though this review retrieved instruments used to assess QoL of older adults in African countries, there is a need for further research on adjustment and validation of currently existing QoL instruments. In addition, the development and validation of a new instrument which can be used in (illiterate) older populations, living in slums in Africa should be considered. Evidence suggests that over 60% of the population in sub-Saharan Africa lives in informal settlements (slums) with little or no resources –5. WhileThe population aged 60 years and above in Africa is projected to be 10% of the total population by 2050 [The WHO defines Quality of Life (QoL) as ‘individuals perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’ . This wiTo gain more insight into the QoL of older people living in slums, validated instruments with good psychometric properties which are culturally appropriate are needed. However, there is little to no research in the area of QoL of the ageing population in Africa, and in slums in particular . AvailabFor this study, a scoping review was performed. We followed the first five steps described by Levac et al. on how to perform scoping reviews . These rThe research question guiding this scoping review is: Which instruments are available for assessing quality of life among older adults in African countries?The main literature search was conducted in May 2018 and updated in October 2020.Databases used were Scopus, PubMed, and ISI Web of Science, supplemented with a free search using Google Scholar. The database search query was composed of three search concepts: ‘population’ (adults 50 years+), AND ‘instrument’ (tools/questionnaires/measurement) AND ‘context’ (developing countries), AND ‘outcome’ . Per search concept, free text words were used, all separated by the Boolean operator “OR”. The free words used for the population included: “frail elderly”, “elder*”, “senior*”, “older person*”, “old people”, “aged”, “aged, 50 and over”, “septuagenarian*”, “nonagenarian*”, “octogenarian*” and “centenarian*”. The free words used for the instrument included “instrument*”, “tools*”, “questionnaires*” and “measurement tool*”. The free words used for the context included: “developing countr*”, “third-world nation*”, “under developed countr*”, “less developed nation*”, “developing nation*”, “Africa” and “subsahar*” The free words used for the outcome included: “Activities of Daily Living”, “ADL”, “quality of life”, “QoL”, “Health-Related Quality Of Life”. Hand searching and screening of references was done after inclusion of a full text.Research that used generic QoL instruments among non-disease specific populations;Studies that use a multi-domain instrument to assess QoL, including at least the physical, psychological and social domain;Research focused on populations of adults which are on average 50 years and above;Publications written in English;Articles published since 2008 (in order to reflect recent research developments);Research conducted in African countries.Studies were included in the review if they met the following criteria:Studies using secondary data, case studies or conference abstracts were excluded, as well as studies of which the full articles were not attainable, also after contacting authors.Even though in this publication we are interested in finding QoL instruments which could be used in slum settings, research done in the slum setting was not used as an inclusion criteria. The reason for this was that imposing this restriction led to limited results.Authors PYAA and IHJE developed the literature search with the assistance of a librarian. After performing the search in the databases, all titles and abstracts were reviewed based on the inclusion and exclusion criteria. Articles which met the inclusion criteria were obtained in full-text and reviewed for final eligibility by author PYAA. Author IHJE checked if she agreed whether or not the final selection of articles met the inclusion criteria. The reference lists of the included articles were also hand searched to see if any studies were missed in the initial search.A data extraction sheet was developed by the authors including the following categories: authors, year of publication, title of article, country, study design, population , setting and name of instrument used to assess QoL Table . First aNext, the QoL instruments found were further assessed on number of items, domains included in the instrument, reliability, validity, language of the instrument, mode of administration (interviewer administered or self-administered) and answer categories . All types of reliability reported in the included articles were taken into account and described in the data extraction sheet. For internal reliability, a Cronbach’s alpha score of > 0.70 was considered a good score. Furthermore, all types of validity reported in the included articles were taken into account and described in the data extraction sheet. When the included articles did not report on reliability or validity of the instrument used in their country and/or study population, this was described as ‘ND’ (Not Described).n = 22) were removed, 682 records remained. Screening of titles and abstracts of these records resulted in the exclusion of 561 records that did not meet the inclusion criteria. In total, 121 articles were retrieved for full-text assessment. After screening these full-text articles, 103 articles were excluded, as they did not meet all inclusion criteria. All reasons for exclusion can be found in Fig. Figure Out of the 18 studies included, nine studies (50%) used a cross-sectional design , 28–30 wn = 6) [n = 5) [n = 2) [The number of participants included in the studies varied from 80  to 9341 n = 6) , 20, 24  [n = 5) , 27–29,  [n = 2) , 16. Fro [n = 2) , Senegal [n = 2) , Angola  [n = 2) , Lesotho [n = 2)  and Tuni [n = 2) , in each [n = 2) , 24 and  [n = 2) . Two of  [n = 2) , 16 specn = 7). This is an eight-item instrument derived from the WHO-QOL-BREF. The “Satisfaction with Life Scale” (SWLS) was used in 3 studies. The World Health Organization Quality of Life Scale-brief version” (WHOQOL-BREF), the “World Health Organization Quality of Life Scale-old version” (WHOQOL-OLD) and the Short-Form Health Survey-36 (SF-36) were all used twice. One study made use of the “Short-Form Health Survey-12  and the other used the RAND-36 [In this review, 7 different instruments were found in 18 different studies , asking to what extent one’s health interferes with e.g. physical function, mental health or social functioning. The environmental domain was only captured in the EUROHIS-QOL-8 and the WHOQOL-BREF.Only 7 studies provided figures on reliability. All studies using the SLWS showed good internal reliability (Cronbach’s Alpha ≥0.81) –23, one Only four studies described results on validation. Macia et al., using the SLWS, described good content validity based on an expert meeting . Van BilSeventeen studies described that the instrument was interviewer administered, or could be interviewer administered. One study did not provide information on the mode of administration . All insn = 7), the SWLS (n = 3), the WHOQOL-OLD (n = 2), the WHOQOL-BREF (n = 2), the SF-36 (n = 2), the SF-12 (n = 1) and the RAND-36 (n = 1). After careful reflection on their respective psychometric properties, it appeared that the SLWS had good internal validity. The other instruments, had little or no information was available about the psychometric properties of the instruments when using them in their specific countries or populations. As not all aspects of life are equally important for all age groups, cultures and settings, it cannot be automatically assumed that all instruments are applicable for its intended purpose [In this review, 7 different instruments in 18 studies were found to measure QoL among older adults in African countries: the EUROHIS-QOL-8 ( purpose . All stu purpose  and Schm purpose  for info purpose . FurtherSomething else that would make the use of instruments more feasible is the possibility of amendment of questions (to make it understandable to the illiterate population) in the instruments to improve suitability of the instrument towards the population or setting (e.g. climbing stairs in a slum setting is not common or performing heavy exercise is less common among an older population). However, doing this will have consequences for performance characteristics of the instrument and should therefore be performed with caution. The original meaning should not change so as to measure the intended items in the domains.As a large proportion of older adults in African countries live in slums and are illiterate, this study also reviewed if the instruments were suitable to use among an illiterate population. Even though there is little information available on time investment when administering the instruments, the number of items per instrument range from 5 to 36, which seems like a relatively permissible time investment. When looking at mode of administration, one study did not describe how the instrument was administered  but all When looking at the domains included in the different QoL instruments found in our review, the physical, psychological and social domain appeared to be (indirectly) included in almost all instruments. The environmental domain, however, was only included in the EUROHIS-QOL-8 and the WHOQOL-BREF. However, the environmental domain is likely to be of importance in African countries and more specifically in slum settings due to factors mentioned in the introduction paragraph of this article, such as poor housing, lack of sanitation and environmental hazards such as improper disposal of waste. A study performed among adolescents in Bangladesh also showed worse scores on physical environment and QoL among slum dwellers compared to non-slum dwellers . Also, aFrom these findings, it can be concluded that the majority of the instruments found to assess QoL in African countries can be interviewer administered and are relatively short, providing a good starting point for use in an illiterate population. However, the instruments lack basic information on reliability and/or validity and more information is needed to know if the domains used in the different instruments actually reflect quality of life of older adults living in African slums.To the authors’ best knowledge, this is the first scoping review which identified and critically reflected on instruments used to assess QoL of older adults living in African countries. Therefore, this review provides valuable new insights into instruments used to measure quality of life in African countries. Another strength of this study is the fact that framework of Levac and colleagues on advancing the method of scoping reviews were followed, resulting in an excellent methodological foundation of this scoping review .However, some limitations should also be mentioned. First, studies reporting on quality of life among disease-specific populations and studies describing the development of QoL instruments were excluded from this review. There is a possibility that these studies used generic quality of life instruments that could have contributed to our results. However, as we were looking for instrument applicable in the general older population and to not development but mainly feasibility of applying the instrument in the specific settings, it was decided to exclude those publications. Second, only two articles were found describing the use of a QoL instrument in the slum setting and these studies did not provide any data on psychometric properties and feasibility of using the scale in the slum setting. As a consequence, very little conclusions can be drawn on the use of QoL instrument in older adults living in slums. Lastly, all articles were excluded that were written in another language than English. As the focus of our study was quality of life in African countries, this might have led to missing publications written in another language.For this reason, excluding non-English articles could also be a limitation.As there is little information available on the psychometric properties of the instruments used to assess QoL of older adults in African countries, further research should focus on validation and reliability of the instruments used among this specific population. Furthermore, there is a need for more in-depth research on the content and domains of instruments to assess QoL among older adults in African countries, and more specifically, in slum settings. Only two studies performed QoL measurements in slum settings but did not describe anything about their experiences of using the scale. Therefore, it is also recommended that in-depth interviews are carried out among aged slum dwellers to see if the content of currently used QoL instruments matches the concept of QoL experienced by them. A possibility that could also be explored is the weighing of specific domains based on importance valued by respondents . FinallyThe aim of this scoping review was to synthesize the current body of knowledge on the instruments used to assess quality of life of older adults in African countries. The following instruments were found: the EUROHIS-QOL-8, the SLWS, the WHOQOL-OLD, the WHOQOL-BREF, the SF-36 and the SF-12. It appeared that little information is available on both psychometric properties and feasibility of using these instruments among older adults in African countries. Also, it is unknown if the domains used in the instruments actually reflect quality of life in this specific population. This highlights the need for further research on adjustment and validation of currently existing instruments and/or for the development and validation of a new instrument, which can be used in illiterate, older populations living in African slums.


Among MSM, substance use increases risk for acquiring HIV and is associated with sub-optimal engagement in HIV-related care. Most research related to substance use and sexual activity among MSM focuses on identifying and reducing risk of HIV acquisition and transmission rather than pleasure and agency. However, substance use may also facilitate sexual pleasure and build community, which could be particularly meaningful for individuals who cope with intersecting stigmas related to the disease, sexual identity, and drug use.To explore the ways in which substance use both promotes and hinders positive sexual expression and healthy sexual relationships, we conducted a secondary analysis of 33 semi-structured qualitative interviews with MSM living with HIV who were poorly engaged in care and reported recent substance use.Thematic analysis revealed that substance use was perceived as: (1) a potential pathway to intimacy and enhanced sexual experiences; (2) a tool to help access partners and gain entry to a community; and (3) a source of empowerment, though some noted that it sometimes came at the cost of sexual disempowerment and unbalanced relationships.Clinically, our results suggest that the complex motivations for substance use during sexual activity need to be carefully considered and discussed with patients, especially when attempting to decrease problematic use as a pathway to improved HIV self-care.The online version contains supplementary material available at 10.1186/s12889-022-12778-w. Gay, bisexual, other men who have sex with men (MSM) are disproportionately affected by HIV infection in the United States (US), accounting for 70% of new HIV diagnoses each year  , 2. EngaActive substance use has been identified as one of several barriers to HIV care engagement among MSM in the US. Substance use may reduce consistency of care, leading to missed appointments and other disruptions in the HIV care continuum . RelatedMotivations for substance use are complex and may differ by population, with minority stressors likely contributing to use among MSM. Several models have been developed to conceptualize motivations for use. Substance use has been characterized as a form of self-medication, such that use is initiated to decrease painful emotions, relieve psychological suffering, and maintain emotional stability . StudiesSubstance use in the context of sexual activity, particularly among those living with HIV, may be catalyzed by other factors that warrant exploration. The literature on the positive motivations for and benefits of substance use during sexual activity in MSM remains limited and is even more sparse in MSM living with HIV, among whom substance use is discussed almost exclusively in relation to sexual risk behavior and HIV transmission. The few positive motivators for use that have been documented among MSM include increasing (1) desire for sexual activity, (2) intensity of a sexual experience, and (3) duration of a sexual experience . So-callAlthough decades of research has documented elevated rates of drug and alcohol use, as well as the negative implications of use as it pertains to sexual activity and what has broadly been characterized as sexual risk behavior, positive relational motivators for use have not been widely explored among MSM with HIV, especially from an intersectional stigma framework. In this sub-analysis of a larger project that examined the ways in which intersecting stigmatized identities impact engagement in HIV care among MSM who use substances , we explMSM living with HIV who use substances were recruited through online websites and apps  as well as advertising/outreach at community settings and providers of substance use treatment, HIV care, and/or other support services . IndividThe protocol and interview guide ; please Thematic analysis,  informedTo conduct the current analysis, we selected two themes from the original coding structure: (1) “substance use”, which was defined as “any content related to substance use”, and (2) “sexual orientation or behavior”, which was defined as “any content related to sexual orientation, sexual behavior, including bisexuality, and straight-identified MSM”. We reviewed all text that fell within these two codes, using content analysis to identify and refine subthemes related to specific motivations for substance use in the context of sexual activity. One team member (AMS) conceptualized three emergent motivations for substance use in relation to sexual activity and presented multiple examples of each motivation to a second team member (AWB), who conducted the interviews for the parent study. Among the two team members, discrepant interpretations were discussed and resolved by revisiting the original context for clarity. Quoted text that illustrates each of the three motivations are presented here.” in the assessment). Rates of problematic use across all substances were lower than overall rates of use; 54.5% of participants reported problematic stimulant use , 36.4% reported problematic alcohol use , 12.1% reported problematic opioid use, 21.2% reported problematic marijuana use, and 45.5% reported problematic use of more than one substance. Please see Table The final sample included 33 participants who all endorsed having sex with men and had a median age of 54 years . Most participants identified as Black/African American (60.6%). With respect to educational level and socioeconomic status, 48.5% had graduated college or had some college, 36% of participants had a high school education or less, and the majority (75.7%) had an annual income of ≤ $20,000. Almost all participants reported recent alcohol use (90.9%), 78.8% indicated recent marijuana use, 60.6% endorsed recent cocaine/crack use, and 39.4% reported recent use of club drugs  offers a potential pathway to intimacy and enhanced sexual experiences; (2) grants access to partners and community, in ways that can be both affirming and harmful; and (3) leads to a sense of empowerment that enables vulnerability and allows for sexual choices that might otherwise lead to discomfort and shame. Others described how substance use was disempowering in certain contexts and created power imbalances that may not be conducive to healthy relationships. Although substance use in anticipation of or during sexual activity was often fueled by the desire to access partners and have positive sexual experiences, participants reported that substance use also contributed to fleeting and ungratifying friendships, verbal abuse, and sexual relationships that stripped them of their agency and power, ultimately leading to rejection in some cases.Yeah, [we] do them together; we drink, smoke, take another drink…and cigarettes. So all of that is there… It’s the way that he and I are intimate with each other, it’s just the two of us, it’s how we get to know each other, get to enjoy each other. Several participants explained the ways in which substance use builds intimacy; enhances sexual experiences, such that use decreased inhibitions; and enabled positive or “optimal” interactions. By improving dyadic aspects of the sexual experience, participants described the ways in which substance use supported relationship growth and development. One participant reported that substance use enabled him and his partner not only to become more intimate in a sexual context, but also to learn about each other, strengthening their relationship:I do the drug to, in essence, to enhance the sexual situation...Well, kind of, you know, like, social drinking. Like, getting to that point where you have that pretty cool buzz, and you don’t go over that. ’Another participant expressed a similar sentiment, noting that substance use was often motivated by the possibility of easing interpersonal interactions and ultimately improving sexual experiences. He describes a thoughtful effort to use just enough to optimize a given sexual encounter:When I’m with people who are using and having sex I’m having the best time. But if I have to go out in public, and either high or under the influence, yeah, I don’t feel so good about myself. Because then I have to face real people in real situations. Although substance use was described as a means to more intimate or enhanced sexual experiences, participants reported that using in the context of sexual activity sometimes separated them from their own reality, creating a conditional or transient sense of happiness. To some, this sense of detachment created tension when they readjusted to social functioning in the absence of substances. One participant reported that the separation made the return to “real people” in “real situations” that much more difficult:When you’re doing this stuff, you’re basically focused on sex and having fun and porn. And you’re in dark rooms or hotel rooms or some back bedroom. And there’s so much of life you miss. There’s so many things I don’t do...I love going to the beach and Six Flags and rollercoasters. I love rollercoasters…We’ve had whole summers go by and we don’t do anything, because we were too busy partying. Although substance use during sexual activity enabled enhanced sexual experiences and therefore a welcomed departure from reality, participants indicated that it also robbed them of the positive experiences that are neither associated with substance use nor sexual behavior. One participant verbalized this concern, noting that time passed while he was using and that he was not able to participate in activities that he enjoys:Overall, participants reported using substances in the context of sexual activity to facilitate intimacy and enhance sexual experiences. For some, these heightened sexual interactions came at the cost of difficulty attending to the present moment. This was’ both appreciated as a momentary reprieve and also recognized as a negative byproduct of use.I was hanging with these guys at their house, visiting, and everybody kept disappearing…They were drug dealers, but I didn’t know that…“Oh, have you ever tried it?” “No, how do you do it?” They go, “You can have anything you want – have anybody, do anything you want.” So, it’s all these gorgeous, masculine guys coming in later on, and they want to get high...“You can have them do anything you want.”…So that’s how I learned about having drugs and sex. Participants described substance use as a tool for accessing partners and building different types of relationships, both with individual sexual partners and with members of their community in “party-and-play” or “chemsex” contexts. Yet, for some, the use of substances to access partners was often associated with some manifestation of sexual or relationship imbalance. One participant spoke to the positive impacts of substance use in broadening his social network and bolstering a sense of desirability. He reported a relationship among substance use, sexual activity, and engaging with highly attractive sexual partners that he perceived to be inaccessible.So, I have dated someone; we met at a sex party, but when we started dating, he was clean, and maybe in 9 months we had s’ex three times, and it just drove me nuts. So, for him, he needed it. For another participant, substance use was necessary to increase the frequency of sexual activity within a monogamous relationship. This participant also spoke to the potential for substances to create substance-related imbalances in sexual relationships, such that one partner wanted to engage or was already using in the context of sex, whereas the other partner may not have been using at that time. For this participant, being out of sync with his partner with regards to substance use lead to a tense and sexually unfulfilling relationship.I just felt like I, when I was doing the gay marriage thing, and canvassing and things…I didn’t want to be, like, the hall monitor…Because I didn’t know enough. I didn’t want it to pass me by because I wouldn’t have felt like I was part of the community. Substance use in the context of sexual activity was also discussed from the perspective of the community, revealing that some participants perceived substance use to be an entry point and/or an opportunity to gain understanding and acceptance from others. One participant conveyed the sentiment that, before he tried crystal meth, he felt like an observer or “monitor” of gay culture rather than an active and informed community member.“And if…I’ve never even met anyone in that circle and I don’t know what they’re talkingabout, and they’re, like, taking down – I’m not being taken down. Like, who is getting taken down by who? Crystal meth? Who’s that? That’s why I did it. He continued to explain that he felt the need to share in the experience of crystal methamphetamine to understand and participate in the community. This feeling was particularly salient in the context of meeting new people or affiliating with a new group; if members of a new group were using substances and engaging with each other around those substances, the participant wanted to be able to share in that experience. He did not want to act as a “hall monitor” or a superficial participant that was not really part of the group, in which others were being “taken down” by meth. Therefore, he reported grappling with the decision to become involved in the methamphetamine scene:My path that I’ve been on, I’m not kidding…was to find a husband. The same participant described his frustrations with his substance use “path” but noted that, in addition to using for the purpose of understanding and taking part in the community, he also used to secure a committed, long-term partner.In sum, participants indicated that they used substances during sexual activity to gain access to certain partners, to maintain relationships with partners, and to increase knowledge of and participation in their community. Some described the association among substance use, sex, and partnership or community with frustration or resignation, suggesting challenges initiating and maintaining relationships in which substances play a significant role.I have to laugh as soon as they say they’re not gay, but they want to come to your house to get high. As soon as they take a hit, they’re the ones whose clothes come off automatically…Like, some guys can smoke weed or coke…, but they’re using that as… a cover-up. “Oh, I was high,” or “I was drunk.” OK, so that’s just the truth drug. You’re just being yourself then. Substance use during sexual activity was described by many as motivated by the desire for self-expression or relief from the pressures of identity concealment. Participants reported that decreased pressure to conceal their identities empowered them to engage in specific sexual acts with certain partners that were previously linked with feelings of vulnerability. In text that was quoted earlier, a participant noted that substance use enabled access to “gorgeous masculine guys”, men that may otherwise have been too intimidating to approach. This statement exemplifies sentiments shared across participants. Indeed, another participant reported that substance use prior to or during sexual activity enabled same-sex sexual experiences that might seem shameful under different circumstances. He conveyed the notion that substance use in the context of sexual activity offered the opportunity for others to be “themselves”, that is, to be more “truthful” in expressing their sexuality.And, it’s progressed to the point that the person also -- and these people, in many instances, they use drugs -- crack cocaine -- they drink, they smoke weed, and they want you to indulge in these behaviors to make the experience optimal what they want. And so, I’ve done that. Though substance use during sex was described as empowering some to be vulnerable, enact their sexual desires, and explore stigmatized identities, multiple participants indicated that substances led to different forms of disempowerment, particularly within a dyad or group. For instance, some described substances as a tool to appease sexual partners, enabling the partners to have the enhanced sexual experiences that they were seeking, but often leaving the participants feeling used. One participant indicated that he used substances to ensure that others had these optimal experiences, intimating that he may not have reaped the same benefits or enjoyed the experience to the same degree:Because sometimes, you know, that whole feeling numb thing is so much better than being alone, so you kind of put yourself in positions where you’re being taken advantage of for the sex and you’re not even enjoying it. But I think that’s why in the last month-and-a-half that I have been really disgusted with a lot of my ways. Another participant described a similar sentiment, highlighting that he engaged with substances in the context of sexual activity to avoid being alone. Substance use in this context may also act as a form of self-medication to cope with the negative emotions  and cognitions that are associated with isolation, which may itself be a strategy to avoid distal and proximal sexual minority stressors. Ultimately, the participant found little pleasure for himself and was left feeling both shame and used by others:You could have sex with someone, and use for one night, and – or for five – you could use for a year. And then, the next day, you call them, and they say, “We don’t want you. F you. We don’t want you anymore.” Click. Indeed, several other participants reported that substance use during sexual activity led to brief or conditional friendships and relationships that ended in rejection and abuse. For example:Again, though participants reported that substance use was motivated by the promise of intimacy, enhanced sexual interactions, access to partners/community, and increased power to express one’s sexual desires with decreased shame, they also noted that substance use sometimes led to unstable, transient relationships. Participants described examples of the ways in which substance use in the context of sexual activity disempowered them, leading to self-disgust and loneliness.In this analysis, we explored emergent themes related to the ways in which substance use during sexual activity promotes and hinders positive sexual expression and healthy sexual relationships among MSM living with HIV. Although studies have addressed other interrelated motives for substance use , wiIn a population with multiple intersecting stigmatized identities , the importance of positive sexual expression and brief departures from the challenges of everyday life  cannot be understated, even as these motivations do not negate the potentially destructive effects of harmful or problematic use. In aggregate, the three main themes that emerged from the data  share a focus on interpersonal interactions and relationships, indicating that substance use in the context of sexual activity may be motivated by relational needs, among them identity affirmation and belongingness. The potential loss of intimacy, pleasure, partners, community, or power within a dyad or group may reinforce the internalized stigma or shame that is commonly reported in this population, potentially reducing engagement in HIV care , 52.Most of the published literature on motivations for substance use during sex among MSM has focused on so-called “chemsex” drugs  as facilitators of sex with multiple partners either in sequence or as a group, not on the use of other drugs, like alcohol and marijuana, which may be associated with different motivating factors, particularly among individuals with multiple intersecting stigmatized identities. In addition to the described use of stimulants (amphetamines and cocaine) and club drugs , participants in this study discussed drinking alcohol and smoking marijuana to build intimacy, decrease initial discomfort , or enhance sexual experiences with single or primary partners, not necessarily with multiple partners or in a group sex context. Certain drugs may have specific positive effects that MSM actively seek , 53; somOur findings do also address positive motivations for using substances that are more often discussed in the literature, providing some context for recently published quantitative data on the association between substance use, including crystal methamphetamine, and wellbeing among gay and bisexual men living with HIV in Australia . CompareRegarding substance use as globally negative obscures the ways in which use can, despite the risks, result in sexual wellbeing benefits, especially for MSM living with HIV. Providers caring for this population may consider operating from a sexual wellbeing perspective. Although the term “sexual wellbeing” has been challenging to define , the terThis approach also aligns with the principles of harm reduction, which refers to reducing the negative effects of certain health behaviors without necessarily stopping the behavior completely or permanently. Using the harm reduction framework, providers identify the negative consequences of substance use as the target for intervention rather than substance use itself, recognizing that use in and of itself does not equal harm , 62. ImpThere are several limitations of this study that are worth noting. Though the parent study reached thematic saturation with 33 interviews, the sample of MSM living with HIV was heterogenous with respect to type of substance use, substance use severity, and sexual orientation . Therefore, given these variabilities, it is possible that motivations for substance use in the context of sexual activity differ by substance use type, degree of substance use severity, and sexual orientation. Importantly, the sample had a fairly diverse age range, but the majority of the men included in the study were over age 50. The results may have differed if the sample had included more younger men. Furthermore, the parent study did not assess the timing of substance use initiation relative to participants’ HIV diagnoses. Substance use may have preceded the HIV diagnosis or vice versa, potentially influencing motivations for use during sexual activity. Finally, there are inherent limitations associated with conducting a secondary data analysis that should be acknowledged. In the interview guide developed for the parent study, specific questions probing positive motivations for substance use were not included. Therefore, the motivations described here are likely not comprehensive; had all participants been asked to describe their reasons for using substances in the context of sexual activity, we would have been able to assess which motivations were most salient. Relatedly, because participants were not asked to indicate which drugs they used in preparation for and during sexual activity, we do not have quantitative data on the specific substances that were used in a sexualized context. These data would have provided adjunctive information on the nature of sexualized drug use across substances, highlighting that substance use during sex is not exclusive to stimulants, which is evident in specific references to alcohol, marijuana, and other drug use within the sample. Though the inductive nature of these analyses is somewhat limiting, themes related to motivations for substance use during sexual activity came up organically during the interviews, without probing, which indicates that this topic is likely salient and clinically meaningful to this population.In sum, this sub-analysis offers insights on positive and complex motivations for substance use in the context of sexual activity among MSM living with HIV. Given these findings, providers may recognize the relational challenges faced by this population. To support the sexual wellbeing of MSM living with HIV, they may choose to assist patients who want to reduce their substance use (and/or stop using) in finding alternative sources of sexual pleasure, community, and empowerment that do not compromise connectedness, intimacy, or agency. Attending to the sexual wellness of MSM living with HIV does not trivialize the HIV transmission risk associated with condomless sex, though it does encourage an acknowledgement of the stigma-reducing potential of the “undetectable = untransmittable” campaign . AcknowlAdditional file 1. Intersecting Stigmatized Identities & Engagement in HIV Treatment (INSIGHT) Study.


To keep a high quality of assistance it is important for hospitals to invest in health technologies (HTs) that have the potential of improving health outcomes. Even though guidance exists on how HTs should be introduced, used and dismissed, there is a surprising gap in literature concerning the awareness of hospitals in the actual utilization of HTs.We performed a systematic literature review of qualitative and quantitative studies aimed at investigating hospital contextual factors that influence the actual utilization of HTs. PubMed, Scopus, Web of Science, Econlit and Ovid Medline electronic databases were searched to retrieve articles published in English and Italian from January 2000 to January 2019. The quality of the included articles was assessed using the Critical Appraisal Skills Programme checklist for qualitative studies, Newcastle-Ottawa Scale for the cross-sectional studies and the Mixed Methods Appraisal Tool for mixed method studies.We included 33 articles, which were of moderate to high methodological quality. The included articles mostly addressed the contextual factors that impact the implementation of information and communication technologies (ICTs). Overall, for all HTs, the hospital contextual factors were part of four categories: hospital infrastructure, human resource management, financial resources and leadership styles.Our systematic review reported that the contextual factors influencing the HTs utilization at hospital level are mainly explored for ICTs. Several factors should be considered when planning the implementation of a new HTs at hospital level. A potential publication bias might be present in our work, since we included articles published only in English and Italian Language, from January 2000 to January 2019. There remains a gap in the literature on the facilitators and barriers influencing the implementation and concrete utilization of medical and surgical HTs, suggesting the need for further studies for a better understanding.The online version contains supplementary material available at 10.1186/s12913-021-06423-2. Globally, healthcare systems are facing great challenges due to increasing ageing population, chronic diseases, and economic restraints. Hospitals are under an increasing pressure to provide high quality services in an era of limited financial resources and growing expectations from patients and society . Even thThe systematic review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  Additio. The proData sources used were PubMed, Scopus, Web of Science, Ovid Medline and EconLit. Each electronic database was searched to identify relevant articles published in English and Italian language form January 1st, 2000 to January 1st, 2019. We have chosen this time range considering the fact that HTs have evolved a lot and quickly, therefore we think that it would not be appropriate or useful to compare the technological set-up of 30 years ago with that of today. We developed a search string consisting of the search terms and keywords. The keywords “hospital”, “secondary care”, “tertiary care”, “biomedical technology”, “technology”, “facilitator”, “barrier”, “management”, “organizational”, “adoption, “acceptance”, “implementation”, “assimilation”, “uptake”, “utilization”, were combined using Boolean Operators and Medical Heading Subjects terms. The search strategy used in all the databases is reported in Additional file P (population) - secondary or tertiary hospitals located within the European Union (EU) or within the Organisation for Economic Co-operation and Development (OECD);I (intervention) - HT, using the definition of the World Health Organization (WHO) for HTs, as “the application of organized knowledge and skills in the form of devices, medicines, vaccines, procedures and systems developed to solve a health problem and improve quality of lives” , 18.;C (comparator) - There is not a comparator applicable for the studies in this systematic review;O (outcome) - Contextual factors that facilitate or inhibit the implementation of a HT in a hospital setting;The search question and the eligibility criteria for inclusion in the systematic review were developed according to the PICOS framework.S (study type) - Quantitative and qualitative studies reporting primary data were included.We referred to those factors related to organization, infrastructure, support and capacity, team structure and collaboration, motivation to change, leadership and resources, that could potentially mediate the effect of a HT implementation and use.Considering the PICOS developed for this systematic review, studies assessing contextual factors, facilitators and barriers related to the implementation of a HT in a secondary or tertiary hospital were considered eligible. Due to a lack of a standardised definition of implementation, we searched for all the concepts related to it, such as “adoption”, “implementation”, “acceptation” and “assimilation”. Therefore, we included the articles that evaluated the actual utilization of a given HT, referring to it as “HT implementation”.Studies that evaluated the technology implementation in primary care settings or the mere introduction of a HT in a hospital were excluded. Reviews , editorials, commentaries, conference abstracts and theoretical studies were excluded.The identified articles from all the databases were uploaded to Mendeley Software and the duplicates were removed. Two researchers  independently performed the initial step of screening based on title and abstracts. In a second step, two independent researchers  read carefully the articles with full texts available in order to decide the final articles to be included in the systematic review. Articles satisfying the eligibility criteria were selected for inclusion in the systematic review. Reasons for exclusion of full texts were recorded and were reported in the PRISMA flow chart. The reference lists of the included articles were carefully hand-searched to retrieve additional eligible articles. Any discrepancies in the screening process and study selection were resolved by consulting a third reviewer (IG).Study identification ;Study characteristics ;Information related to the HTs investigated .Two researchers  independently extracted from each article the following data:Any discrepancies in the data extraction process were resolved through discussion with a third author (IG).Afterwards, we labelled the extracted contextual factors according to their topic and added up the studies that displayed each one. Additionally, these factors were grouped into the four areas: hospital’s financial resources, leadership styles, human resource management and hospital infrastructure. Within each area, the contextual factors were described as either impeding or facilitating the implementation of the HT, as reported by each study. Each factor was checked in duplicate by two researchers  and incongruence were resolved through discussion. If a study performed statistical analysis in order to investigate the relation between a given factor and the HT implementation, variables were categorised as facilitator in case of positive association and as barrier in case of negative association.We performed a synthetic descriptive analysis of the studies according to the area of contextual factors.To assess the quality of the included studies we used the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies . As for The search strategy identified 5472 articles from the five databases, as showed in detail in Fig. The main characteristics of the included studies are reported in Table Seventeen studies (51.5%) , 56–59, Thirteen studies (39%) , 54, 55,The Mixed Methods Appraisal Tool was used to assess the quality of three studies , 30, 37 The contextual factors relevant for the implementation of HTs are reported in Table The first area concerned hospital’s financial resources. According to the results of 13 studies (39%) , 59, 60,Second, a total of 12 articles (36%) , 57–59 mThird, Human Resource Management (HRM) was another important factor emerging in several studies. HRM appears to cover a crucial role in the phase of staff supply and planning, due to the need to define new roles, including those in charge to support the change , 49, 59.Finally, evidence also suggests that some determinants related to the infrastructure of the hospitals might influence HTs’ implementation. For instance, the technological capability of the hospital  or even the affiliation to some universities or to a multihospital network, could be associated to HTs' implementation –57, 59 .The present work provides a novel point of view in understanding how hospital contextual factors may hinder or facilitate a full implementation of HTs. Although HTA is attentive to capture the effects of technologies on multiple domains , the inverse relationship, i.e. how organizational/contextual factors may affect HTs’ implementation, remains unexplored. Addressing this query implies ascribing to HTs the power of “producing value” within patients’ continuum of care. The term “value”, here, is ascribable to Porter’s definition, which is defined as “the patient health outcomes achieved per dollar spent”. As stated by Porter, “value encompasses many of the other goals already embraced in healthcare, such as quality, safety, patient-centeredness, and cost containment, and integrates them. It is also fundamental to achieving other important goals such as improving equity and expanding access at reasonable cost” .This systematic review provides valuable insights concerning the relationship between contextual factors and HTs’ implementation. Our results, in line with previous evidence, showed that facilitators and barriers to HTs' implementation vary across studies and countries. However, this work suggests that facilitators and barriers to the actual utilization of HTs could be reconducted to four overarching domains. The first dimension concerns the hospital’s availability of financial resources. Although intuitive in principle, this finding has further implications than the mere ascertainment that a hospital with more resources is advantaged in implementing the use of HTs. Indeed, implications concern the internal distribution of resources and their coherence with organizational units’ technological assets. This, in turn, provides food for thought on the consequences of misaligning HTs and budgets within or across organizational units.The second dimension that affects HTs’ implementation refers to leadership styles and management. What seems to emerge here is that HTs should be driven in a very participative manner. Top management involvement is required to implement HTs, suggesting that an excessive decentralization of responsibilities to lower levels may hinder implementation. On the other hand, it emerges clearly that top management has a role of “mediation” of professionals, to be exerted by involving professionals at all levels - including nurses and final utilizers of the HT. This provides interesting implications in terms of managerial styles, suggesting an increased effectiveness of attitudes that approach a concern for people rather than a concern for results .Third, HRM appears fundamental in utilizing HTs. HRM seems to have a major impact in terms of planning people’s work, both through “standard” training pathways and the development of behavioral skills such as, team-working. Development and integration of technical and behavioral skills is challenging, especially in a dynamic and complex sector such as healthcare, where the need for education is of utmost importance. In particular, future research should address the relevant topic of how incentive schemes may affect the use of HTs. This may be of great interest in an era in which hospitals are increasingly required to be accountable and tend to introduce Management by Objectives logics within their daily functioning . FinallyThe role of of the identified contextual factors could depend on the environmental context in which the hospital operates. A systematic review that evaluated the influence of context on quality improvement reported that variations in the characteristics of the external context in different sites, such as physical environment, socio-cultural context or political and funding environment can influence implementation outcome . Future Although this systematic review employed a robust methodological approach and it was rigorously conducted, few limits need to be identified. In the first place, as in all systematic reviews, our study might be subject to publication bias. Even though the search strategy was performed in five databases, we only included articles published in English and Italian language, from January 1st, 2000 until January 1st, 2019, suggesting that we may have missed a number of articles. We acknowledge that the search strategy is rather extensive in scope and may lack analytical evidence on specific aspects of HTs' implementation. Even though the search may not have identified all relevant literature, this risk of publication bias has been minimised by manually screening the reference lists of the included articles. However, although it is of utmost importance to analytically target specific features of implementation, with attention to specific types of HTs, the intent of the authors was to generate a broad evidence of the state of the art in literature, in order to assess the desirable directions of future research. We also acknowledge that, even if we restricted our search to OECD, differences across countries  might be relevant and generalization of our findings should be cautious. Even though our systematic review was not restricted to any type of HTs, the vast majority of studies concerned information and communication technologies, and nothing emerged in reference to clinical equipment and drugs.Understanding the relationship occurring between hospital contextual factors and the implementation of HTs is an arduous task. On one hand it is clear that HTs may affect the context, on the other the inverse relationship also seems to hold true. Although HTA has definitively incorporated the organizational domain within its span of interest, the way in which this domain may enable or hinder a full implementation of HTs is still rather unclear. This work has the potential to contribute to a better understanding in this direction. Policy makers often face challenges when making decisions regarding the evaluation and implementation of HTs. Therefore, we believe that our results might contribute to the development of strategies addressing these factors, aiming a successful implementation.To conclude, there seem to exist two main gaps in literature: one concerning the contextual factors of interest that could play a role when implementing a HT. Although relevant evidence has emerged, several items, such as managerial accounting tools may have been overlooked. The second, −and perhaps more salient one, concerning the typologies of HTs investigated. Elucidating contextual factors is essential to identify effective, sustainable, and reproducible strategies that aim to overcome the barriers and improve HTs' implementation. Future research is needed to shed light in this direction, providing guidance to hospital management, to reduce the uncertainty of the concrete effects produced by HT in settings that present numerous contingent factors.Additional file 1.Additional file 2.Additional file 3.Additional file 4.Additional file 5.Additional file 6.