Youth experiencing homelessness (YEH) face myriad injustices regarding their reproductive and sexual health and rights. Reproductive and sexual health research with YEH often explores condom-use and sexually transmitted infections, potentially contributing to narrow conceptualizations of YEH as “unclean” or in need of disease-screening. A narrative theory perspective was applied to this study, which allowed for the emergence of alternative storylines, or counter-narratives, which attend to manifestations of power and oppression within the lives of marginalized individuals. Qualitative interviews engaged 30 young people (ages 18–21) accessing shelter services. Narrative analyses identified YEHs’ documentations of dominant narratives related to structural oppressions, stigma, and numerous dimensions of reproductive and sexual health including how they create, through their resistance, counter-narratives that include their preferred futures. YEH emphasized systemic sources of stigma and outlined their criticisms of the state. Within-group stigma emerged as a noteworthy theme, with YEH showing both empathy and ambivalence towards other YEH, along with internalization of stigmatizing narratives about pregnancy and homelessness. Approaches to service provision that further amplify youths’ voices in naming and challenging the many oppressions and stigmas they face should be prioritized. Moreover, policies should be implemented to dismantle the actual root causes of challenges faced by YEH, rather than perpetuating them through measures rooted in interlocking oppressions of discrimination, inequity, and judgment. In the USA, over 3 million young people between the ages of 18 and 25 experience homelessness each year , 2018. TYouth experiencing homelessness face an array of injustices pertaining to their reproductive and sexual health and rights, and multiple barriers to accessing sexual health care . In a USYouth homelessness is a violation of basic human rights and reflects structural failings that hamper young peoples’ access to sufficient housing, food, justice, education, health care, meaningful employment, and freedom of expression at a critical time of physical, social, cognitive, and emotional development . Yet, deindividual stigma, focused on individual perceptions and how these shape micro-level interactions of discrimination, as well as structural stigma, focused on macro-level forces, or the “societal-level conditions, cultural norms and institutional policies that constrain the opportunities, resources and wellbeing of the stigmatized” , beliefs , behaviors  assigned to an individual or group, resulting in reduced perception of status and worth . matized” . Based oYouth experiencing homelessness are a heterogeneous group with multiple intersecting identities, and an intersectional approach is therefore key in considering the impacts of both individual and structural stigma for individual youth. The term intersectionality refers to the various ways that multiple identities interact to shape dimensions of experience, such as how the experiences of women of color in the context of violence against women, are informed by racism and sexism, and are generally underrepresented within antiracist and feminist discourse . In the In addition to the poverty and class-based oppression experienced by YEH, individual experiences of youth homelessness may be shaped by racism, sexism, heterosexism, homophobia and transphobia, and able-ism, as well as other forms of structural oppression. Research shows that lesbian, gay, bisexual, transgender, queer/questioning, and other individuals identifying as sexual and gender minorities (LGBTQ+) are overrepresented in YEH populations in the USA , as are Black youth . RacialiResponses to experiences of stigma are varied. YEH may internalize stigma, leading to feelings of guilt and shame that can negatively impact mental health . Stigma Recent research with LGBTQ+ youth experiencing homelessness illustrates the range of ways in which youth show resilience and resist stigma, despite the many challenges they encounter .Many dominant storylines regarding homelessness are laced with stigmatizing descriptions whereby homelessness is positioned as a choice caused by intrinsic failings . Dominant narratives tend to be problem-saturated with conceptualizations of those experiencing homelessness as mentally ill, addicted to substances, lazy, idle dangerous, delinquent, deficient in skills and abilities, and untrustworthy . The ongSimilarly, dominant narratives tend to depict those who are pregnant or parenting while homeless as being irresponsible and more deserving of scrutiny and surveillance with regard to their approaches to parenting; these beliefs lead to increased child welfare involvement, parent-child separation, and feelings of degradation . In contrast to these problem-saturated narratives, pregnancy and parenting have been illustrated by some YEH as motivating factors for establishing positive life changes, such as finishing school, reducing substance use, or obtaining housing and employment . PregnanGiven the role of academic scholarship and knowledge production in shaping dominant narratives, research about marginalized groups can sometimes, even if inadvertently, contribute to further stigmatizing and marginalization. For example, research on sexual and reproductive health among YEH generally concerns condom use and sexually transmitted diseases , potentiYouth experiencing homelessness, particularly those with additional intersectional marginalizations, are acutely aware of dominant narratives and the role they play in perpetuating disempowerment, social isolation, anti-homelessness policies, criminalization, and exposure to dangerous circumstances . As suchThis study was part of a larger one that examined the perspectives and experiences of YEH regarding pregnancy and parenting, and reproductive and sexual health. The research questions guiding the current analysis were as follows: (1) How do YEH experience and make meaning of individual and structural stigma in their daily lives? (2) How do experiences of stigma influence their perspectives regarding pregnancy, family planning and sexual and reproductive health? (3) How do youth respond to, internalize and/or resist such stigma?Criterion sampling, an approach deemed appropriate for studies in which all participants experience the phenomenon under study , was useYouth were approached in the shelter milieu by the study’s Principal Investigator (PI), a social work researcher , who at the time was frequently present in the shelter for data collection across several concurrent research studies. As the PI spent considerable time at breakfast, lunch, and “hang-out” times with young people at the shelter, most youth present at the time of the current study were familiar with the researcher and had interacted with her during such gatherings. The study purpose was described to youth as being a project that sought to examine the reproductive and sexual health attitudes and needs for supports specifically among YEH, and with acknowledgment that these concepts can mean a countless array of things depending on who is asked and that this study sought to collect and honor a diverse range of insights that were rooted in contributors’ unique identities and lived experiences. The researcher also named upfront that she had extensive work experience and interest specifically in areas of reproductive rights and reproductive justice, LBGTQ+ health and rights, and youth-led organizing, and that her education goals and research were similarly rooted in these areas. To participate, youth were required to provide written informed consent indicating their willingness to engage in the research interview. All study details were approved by the PI’s university-based Institutional Review Board. Permission to audio-record interviews was obtained from all participants. Participants were then engaged in individual interviews, lasting 45–60 min, and facilitated in a private office in the shelter by the study PI. Respondents received a $25 gift card to a general retailer or local food vendor.A semi-structured interview guide was used to explore participants’ attitudes and experiences regarding pregnancy and parenting, family planning, their needs for information and social supports, and other topics of reproductive and sexual health , reproductive and sexual health knowledge and service utilization experiences). An introductory, hypothetical question was posed at the beginning of each interview, and was followed by a series of potential prompts that were utilized as relevant and dependent upon respondents’ answer trajectories. At the beginning of each interview, a question was asked: “To get started, I’m going to ask you some hypothetical questions. If you were to wake up tomorrow and learn that you are pregnant or got someone pregnant, how do you think you’d react?” From there, participants’ perspectives dictated interview flow, and the semi-structured guide offered a general framework for asking participants overall consistent questions. Although the precise order of each interview was unique to the youth respondent because of their answer trajectories and in wanting the conversation to flow freely and comfortably, the researcher was nonetheless intentional about making sure that topics of abortion, contraception, STIs, parenting, social support, health care utilization, and social norms regarding reproductive and sexual health were approached in each interview in at least some capacity. At the close of each interview, participants were asked to complete a brief, voluntary, pen-and-pencil survey to collect sociodemographic information to assist in describing the sample. Participants answered several questions, such as pregnancy history, foster care history, homelessness duration, and how many cities they had lived in since leaving their home of origin see . SamplinQualitative data were initially analyzed utilizing a phenomenological research epistemology with thematic analysis , which is considered suitable for the investigation of topics that are not well understood to seek more profound meaning about an experience or circumstance that a group of individuals shares . The broQualitative interviews were transcribed and uploaded to Dedoose, the secure, cloud-based, qualitative analysis software platform. After initial qualitative thematic analysis by the PI, additional analyses were conducted by a team of four research assistants, who worked independently in order to reduce bias and increase rigor in analyses. The research assistant team was comprised of social work graduate students (two MSW and two PhD students), who identified as predominantly middle class, white, cisgender female, and who had a range of one to 10 years of clinical social work experience. The team was comprised of individuals with other intersecting identities and lived experiences, including parents and those who had experienced pregnancy, Jewish ethnicity, and an array of sexual orientations represented. The team had limited personal histories of experiencing homelessness, though had worked in various frontline service environments with individuals experiencing homelessness and other marginalizations.From a secondary examination of the data by research assistants, an additional area of investigation was identified, distinct from the original scope and goal of the interviews: that of stigma and resilience demonstrated in relation to youths’ experiences of homelessness and reproductive health. Additional topics, themes, and their examination are detailed elsewhere , 2020a. n = 16) of participants in the sample identified as women, 33.3% (n = 10) as men, and 13.3% (n = 4) as transgender, gender-non-conforming, or gender-fluid. The sample was also diverse regarding racial identity and sexual orientation; 56.7% (n = 17) of participants identified as youth of color, and 40% (n = 12) identified with sexual orientations other than straight/heterosexual. On average, participants were 19.1 (SD = 0.8) years old and had experienced homelessness for an average of 8.9 (SD = 9.0) months. Participants had lived in an average of 2.5 (SD = 2.0) cities since leaving their home or place of origin. Nine youth (30%) had been in foster care, and four youth (13.3%) indicated that they were currently pregnant, information that they voluntarily disclosed, unprompted, within their respective interviews.As shown on Experiences of stigma and discrimination were common among YEH interviewed. Sources of stigma, described as judgment or negative perceptions about homelessness, existed both within and outside of YEH communities. Stigmatizing perceptions described by participants mirrored those seen in extant literature, such as perceptions of laziness, lack of motivation to care for themselves, and inability to plan for the future. Experiences of stigma were noted in instances when participants felt excluded or neglected, including rejection by family members and friends, and negative interactions with health professionals and other service providers.Several participants described experiences of stigma and judgment from health-care workers, particularly doctors, nurses, and staff at reproductive health centers. YEH reported having their statements to medical staff questioned based on stigmatizing assumptions about their sexual practices: “Yeah, [doctor will be thinking] here’s an 18-year-old girl staying at a shelter and has like three potential baby daddies and is a mess. Great” (Arden). Having access to services that made efforts to reduce stigmatizing language were heralded as particularly helpful if they “…told people in a way that didn’t make them feel like it was a lecture or that we’re all a bunch of dumb homeless kids, that would be a start” (Kiran).I don’t think those relationships hold up very long for most of us. Most people who aren’t homeless judge people who are homeless, even if their situation for becoming homeless is really honest and sad. There’s just a lot of discrimination about homeless people, so those friends usually don’t really stay friends (Jayme).Unsupportive family members were often the source of participants’ feelings of stigma, especially regarding LGBTQ+ status: “I no longer talk to [my parents]. They kicked me out when I came out, so we’ve been on thin ice for years” (Reese). Some participants also reported the loss of friendships or community resulting from homelessness stigma:Stigma towards YEH was also identified within society more broadly. Government policies, the words and inaction of individual politicians, and a lack of access to services were described as sources of stigma, which were particularly salient considering recent governmental decisions at the time of interviewing. Participants also reported feelings of stigma as a more amorphous sense that society is generally hostile towards YEH. Participants discussed feelings of stigma in terms of specific reactions from strangers, or from a general sense of stress and judgment they experienced in the community: “The reason I’m homeless has nothing to be with being an irresponsible, freeloading type of person like most people probably think” (Lavern).An overarching theme described by many of the participants was that of being “unseen” and “unclean.” Youth homelessness was an issue that many choose not to see or address, and that when seen, YEH were considered dirty and diseased. Participants often described themselves and other YEH as “invisible” and expressed feelings of being forgotten or unacknowledged: “I think our challenges are really forgotten, or not even known, by most people…” (Mattie). Some participants expressed that being listened to while being interviewed felt like a novel experience because they are so used to be ignored: “I realized when I was talking that I’m so forgotten now, especially as a homeless person, that people don’t even really ask me what I think or feel about some of these important things” (Swarna).Getting birth control is just sort of weird because then the doctor judges, like why are you homeless and having sex? You could get pregnant, don’t you think that’s a little irresponsible at this time?.. It’s just a painful time, going to the doctor. I feel like I’m like this leper of society. I feel like they look at people like me and just think ‘well, she’s garbage' (Chidi).Feelings of being perceived as unclean, both by health-care providers and by the general population, were often described by participants in reference to their sexual and reproductive health. For instance, one participant described:And the ER doctor was such a jerk. He said, ‘well, you probably just have another STD.’ And I was like ‘Excuse me, I don’t have any STDs, and I know what this is. It has been diagnosed, and treated, but it can still come back.' And I felt so disrespected. And judged (Jordan).Participants also described that their STI status was often assumed by their health-care provider. For instance, one participant described how an ER doctor’s assumption that her recurring bacterial vaginosis was an STI:Another participant described similar assumptions on the part of potential sexual partners: “the other person assumes the homeless person has diseases.” (Mattie). Stigma within health care settings was profound across many interviews, though was particularly compounded for participants with intersecting marginalized identities. For example, one participant described the difficulty in finding a doctor “who gets how to work with LGBT people. I mean, so many doctors don’t. They’re all weird like we have the plague or something.” (Reese).Stigma related specifically to pregnancy was described throughout the interviews, both by participants who had experienced or observed instances of judgment and exclusion due to pregnancy, as well as by participants who described their own judgment and negative stereotypes of pregnant YEH; the complexities of this within-group stigma are further explored in the following section. Stigmatizing experiences related to pregnancy appeared to be exacerbated by homelessness and age for those interviewed. Participants who had experienced pregnancy recounted being judged negatively by health-care providers, family members, peers, and society at-large. Participants reported that even within the YEH community, pregnancy often signaled a transition in friendships as, “whoever’s not your real friend will immediately start talking shit. During your pregnancy you will lose every single fake person. It will start the moment you announce, and it will end the day that the baby is born” (Jae).sic] like food and even housing…” (Cruz).For many YEH, pregnancy was viewed as an indicator of laziness and irresponsibility, connecting to broader dominant negative narratives about this group. In discussing YEH who are pregnant, one participant shared this dominant narrative: “They’re just too lazy to get a job and just do not try to get help the right way. Pregnancy is a short-cut. Like 'I can get insurance if I’m pregnant” (Jayme). These labels of laziness and irresponsibility were also identified as being felt by youth who were pregnant at the time of interview: “I also feel a little judged, like people are throwing shade at me behind my back about being pregnant, like I’m some irresponsible hoe or something” (Hira). A connected dominant narrative concerning YEH pregnancy was that young women become pregnant to obtain access to more public services and supports, and to take advantage of the system. Within the shelter system, participants stated that pregnant YEH would often be given access to additional services: “Some think they’ll get more stuff for free. And I guess you do get better access to things . Not another statistic of someone on a reservation. So if abortion is what needs to happen for me to be Dr. [name blinded] then that is the choice I would make (Sam).For the first group, avoiding pregnancy was seen as an essential part of their hopes for the future and moving forward with their career and educational goals. Many participants discussed their career and/or educational aspirations in the context of the pressures that they feel to avoid negative stereotypes associated with youth homelessness or in relationship to their racial identityWell, so I know everyone is all like “Black girls, Latina girls, they always become pregnant.” And I don’t want to feed that stereotype by becoming pregnant really young either. And so my mom was a teen mom, and I really respect her and all but…I learned so much from her, she’s really an amazing person. But all the poverty, all of the hardship. It, um, coulda been so different, for both of us. We’ve had a lot of hard times. … I guess I just want to experience the world you know? See places, go places, learn things, meet different kinds of people, and not just be another girl. Mixed race girl, you know, getting pregnant (Jordan).Similar feelings were expressed by a participant who described her desire to avoid racialized stigma she saw as associated with young Black and Latina girls who become pregnant:.And my job is pretty good… I think I’m nearly to a place that I have enough saved to get an apartment. I think I can become a manager at my job in the future, and I’m doing some freelance graphic design work. I have a few clients and I think as that takes off a bit more, I will actually be doing really well financially (Cruz)In contrast, other participants described the possibility of a pregnancy and a child as compatible with their future goals, and therefore viewed it as potentially positive. These participants described their optimism about a hypothetical pregnancy in the context of being partnered in strong relationships and their sense that having a baby was compatible with their work and educational goals. They did not describe feeling stigma attached to pregnancy, but rather a sense of pride that they could make a pregnancy work at this stage of their life, and a sense of hope for their futures. For example, one participant described feeling that having a baby could be a positive thing, though she and her girlfriend are not currently planning to do so, because of how hopeful she feels about her relationship and her career goalsHaving a child would be like a lot of pride, and something other people would see you, see good in you, for doing. …. It takes a lot of work to be a parent, and I think there’s a lot of honor and pride in that….People start to show them more respect, like “you’re going to be a parent, that’s important” rather than seeing them as some dumb, homeless kid (Jadyn).Several participants discussed how becoming a parent may be perceived as an avenue to escape the stigma experienced by YEH: taking on a new role as parent provided a different, positive identity in contrast to the stereotype of “lazy homeless youth” and this could provide a new sense of pride and self-worth, new purpose for life, and a way of becoming seen by the general public as a legitimate person worthy of respect:Like having a baby, that’s a big accomplishment. And raising it, and figuring out all of those things that need to be figured out in order to do that, that’s really impressive. And I think society thinks we can’t pull that off, but I think getting pregnant can be a way to break that stereotype, if that makes sense. (Jun).Some described how becoming a good parent could be a way of showing “society” that their perception of YEH is wrong. Participants expressed that pregnancy could garner them respect in the eyes of others, given that it is a large responsibility that they are choosing to take on: “Sort of middle finger to the world, too, like ‘I can be a great parent, even if you think I’m like homeless trash” (Lavern). Another participant described how parenting would be a remarkable accomplishment given the many doubts and barriers to navigating systems and supports exist for YEH:Pregnancy was described as a way to actively reject the feelings of being unseen, as becoming pregnant or having a baby could increase the visibility of YEH in the eyes of carers and workers in their lives: “I think homeless people are often feeling invisible… so when you say you’re pregnant, you’re now a future mother, and not as much a random homeless person who people are afraid of and who seem to hate so much” (Moana).:… I have been doing a lot of groups, getting my life in order. Working on my recovery, and getting back on my feet again. So the boys are with my mom, and I’m here at the shelter, but the shelter has given me a lot of good things. Good groups, case manager. I feel hopeful and think I can be back into a place with my kids in about a year if I keep working (Arden).None of the participants who were parents were living with their children at the time of their interview, but they did express their hope to be reunified with their children in the future and the importance of having their children in their lives. For example, one of the mothers described her children as motivating her recoveryAccordingly, while some YEH described their own belief that having a child would enable them to break stereotypes or challenge stigma, others identified this line of thinking in other YEH but expressed skepticism about it, observing that YEH who become pregnant generally face new and greater challenges, and in some cases, additional forms of stigma.It’s hard to be a Black man in our society, you know, and I’m guessing my kid would look Black too…I worry every day that I’m going to be shot by a police officer. Or that someone’s going to call me some racist name. At least out in some nature area, no one is going to kill my son or call him a name (Chantrea).Several participants described how systemic issues shape their own lives, or those of other YEH, and the options available to them. Shining a light on how power operates at systemic levels, these participants actively resisted dominant oppressive narratives that cast YEH as individually responsible for their poverty and life situations. In many of the interviews, participants named forms of systemic oppression they experience within their own lives, including sexism, racism, homophobia, transphobia, and classism. In some cases, participants articulated a clear link between systemic oppression and the ways in which it has shaped their own life circumstances and vision of the future. For example, a Black cis-male youth described his fears about raising his hypothetical child due to the dominance of anti-Black racism:I think the only things we have going against us are poverty. And racism. Because otherwise we would have what we need to not be homeless and not having to work so extra hard just to have a good life (Jayme).Other participants asserted explicitly that it is structural issues that have led to their current situation of homelessness. For example, one participant described a sense of pride in the career and other life goals that he and his girlfriend were working towards:The government, the wacko conservatives, especially, really like to force people to have babies, bring more and more babies into the world, but then the help gets cut off when it’s a real person that needs things when it’s really alive. It makes me so mad. We’re like a fetus-loving culture but then we treat real children like shit…. And the government seems fine in just letting it happen. Letting people live in absolute shit and filth with nothing, not even basics (Cruz).Some participants discussed the state’s responsibility for injustices they perceive around them, criticizing the government’s failure to support YEH and other people living in poverty. A few participants articulated their sense that the government does not care about people living in poverty and is content to let people live without their basic needs being met, rather than investing the necessary resources into social programs:In addition to the inadequacy of supports for economically marginalized people, many participants highlighted systemic problems with accessing health care, describing the barriers YEH face in accessing health care, and the realities of class-based health inequities. For instance, one participant described the injustice of health-care inaccessibility: “I mean, everybody–any country that doesn't take care of its sick or doesn't let people have access to health care I think is committing a crime, so it’s ridiculous” (Hira). Several participants described the difficulties of navigating the complexities of the health care system. Finding health insurance was often described as “confusing,” with one participant speculating that “Like insurance or doctors or housing vouchers. All of that is almost on purpose confusing, maybe just so we don’t find out about them and so we can’t end up using any of those things available” (Cruz).I think a lot of my future is really bright and hopeful but I admit that I just don’t know about so many things that are sort of obvious to people who have more money or who haven’t had life challenges that I have (Jadyn).Some participants identified that YEH and economically marginalized youth have less access to information about reproductive health than their more privileged peers, referring to YEH as “forgotten” and “trapped.” For instance, one participant stated,Within-group stigma, often referred to as “intragroup stigma,” is the process by which stigmatized individuals apply the pejorative labels assigned to them towards those who are more evidently stigmatized . As discussed in the section about pregnancy stigma above, some participants engaged in within-group stigmatizing within the interviews, repeating dominant pejorative narratives and labels about other YEH. Participants often distanced themselves from these negative labels and stereotypes by describing a multiplicity of stories, experiences, and truths within themselves, while describing other YEH in one-dimensional stereotypical ways.I think they need to just know more, and why it matters for them to know and care about these things, because they’re not as invincible as they think. Like, your life is not just like a video game or something that you get to restart if you fall in a hole. So they just need more awareness and maturity. Most of the people in the shelter, I will tell you, are acting more like 12 year-olds… (Arya).Typical labels that participants assigned to other YEH included laziness, immaturity, perceived invincibility, impulsivity, and poor judgment. In addition to pregnancy, these labels typically were assigned when discussing topics of family planning, and condom and contraception use. For instance, “Yeah, I think [other YEH] live in a bubble and assume that nothing bad could be going on with them because they’re too young, and pregnancy or diseases or life-threatening things just don’t really happen to young people” (Moana). Several participants described YEH as immature, with one participant stating:I think [YEH] need to find a way to improve their self-esteem and stay accountable to goals in a way that isn’t tied to pregnancy…and not just be some homeless person who is trying to game the system or tie down a relationship by getting pregnant…(Karsyn).Many of the participants applied common homelessness stereotypes to other YEH, while positioning themselves as resisting these narratives. For example, in response to a question regarding what would help YEH, one youth described,This participant positioned himself as an exception from YEH stereotyping and stigma, which did apply to other YEH. This perspective appears to endorse the dominant neoliberal narratives of hard work yielding positive results, while YEH not pursuing upward mobility through success are deemed to be deficient in intrinsic ability or willingness, and therefore deserving of the stigma assigned to them.And how could you blame anyone here for wanting those things? People are desperate, and homeless, and willing to do whatever just to be able to see doctors, get housing, get things for free, because they have nothing. It’s a horrible life. Homelessness is possibly worse than death (Cruz).In contrast to instances of within-group stigma, some participants also expressed empathy towards their peers. For instance, while many participants were critical of YEH who viewed pregnancy as a means to access more resources, other participants described the same strategy as understandable within the context of the scarcity of supports for YEH:…most people [YEH] haven’t had a lot of education about any of this. Like healthy sexual health things, and like pregnancy, and getting tested. Just sex things in general. Because a lot of us moved around a lot growing up. Some were in foster care, some with a lot of placements. And some didn’t finish school or nothing like that either. So if parents or like their foster parents didn’t really talk about it, then they maybe don’t know everything they should to be healthier about that (Ale).Similarly, while many participants criticized YEH as “lazy” for not using birth control, ascribing this to inherent individual failures, other participants expressed empathy and understanding for how systemic barriers may shape people’s access to sexual and reproductive health-care knowledge and resources. Another participant described,Rather than portraying YEH as “lazy” and “dirty” and asserting that not being diligent about contraception and sexual health testing as an intrinsic moral failing on the part of the individual, this participant articulated empathy and understanding for why YEH make the choices that they do within a broader systemic context which does not provide opportunities for YEH to obtain the information and resources they need.Many participants discussed the effects of their intersectional identities and articulated an awareness of how broader social, economic, and political forces contributed to the stigma faced by YEH, demonstrating a reluctance to subscribe to dominant narratives surrounding youth homelessness. One participant stated that politicians who stated that they “only like a certain type of skin color… [The United States is] for everyone- not just for a certain race… [racist politicians] are trying to repeat a time that was very detrimental to the universe. To everybody” (Hira). It appears that the lived experiences of these participants facilitated awareness of systemic barriers to upward mobility. The process of externalizing problem-saturated stories and connecting individual experiences with the broader social context provided a counter-narrative leading to further empathy and understanding.Despite the polarity in views described, most participants vacillated between feeling empathy towards other YEH and expressing internalized judgment when sharing their own narratives and explaining reproductive and sexual health care among YEH. Within single interviews, multiple positive and negative narratives about YEH were often expressed. These juxtaposing narratives were seen especially in relation to reproductive health. One participant described other YEHs’ attitudes towards receiving regular gynecology check-ups: “And some just think nothing will ever happen specifically to them…the mentality is that people would rather get drunk or high every single night and hope for the best, that the pregnancy ends. Or that the pregnancy won’t somehow be affected…” (Jae). Simultaneously, this participant expressed empathy for fellow YEH by expressing an understanding for the unique stress that homelessness brings: “And because I think a lot of people are like, ‘I just don’t have the emotional stamina to figure this out today.’ That’s how I feel a lot, actually” (Jae).Findings of this study highlight the importance of allowing YEH to share and shape their own narratives around experiences of stigma and resilience. Throughout the interviews, participants repeatedly identified stigma and prejudice that they experienced socially, both within and outside of the homelessness contexts. The results of this study mirror other research demonstrating that YEH experience stigmatizing attitudes that result in stress and less access to resources. As well, this study contributes a more nuanced understanding of how YEH actively resist stigma and challenge dominant societal perceptions within their everyday lives, and with regard to narratives pertaining to reproductive health, pregnancy, and parenting. Several important considerations have been garnered through these research efforts.Participants considered their experiences of stigma within the larger systemic forces that create homelessness and castigate YEH. The research team interpreted the rich descriptions provided by participants as insights into the societal forces that have resulted in conditions of oppression for YEH. It was discussed whether participants’ identification of systemic oppression should be considered resistance to stigma, as for YEH, such oppression shapes daily life and may seem obvious. We therefore reflected on whether our interpretation was a result of our own privileges and social work research lenses. However, the team ultimately agreed that participants’ abilities to contextualize their own hardships within broader systems of oppression may provide powerful counter-narratives that defy stigmatizing narratives about homelessness being a result of individual failures. YEHs’ abilities to shift narratives of “brokenness” from themselves to the system allows youth to see the complexity of the world and serves to decrease self-blame; as extant research suggests, such self-blame is associated with negative mental health outcomes . These fobjects of discourse  should be further explored. Another limitation of this research is related to the subsequent analyses of the qualitative interview data, which were completed after the original interviews were collected and analyzed. As the interviews and original analysis were completed with another purpose in mind, the secondary finding of YEH resilience and counter-narrative should be further investigated and replicated as the focal point of future research.This study provides a YEH-centered and strengths-based perspective of resilience and resistance to stigmatizing narratives related to homelessness and reproductive and sexual health. For individuals who work with YEH, these findings may assist workers in becoming more attuned to positive narratives of resilience and the many aspects of identities that YEH embody beyond the presenting clinical concerns. As YEH are identifying socio-political forces that require change, practitioners need to become more attuned to engaging clients in discussions of politics and finding ways to assist their clients to engage in resistance against broader systemic forces that promulgate youth homelessness. For clinicians working with YEH in a therapeutic context, modalities that focus on establishing YEHs’ stories about themselves and experiences may be particularly salient, such as narrative therapy and arts-based activities. Although this approach has been described in work with youth in a variety of treatment settings, further intervention research is required to understand the effects of narrative approaches and their applicability to YEH and sexual health. Narrative approaches offer YEH a means to combat stigma and discrimination, elevate the preferred stories of youth, and see youth as more than the stigmatizing narrative assigned to them.As well, professionals can engage in advocacy, research, and policy work to address the systemic context that plays a role in the development and maintenance of stigma, and the anti-homeless policies stemming from it. Counter-narratives are important for YEH, workers, and policy makers to better understand experiences of youth homelessness and intersections with pregnancy and sexual health. Though it is of great importance to amplify the voices and resistance of YEH in all dimensions of research, service provision transformation, and policy change, the onus for dismantling structural inequity does not lie solely within YEH; social workers, frontline service-workers, advocates, community members, and policy decision-makers alike must step up as part of the process of influencing change and disrupting the root causes of these oppressions and stigmas that so disproportionately harm young people. As such, we join with Finally, the dominance of participant narratives about experiences of stigma within health-care settings in this study demonstrate the role which health care providers can play in contributing to the harm of social stigma, thereby creating barriers which prevent YEH from accessing the reproductive, sexual, and other health information and supports that they need. These narratives serve as a powerful reminder to all health and service providers of the importance of meeting every client with respect and empathy and providing non-judgmental care.


Continuing medical education (CME), as a systematic attempt to facilitate change in General Practitioners’ (GPs) practices, is considered crucial, assuming that if physicians are up-to-date, they will change and improve their practice, resulting in better performance and ultimately better patient care. However, studies continue to demonstrate considerable gaps between the real and ideal performance and patient-related outcomes. The objective of this study was to explore GP’s perception of the factors affecting the implementation of a CME digital platform in a primary health care setting in Portugal.Our work is framed in a larger effectiveness-implementation hybrid type 1 study, where a Digital Behaviour Change Intervention (DBCI), called ePrimaPrescribe, was developed and implemented with the aim of changing benzodiazepines (BZD) prescribing patterns. Our design used mixed methodologies to obtain an enriched knowledge on GPs’ perspectives on the facilitators and barriers to implementing a Digital Behaviour Change Intervention (DBCI) applied to CME. To do so, we used data coming from an onsite questionnaire, an adapted version of the Barriers and Facilitators Assessment Instrument (BaFAI) and in-depth interviews.From the 47 GPs successfully included in the intervention arm of our cluster-randomized effectiveness study, we collected 37 onsite questionnaires, 24 BaFAIs, and performed 12 in-depth interviews. GPs reported as the main barriers to CME a lack of time, a perception of work overload, a lack of digital competence, a lack of digital infrastructure, and motivational and emotional factors. They reported as facilitators to CME delivered through a DBCI the convenience of the delivery method, the practical and pragmatic characteristics of the content, and the possibility for CME to be mandatory.The perceptions of the barriers and facilitators reported by GPs represent an important contribution to improving knowledge regarding the factors influencing the implementation of CME in primary health care settings. We consider that our study might bring useful insights to other countries where primary health care plays a central role in the provision of care.NCT04925596.ClinicalTrials.gov number The online version contains supplementary material available at 10.1186/s12913-022-08019-w. Continuing medical education (CME), defined as any and all ways through which doctors learn after the formal completion of their training , is a syIn recent years, there has been an exponential growth in the potential of e-health CME interventions. E-learning approaches have shown similar effects on outcomes as conventional face-to-face approaches, in terms of learners’ knowledge and learner’ satisfaction, and similar limitations in terms of changes in processes and outcomes of care –8. ThereDigital Behaviour Change Interventions (DBCIs) are behaviour change interventions that involve computer technology or digital encoding of information . This spIn Portugal, General Practitioners (GPs) have a four-year mandatory residency training period. During this time, knowledge acquisition in different specialized areas, such as cardiology, paediatrics or psychiatry occur in hospital settings for a few months. After completing their residency, and when choosing to join primary health care units integrated in the Portuguese National Health Service (NHS), GPs are granted with 15 days a year to engage in voluntary CME training, such as conferences and symposiums. Moreover, in most units there is a voluntary and non-accredited training program, with weekly to monthly presentation and discussion sessions, that are either held as traditional discussion meetings or involve invited participating specialists. There is no need for recertification after residency completion, hence compliance with CME is affected by personal, motivational and organizational factors.Our work is framed in a larger effectiveness-implementation hybrid type 1 study, where a DBCI called ePrimaPrescribe was developed and implemented, with the aim of changing benzodiazepines (BZD) prescribing patterns and, in a broader sense, the management of mental health issues in a primary health care setting. The objective of the analysis presented in this paper was to explore the perception over the factors that affected GPs’ voluntary compliance with our CME digital platform in primary health care settings. Identification of the barriers and facilitators to CME compliance is important for both CME providers and GPs since understanding the facilitators and barriers to implementing learning from CME can have important implications for the effectiveness of health care delivery. Hence, with this work we hope to contribute to shaping of CME, adapted to the characteristics and challenges of real-world routine clinical practice in primary health care settings.Our study used a mixed-methods sequential design to obtain rich knowledge on GPs’ perspectives on the facilitators and barriers to implementing a Digital Behaviour Change Intervention (DBCI) applied to CME. The primary intention of this design was to add a qualitative strand to in-depth initial quantitative results .The quantitative approach allowed us to obtain measurable evidence on providers’ perspectives, while the qualitative approach provided a deeper understanding of their perceptions.We started by collecting data concerning the barriers and facilitators to implementing a DBCI using two questionnaires. The questionnaires allowed us to explore some of the practices, perspectives and points of view of a large number of individuals, though the depth of the research was limited by the standardized approach, which failed to account for the contextual and procedural circumstances and dynamics. This resulted in a lack of sensitivity to explore the differences, inconsistencies, meanings and arguments that emerged . In orde2, an estimated population of 166.706 inhabitants (2011), a population density of 22.5 inhabitants/km2. All primary health care units from the Central Alentejo region were considered eligible. We contacted each primary health care unit coordinator, explained the project, and invited their participation. Of the total 250 GPs working in these primary health care units, 110 were included in our study. The 110 GPs included had similar characteristics regarding type of primary health care unit where they were prescribing (UCSP vs. USF), their sex, age, years of clinical experience and training in mental health, hence they were considered representative of all target GPs. Portugal has an NHS with free coverage for the entire territory. Primary health care is responsible for the provision of care and has a gatekeeping function for hospital care. In Portugal, the NHS distinguishes two types of primary care units. The default one is the ‘personalized care unit’ model (UCSP), in which professionals receive a fixed salary; the second is the ‘family health unit’ model (USF), which enjoys higher functional and organizational autonomy ” .Both at baseline and at the end of intervention implementation, the lack of time was mentioned as one of the most important factors limiting CME implementation, regardless of it being online or onsite Table . In factWork overload, which led GPs to attempt to do many things at the same time because of the limited time they had to fulfil the different tasks they are expected to perform, was referred as anxiogenic. GPs expressing this perception ended up not even trying to use the DBCI, thus demonstrating how the lack of time and its effect on participants’ emotions directly influenced intervention implementation.As a barrier to CME implementation, GPs mentioned feeling overwhelmed by their need to receive training in too many different areas, since they are first in line as primary medical care physicians and patients come with very different complaints. Moreover, they also mentioned the fact that they face excessive bureaucracy in their role, leaving little time for training or further studying. In some ways, the GPs’ underlying GPs discourse translates into frustration over the impossibility of “doing it all”."The fields of Family Medicine are many, many, and, and therefore it is difficult to maintain continuous training in, in cardiology, in diabetes, in child health, in, 'you see, in mental health, in, it's this, that, the other. So I think, hmm, they're a lot, they move in many areas at the same time, don't they?” .“Because I always have to look at a lot of things on the computer, uh, I'm not an individual who has much experience in using computers and it bothers me a bit to be watching, having to look at the screen” .“I might prefer things online, because I can access it more easily” .Barriers related to skills were also mentioned, such as lack of digital know-how because of age. Senior GPs found digital tools challenging due to a lack of knowledge regarding new technologies and long-term working habits. Younger professionals reported being more prone to using digital tools than senior ones.“I tried to get into USF X at the time…and I couldn't…and then there was no sound and then I couldn't load…and then it was blocked…and therefore, the accesses I ended up doing were at home… and then when I needed it at the I work, to clarify any doubts… I couldn't use it” .Technical issues, such as bad internet connection and lack of sound devices were mentioned as significantly influencing implementation of our DBCI platform Table . The lac"I understand that older or less patient colleagues no longer have the…motivation to do this type of training" “I don't have much patience anymore because I'm going to retire after year!” In general GPs reported low motivation to comply with CME, especially after their junior residency period. Senior GPs mentioned that residents (hence younger and during their compulsory residency training period) usually make an effort to comply with training but felt that they themselves had a lower motivation level to participate, mostly due to habit and the perception of a higher work overload. These were some of the reasons pointed out by GPs to excuse a certain therapeutic inertia, particularly concerning BZD prescription and starting BZD withdrawal schemes."Afterwards, at home, few colleagues have the will or patience to go open another platform and see something else… they were and are too fed up with work to go do or think about work when they get home" ."At a certain moment I realized that I was late… and, and that also made me feel a little guilty… deep down I felt that I was failing" .The influential factors regarding motivation ranged from problems with changing old routines Table  and therGPs considered that one of the main facilitators of CME implementation and successful compliance would be the convenience of its delivery method Table . However"The ideal would be things in person, reduced audience, and maybe with a little more frequency. That is, I don't know, every three months, every two months, talk about it…or remember, or give… training, or even if it was just once or twice a year, but with tools that you could use. I think it would be, it would be what would work out better" .It was also said that onsite training, such as conferences or periodic meetings with experts, allowed GPs to escape their routine, and made it easier to establish limits between work and off-work time. Junior and senior GPs shared the preference for onsite training, although the reasons presented for this preference were different. Senior doctors mentioned preferring onsite training due to technical difficulties and personal preference; junior doctors seemed to prefer onsite training as a way of assuring the protection of their time to comply with CME.“For me, it would always be more advantageous one, one, one training, even if it was one day a week… or two days a week that I could manage… and at that time I'm just for this… for me it's more profitable than, trying to read, because, and we would be talking to each other…” .For senior GPs onsite CME was also preferred to online due to their lack of openness to digital tools."I prefer one with, training with the person present…no, things on the internet, no, don't invite me" .“It's a good option, especially for these issues of time and travel. It can even be done anywhere, anywhere…" .Some GPs claimed advantages of an online delivery method, arguing for the feasibility of implementing CME online platforms implementation, for the ease of access to knowledge and the ease of access concerning technical aspects, such as the possibility of using it at any time according to personal availability. For these GPs, CME available online is more convenient, avoids unnecessary travel, responds to the need to be updated, and is an accessible way to improve one’s knowledge and practice. The only downside they acknowledged relating to this delivery method was, once again, to time management, since most GPs claimed they were not supposed to use their 15 days’ leave a year on this type of CME. Notwithstanding, even for GPs advocating for online CME options, it was recognized it was helpful to have an onsite presentation of digital platforms."I think it would have to be more, uh, more practical, let's say, it would have to be a more practical training. I'm not saying that no to the issue of pharmacology and all of this, but, uh, [it should] be a thing, uh, eminently practical, with, comprehensive in relation to the various types of treatments that exist, therapies that exist, but it would be more, more practical" .Participant GPs suggested specific content characteristics to facilitate CME implementation. Most highlighted the specificity and didactic benefits Table , such as“Theoretically there should be a part of our working time to, for personal training, hmm, to read articles, including distance training, which nowadays is often more practical, hmm, and more economical, hmm, in practice. Speaking for myself, I spend, um, ninety-nine percent of my professional time seeing patients" .“I don't know, if this comment fits here. I think that, in our training, over the years, maybe there should be mandatory training, right? …if we were somehow obligated, in quotes, I don’t mean doing training all the time, but if there were some things that were mandatory, I'm sure people would go there, would do it, whether through… of platforms, whether it was otherwise, isn't it?” .Taking into account all the factors mentioned in the examples above, the barriers to CME identified by GPs are manifold, and reveal the entanglement of organizational and personal, or more subjective, factors in the perception of GPs about CME in its different possible modalities. The table below synthesizes these results, of the BaFAI questionnaire, and the globality of factors considered by GPs as barriers to CME:The primary context framing our narratives were GPs’ perspectives on the implementation process of a DBCI, after being involved in an effectiveness cluster-randomized trial aiming to change their prescription patterns. The reported content, derived from two different questionnaires and in-depth interviews, was enlarged to discussing CME in the primary health care settings and the possibility of delivering CME through online platforms such as our DBCI.When questioned about their motivations to use and expectations coming from using our DBCI platform, or more generally towards CME compliance, knowledge acquisition and practice improvement were frequently mentioned. Research by Kelly reports similar findings regarding motivation, stating that doctors felt that gaining knowledge was a good reason to comply with CME . A meta-Time was consistently pointed out, both by the interviewed GPs in this study and by a large body of literature, as the main barrier to CME implementation , 24–28. GPs feel, in general, that their training is overall insufficient to handle the variety of clinical situations they have to solve, given that they are in the first line of medical care. Consequently, that they acknowledge that they need to receive continuous training in many different areas. This perception, when confronted with the lack of time, leads again to negative feelings of a lack of discipline, laziness, and of guilt, as well as saturation with work. Indeed, the assumptions that GPs have a manageable workload appears questionable at a time when there is a worldwide strategic shift of responsibility for health onto primary care .GPs often mentioned emotional barriers limiting CME implementation, relating to their perceptions of work and bureaucracy overload, saturation from daily work, and guilt. This points to a general underlying negative perspective and sense of low satisfaction towards their daily clinical role and performance. We might consider this as inevitably jeopardizing any motivation to attend CME, regardless of the type and content of the training. A recent study discussed GPs’ wellbeing as an important factor regarding quality of care, GP prescribing patterns, patients’ adherence to medical treatments and patient satisfaction . Other eOlder age and greater clinical experience were frequently cited as having a negative influence on GPs’ availability for training, suggesting that the opposite—younger age and lower number of years of clinical experience—would be associated with higher levels of motivation to attend CME. However, this might be only true for GPs during their residency/formal training period, since the narratives of young GPs revealed a similar discourse as the ones of senior doctors, pointing to time limitations as a significant barrier to CME. The existing literature regarding age and clinical experience is in accordance with our findings , pointinLack of digital savvy and lack of proper hardware at primary health care units were also mentioned as important barriers to the implementation and acceptance of online CME, especially for senior GPs. This finding is supported by further evidence, reporting that senior GPs with more years in clinical practice are less likely to have access to or to use computer-based technologies , 34, 35.Considering the convenience of the CME delivery method regarding to acceptability, and the opposing perspectives regarding onsite versus online preferences, the literature indicates a general preference for live training due to the value of personal interaction and the perception that CME that does not involve personal interaction was adjunctive , 28, 35.Having easy access to some kind of interaction with specialists allows for clarification, the personalization of information, exploration, feedback, and reflection. It can also address other needs of doctors that may not be recognized or quantified, such as the need for support, recognition, motivation and fulfilment, and the ‘need’ to belong to a professional community. Thus, it would also be interesting to explore in future research the suggestion of complementing innovative CME delivery methods with a facilitated way of liaising with specialists, such as the implementation of a telephone helpline, as a way of guaranteeing a middle-ground option between onsite and online CME.Another key solution pointed out by participants was for CME to be mandatory. In fact, “forcing the change” is a significant aspect of our narratives, translated by a common perspective that CME implementation would only be possible through the implementation of obligatory training . ParticiThis study is, to our knowledge, the first to explore the barriers and facilitators perceived by GPs in Portugal to CME implementation. As mentioned, primary health care in Portugal is the main branch of health care responsible for the provision of care and has a gatekeeping function for hospital care. In this sense, the results of this study can be applied to countries where a similar NHS exists, and where primary health care plays a central role in the provision of care.We recognise as the main limitation to our study the small sample size of participant GPs, especially regarding qualitative data coming from the in-depth interviews. Notwithstanding, our findings are generally consistent with recent literature regarding physician perceptions and preferences for type of CME/professional development activities, and use of educational technologies (including online platforms) for professional development, and barriers to implementing learning from CME. More specifically, and in agreement with our data, a modest desire for more online learning is reported , and theWe consider one of the main strengths of our research to be the choice of a mixed-methods approach, which combined different data sources, allowing for an in-depth acknowledgement of the factors involved in CME implementation. One of the data sources, the BaFAI, also documented that the barriers and facilitators to implementing the DBCI platform used for our effectiveness cluster randomized trial were similar to barriers and facilitators found in our control group, which used a similar methodology and format but a different content. This suggests that, when considering the implementation of a DBCI aimed at changing GPs’ behaviour in primary health care settings, our reported barriers—the need for time investment; the general attitudes towards the DBCI; the motivation and self-perceived role of the professionals involved; and the resistance to a change in old practice habits—are worthy of inspection and consideration, regardless of the content of the intervention. The results also show, clearly, that a DBCI is difficult to implement if adequate instruments and facilities are not available. Furthermore, and in a broader sense, the implementation of CME requires deep reflection integrating bottom-up perspectives, since successful implementation will always significantly depend on perceived challenges coming from daily routine clinical practice.Additional file 1.


In 2018, USAID published a report based on Demographic and Health Surveys data on the relationship between men’s involvement and women and children’s health outcomes. Using a flawed operationalization of “men’s involvement,” USAID’s analysis implies that Senegalese men are not involved in women and children’s health.The findings of this study come from 12 months of ethnographic research in Dakar, Senegal that examined the roles and responsibilities of expectant fathers. Research participants included 32 pregnant women and 27 expectant partners recruited from three maternity wards. Research methods included long-term, immersive participant observation and semi-structured interviews.entourage who share responsibilities for support. Expectant fathers, as members of the entourage, are expected to provide financial and emotional support, while other members of the entourage are expected to undertake the responsibilities which USAID have designated as “men’s involvement.” Men typically do not undertake additional forms of care and support because they are considered “women’s business,” meaning that women actively discourage men from doing those things, in order to preserve women’s autonomy.Pregnant women in Senegal are surrounded by a kin-based network of care providers called the This research demonstrates that expectant fathers are involved in antenatal care in ways that USAID does not track through DHS. Further, I argue that USAID’s heterosexist, monogamous, and nuclear operationalization of “men’s involvement” aligns with a long history of Eurocentrism in development discourse which may be potentially harmful and obstructive to improving maternal and child health when the problem that is targeted is not a problem at all. This study is yet another case that demonstrates an urgent need of public and global health engagement with local stakeholders and ethnographic researchers.The online version contains supplementary material available at 10.1186/s12884-022-05093-0. In 2010, Lu and colleagues asked, “Where is the F in MCH?” –5, peer In 2018, the United States Agency for International Development (USAID) released a report titled “Does Men’s Involvement Improve the Health Outcomes of their Partners and Children?” (henceforth “DHS 64”). In order answer their question, Assaf and Davis, the authors, draw on a well-known model from health promotion, “knowledge-attitude-behavior”   among those who decide with their partners how to spend men’s earnings (19.3%). The implication of these findings is that Senegalese men are uninvolved in women’s health, although DHS 64 was not conclusive that men’s involvement was causative of women’s and children’s health outcomes.Overall, with respect to Senegal, Assaf and Davis found the following: In the case of correct knowledge, 39.1% of surveyed Senegalese men knew to give water to a child with diarrhea while only 10.7% had correct knowledge of women’s fertile period. In the case of the positive attitudes, Senegalese men do not generally agree that contraception is only a woman’s business (88.9%), nor that using contraception leads one to become promiscuous (67.5%). In the case of supportive behaviors, Senegalese men were among the least likely to be present during an ANC check-up (20.6%) or discuss family planning with health workers (5.6%). Senegalese men ranked fairly low  are both true and deeply flawed. My long-term ethnographic study demonstrates that Senegalese men are in fact a key component of antenatal care, and that Assaf and Davis’ findings are limited by the operationalization of “men’s involvement” using a Eurocentric, biomedicalized set of indicators that privilege positivist measurement. After a brief explanation of how long-term, ethnographic methods provide a unique window into the lives of Senegalese expectant parents, I will discuss the cultural context of the analysis  of a 199The findings of this article come from an ethnographic study conducted in Dakar, Senegal over 12 months in 2018. The purpose of the study was to examine the ways that expectant fathers involve themselves in antenatal care, what they are expected or encouraged to do by their partners, families, social networks, and the State, and how they navigate these activities in light of the social expectations of masculinity. The findings of this study come from data collection methods including semi-structured interviews , 18 and In Senegal, pregnancy is both taboo and highly gendered and makes recruitment of expectant fathers particularly challenging. It is taboo in that talking about a specific pregnancy can attract bad luck or misfortune. Americans have a similar taboo that typically lasts for the first trimester of pregnancy, but in Senegal this taboo holds for the entire pregnancy. In practice, what this means is that all people who know of a particular pregnancy  should not speak to outsiders about it. It is also highly gendered, meaning that men typically find the topic embarrassing to talk about. With both of these cultural aspects combined, locating men who are willing to (a) identify themselves as expectant fathers and (b) talk about pregnancy can be difficult.To overcome this challenge, the author worked closely with midwives and chief medical officers in three hospitals across the city of Dakar to develop a protocol in which pregnant women were recruited, interviewed, and then asked if their partners would be willing to be interviewed. Ultimately, we interviewed 32 pregnant women and 27 expectant fathers recruited evenly  from each hospital maternity ward.Semi-Structured Interviews lasted approximately one hour and took place either in maternity wards (when midwives could spare a room) or in a location of the interviewee’s choice . To avoid flouting the pregnancy taboo, we did not interview pregnant participants about their pregnancies directly (unless they volunteered information), rather we were interested in the experiences of pregnancy, who was caring for them, from whom they sought advice, and their relationships with their partners , a key method in the ethnographic toolkit is participant-observation. In general, participant-observation entails that the researcher eschews strong notions of objectivity, steps outside of the interviewer-interviewee relationship, and becomes an active participant in the phenomenon they are studying. This role of the researcher, to be present and attentive in the lives of research participants, affords opportunities and perspectives that can fill gaps in standard interview-based qualitative research – gaps that the researcher may not have even anticipated during the research design phase. This is a driving force of the iterative and ongoing qualities of ethnographic research.The advantage of participant-observation is that the researcher is always “on” and therefore everything is “data.” This means that every social transaction, community or family meeting, or casual conversation (i.e. “unstructured interview”) can be counted as data collection . The obentourage, gender roles) comes from a patchwork of exploratory visits to Dakar, Senegal over 10 months across the six preceding years in which the author sustained ongoing research relationships which included participant-observation and semi-structured interviews with young men and expectant fathers.With respect to this study, the author spent many hours over 12 months with expectant fathers in their daily lives – at work, running errands, family meals, religious holidays, doctor’s appointments, family celebrations , and more. Notably, the author was often present with couples and their families when pregnant participants were in labor and childbirth. While the findings of this article come from ethnographic research conducted in 2018, much of the cultural context . The entourage is usually made up of their jëkker (husband), goro (mother-in-law), and njëkke , – all of whom likely live under the same roof – and maybe some others, like their bajen (their own father’s eldest sister), their co-wives (if applicable), or a very close friend . Women often regard birth workers like midwives and bajenu gox as honorary members of their entourage.The ideal situation in Dakar, in keeping with traditional Wolof kinship practices, is that pregnant women are married and that married women move into their husband’s household  . It is isee Fig. . As discgroup is a group of family or friends which emerges around a sufferer to take charge of those responsibilities. An entourage, on the other hand, emerges as a kin-based collective that provides emotional support, physical safety, and financial security. Whereas the TMG typically acts on behalf of incapacitated patients, the entourage does not view pregnant women as incapable of making decisions for themselves. She is not considered a “sufferer,” nor is pregnancy considered an “illness.” They are there to help her navigate her experiences with pregnancy and in biomedical spaces, such as maternity wards.The entourage acts similarly to what the medical anthropologist John Janzen identified as a “therapy management group” (TMG) . Therapyngente (naming ceremony) that takes place seven days after the child is born. Either the goro or the njëkke (or both) can accompany the pregnant woman to antenatal care (ANC) visits. I will discuss expectant fathers’ roles next.The responsibilities of antenatal care are distributed to individuals in the entourage, therefore no one person is wholly responsible for her care. Some tasks can be shared by multiple people in the entourage , while some are the sole responsibility of one individual . The goro (mother-in-law), for example, is responsible for sharing intergenerational obstetric knowledge, such that an entourage may necessarily become more hands-off with each successive pregnancy (so long as previous pregnancies have had consistently positive outcomes). She is like the project manager, while the njëkke is her second-in-command. The njëkke (the sister-in-law) is a kind of organizer who both works with the goro to execute certain tasks or preparations while also learning obstetric knowledge from her as well (if she is inexperienced). She is also responsible for naming the newborn at the The entourage has two specific expectations of expectant fathers: that they demonstrate (1) financial and (2) emotional support.sersé larzã (“find the money” in Dakarois French), is, according to the midwives and goros in this study, the most important job of anyone in the entourage. Wages are low and employment can be difficult to find, so for the working-class men who participated in this research , finding money consumes a great deal of time and effort. It can involve working multiple jobs and one-offs, often in dangerous manual labor (with little or no worker protections), as well as calling expatriated relatives in Europe or North America to seek financial assistance  are based on the notion that knowledge and power implicate each other. The exercise of power requires the production of certain types of knowledge, while the production of knowledge requires the exercise of power to validate its assertions” .In his critical discourse analysis of a USAID Salvador , Luis Avglobal values placed on family are heterosexist, monogamous, nuclear, and fully dependent on a specific set of gender stereotypes that make no room for the generative and creative possibilities of non-European networks of kinship and care. Avilés writes of the Eurocentricity that is deeply interwoven into development discourse such that, simply put, “Europe is the model to emulate” [The implicit rules of discourse, knowledge, and power are interlaced into the design and execution of DHS as well as the limitations it places upon the possibilities for operational definitions in reports like DHS 64. Discourse is also mobilized when the inherent values of such a report are reproduced by its dissemination. In DHS 64, the purportedly emulate” . So too emulate” , 28. Furemulate” .USAID’s characterization of men as “uninvolved” was a surprising revelation to the Senegalese physicians, midwives, mothers, fathers, and Ministry of Health officials in this study who unanimously viewed men as an integral part of women’s and children’s health. It was apparent to many that the authors of DHS 64 had never been to Senegal to examine the topic of their report. One physician remarked that USAID could not see the deep level of men’s engagement that I was seeing. One midwife noted with irony that there were men who went above and beyond and wished they could do even more for their pregnant partners. The key findings of this article demonstrate why Assaf and Davis’ operationalization of “men’s involvement” is not sufficient for understanding the full picture of how (or whether) Senegalese men are involved in contributing support and care for women’s and children’s health. Further, without a holistic view of what Senegalese men are expected to do or are actually doing, there can therefore be no reliable analysis of whether local expectations have a positive effect on health outcomes.not viewed as problems locally, but are accepted as assets of local gender and kin norms. As Lucia Guerra-Reyes’ work [I speculate that an intervention based on findings like those in DHS 64 would have harmful downstream effects on both women’s and children’s health, as well as future public health research and practice. Such interventions would likely fail by attempting to address issues that are not only es’ work  demonstres’ work , and it es’ work –33) for As it relates directly to this study, Assaf and Davis report in DHS 64 that men are not likely to be present during ANC visits or discuss family planning with a healthcare worker. While my ethnographic data support both of these findings, they do not support the implicit conclusions of such global health logics that Senegalese men are therefore uninvolved in women and children’s health. Senegalese men are involved in women and children’s health in ways that the DHS does not track. The numbers simply do not tell the whole story.In this article, I have demonstrated that in Senegal, antenatal care roles and responsibilities are distributed among a small network of kin-relations called the entourage. As a part of this entourage, expectant fathers are relied upon to find money to pay for the added expenses of pregnancy and to provide emotional support – often the two overlap. Pregnant women, their mothers-in-law, and midwives all agree that these responsibilities are critical to the health and wellbeing of women and children, and yet almost none of them serve as indicators of “men’s involvement” in global health literature, nor can they be measured by current indicators in the DHS.I have also demonstrated that Senegalese men do not undertake the forms of care and support that Assaf and Davis call “involvement” because those responsibilities are not theirs to act upon, nor would it be financially feasible for most Senegalese.Finally, I have demonstrated that Eurocentric measures of men’s involvement, while ostensibly universal, are so narrow as to be impractical for intervention. The assumption that, because men aren’t accompanying their pregnant partners to ANC visits, no one is accompanying her reveals deeply entrenched ethnocentric and limited conceptions of masculinity, of family dynamics, and of care. Narrow conceptions of what a father “should” know or do as forms of maternal support are also tied to equally myopic assumptions of nuclear households that presume men are solely responsible for women’s and children’s care. These measures tell us nothing about the relationship between men’s actions and women and children’s health when men are not the only people involved in their care. Like “culture,” kinship is not fixed nor bounded—even in nuclear families (which is a rare occurrence in Dakar). It is important to widen the scope of interrogation to include all meaningful relationships in someone’s life, perhaps approximating what I’ve described here as an entourage or Janzen’s TMG. Measures of men’s involvement can only be meaningful in locally specific, context dependent analysis and practice.Additional file 1. Semi-structured interview guide for pregnant women.Additional file 2. Semi-structured interview guide for expectant fathers.


Marketing of food items high in added saturated and/or trans-fat, sugar, or sodium (HFSS) negatively affect consumption patterns of young children. The World Health Organization (WHO) advised countries to regulate the marketing of foods and non-alcoholic beverages to young populations. The aim of this manuscript is to provide a situational analysis of the regulatory framework of food marketing policies targeting children in the Eastern Mediterranean Region (EMR). A semi structured questionnaire was shared with the focal points of EMR member states inquiring about the reforms and monitoring initiatives in place. Electronic databases were searched for relevant publications between 2005 and 2021. Results revealed that even though 68% of countries discussed the recommendations, progress toward the WHO set goals has been slow with only 14% of countries implementing any kind of restrictions and none executing a comprehensive approach. Reforms have focused on local television and radio marketing and left out several loopholes related to marketing on the internet, mobile applications, and cross border marketing. Recent monitoring initiatives revealed a slight improvement in the content of advertised material. Yet, unhealthy products are the most promoted in the region. This review identified the need to intensify the efforts to legislate comprehensive food marketing policies within and across EMR countries.  The Eastern Mediterranean Region (EMR) has been facing many health challenges due to unhealthy lifestyle patterns, political instability, and fragile health systems , 2. As aChildren, starting from a young age, are exposed to food marketing at home, nurseries, schools, and in public spaces, most of which are for products high in added saturated and/or trans fatty acids, sugar and sodium (HFSS) , 12. Marn = 22). Results were rounded to the nearest integer. Moreover, a systematic literature search was implemented on the following databases: Medline, PubMed, Scopus, Embase, Google Scholar, Al Manhal, Arab World Research Source, E-Marefa, and Iraqi Academic Scientific Journals. The last four databases were chosen as they provide data sources that are specific to the region, since Arabic is the language most spoken in EMR countries. Manual search was conducted on the websites of the WHO and Food and Agriculture Organization. Inclusion criteria included manuscripts, governmental documents, reforms, and policy briefs in countries of the EMR. The following terms were used: “Eastern Mediterranean Region” countries OR “Middle East” OR each state alone AND “Children” OR “Child” OR “Toddler” AND “Diet” OR “Diet Therapy” OR “Nutrient” OR “Consumption” OR “Saturated Fat” OR “Trans Fat” OR “Sodium” OR “Salt” OR “Sugar” OR “Juice” OR “Sugar Sweetened Beverages” OR “Soft Drinks” OR “Obesity” OR “Overweight” AND “Marketing” OR “Promotion” OR “Advertisements” OR “Policy” OR “Reform” OR “Pledge.” The literature search was restricted to the Arabic, English and French languages and to publications between January 1, 2005, until November 7, 2021. Individual EMR countries included in the search were selected based on the WHO country categorization: Afghanistan, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of), Iraq, Jordan, KSA, Kuwait, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Occupied lands of Palestine, Pakistan, Qatar, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates (UAE), and Yemen . The questionnaire was shared by email via the WHO EMR office in December 2021 in Arabic and English languages (English version available in nd Yemen .In order to understand this situational analysis, we define in this section a few concepts relevant to the food marketing regulatory framework. The effectiveness of marketing is a function of two elements: the exposure of children to the marketing message and the power of the communication. The WHO defines power in marketing as the “content, design and creative strategies used to target and persuade” . MarketiThe industry and the government are the main regulatory actors that design and implement food marketing restrictions. Regulation can be done in a voluntary approach when the industry initiates and monitors the restrictions or in a mandatory manner when governmental entities design the policies and implement judiciary actions . ComprehNutrient profiling is the practice of classifying a product as “healthy” or “unhealthy” based on its salt, fat and sugar content . ProfiliWeak multisectoral collaboration is a challenge identified in the implementation of policies across the region. A recent scoping review revealed that regulation of marketing of food is weakly implemented in Iran due to weak scientific criteria in the legal reforms, lack of judiciary actions linked to violations, poor collaboration across sectors, and inadequate monitoring . QualitaGovernmental and academic bodies assessed the nature and quality of food marketing on media outlets in the EMR countries. A content analysis of the advertisements mostly viewed by a sample of 7–12-year-old children on local television channels in Egypt in 2015–2016 revealed that 74% of commercials were for unhealthy products such as sweets, chips and soft drinks . In OmanPrior to the governments’ policy changes, the food industry had responded to a call by the WHO in 2004 to regulate food marketing. Eight global food and beverage companies in countries of the Gulf Country Cooperation signed the Responsible Food and Beverage Marketing to Children Pledge in 2010 . ThroughThis review showed legislative action to regulate food marketing to children is very limited in the EMR. In the absence of comprehensive marketing legislation approaches, a few countries started implementing legislative actions through a stepwise approach and a few others have started planning for the change.This report highlighted how the few legal reforms implemented have been mainly limited to local television and radio outlets. This finding identifies several challenges. First, despite the rise in the adoption of digital media and the displacement of legacy media, mobile applications and online outlets and products’ packaging have been frequently omitted from legal reforms . Yet, onThe WHO EMR office assessed the adoption of nutrient profiling in years 2013, 2015, and 2017 . This stWe learn from other countries around the globe that reliance on the industry’s self-regulation has yielded limited success. Even though the food industry funded reports suggest an impressive level of compliance with voluntary pledges, there exists a great deal of discrepancy with the results of scholarly articles and evaluations . CompaniThe lack of overall progress to date, and the finding that no country in the EMR has implemented a comprehensive approach, suggest that the recommendations of the WHO 2018 report on implementation of marketing restrictions in the region remain largely relevant . EMR couThis study provides an overview from governmental and academic bodies on the status of EMR countries in reaching goals for marketing legal reforms. Its strength is in filling an important literature gap and in employing a solid methodology. A systematic search on major databases and governmental websites was applied to yield a comprehensive overview on the subject. For completeness and since such legal reforms may not be found in scientific databases, the search was coupled with a survey of country representatives. The study has several limitations as well. Even though we employed a systematic search strategy, articles were not screened in duplicates. Moreover, data was missing from some countries due to lack of policy digitization and the lack of monitoring studies in these nations. Lastly, many countries lacked data on the extent of implementation of the legal reforms.To our knowledge, this is the first scholarly article that analyzes the regulatory framework of food marketing restrictions toward children in the EMR. Reinforcing the results of the 2018 WHO report , this stAA-J and JJ: conceptualization, methodology, and writing—review and editing. JJ: investigation and writing—original draft preparation. Both authors have read and agreed to the published version of the manuscript.The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the World Health Organization or the other institutions with which the authors are affiliated.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Ana Antic notes in her Introduction that this edition addresses the public emergence of the harmed (‘traumatised’) or politically tainted child—shades of Kipling’s ‘half devil, half child’ or, here, Wagner’s ‘white child gone bankrupt’. Souls to be saved which would otherwise be ‘lost’. These essays seek to interrogate the subject across disciplines and domains: social history, social anthropology, psychology, humanitarian and human rights discourses. In part this is a critique of the conceptual assumptions and limitations of Western scholarship, particularly so in relation to psychology, whose universalist and biomedical underpinnings present a barrier to nuance and complexity.I would like to reflect on 3 key poles. Firstly, what is ‘psychology’? Is it only what the clinical psychology profession says it is? Is it a moral philosophy of the self? Is the business of other people’s minds more a matter of philosophy than of science, which cannot separate fact from value? Can ‘psychology’ be distinct from ‘culture’? From an anthropological point of view, what psychology invokes includes personal identity, selfhood, subjectivity, memory, consciousness, emotion, motivation, cognition, madness, and ‘mental health’. In modern Western society the backdrop is of the medicalisation of everyday life, the commodification of ‘mind’, neoliberal injunctions towards self-improvement, and the insertion into public consciousness of the language of psychological deficit.We’ve had a Hundred Years of Psychotherapy- and the World’s Getting Worse . Their mothers wailed and threw themselves on the floor of the ward, but as far as the political order was concerned they died so ‘quietly’. To put it another way, if children’s lives are precious, which children? Perhaps a fundamental verity applies, part of what might be called an anthropology of ‘distance’: we retain our full sensibilities only in the local, amongst family, tribe, amongst people we know. Beyond that we are only occasionally engaged, prompted by an unusual event that captures our imagination, but even then not for long. The suffering of a family pet may mean more than that of children we do not know in places we do not know. An estimated 5 million (5 million!) children under the age of 5 died as a result of armed conflict in Africa in 1995–2015. What place do they have in the public record, these teeming near-ghosts, what traces of their weightless passage through the world? Can the social historian capture this?Ana Antic asks whether humanities researchers can create accounts of the politicised child whose depth and fidelity serve not only the historical and anthropological record but also illuminate credible forms of assistance. The contributions in this edition show some of the ways ahead.