Chronic health conditions associated with long-term drug use may pose additional risks to people who use drugs (PWUD) when coupled with COVID-19 infection. Despite this, PWUD, especially those living in rural areas, may be less likely to seek out health services. Previous research has highlighted the increased disease burden of COVID-19 among PWUD. Our manuscript supplements this literature by exploring unique attitudes of PWUD living in rural areas toward the pandemic, COVID-19 vaccination, and the role of harm reduction (HR) organizations in raising health awareness among PWUD.Semi-structured interviews were conducted with 20 PWUD living in rural southern Illinois. Audio recordings were professionally transcribed. A preliminary codebook was created based on interview domains. Two trained coders conducted iterative coding of the transcripts, and new codes were added through line-by-line coding and thematic grouping.Twenty participants  completed interviews between June and November 2021. Participants reported negative impacts of the pandemic on mental health, financial wellbeing, and drug quality. However, the health impacts of COVID-19 were often described as less concerning than its impacts on these other aspects of life. Many expressed doubt in the severity of COVID-19 infection. Among the 16 unvaccinated participants who reported receiving most of their information from the internet or word of mouth, uncertainty about vaccine contents and distrust of healthcare and government institutions engendered wariness of the vaccination. Distrust of healthcare providers was related to past stigmatization and judgement, but did not extend to the local HR organization, which was unanimously endorsed as a positive institution. Among participants who did not access services directly from the HR organization, secondary distribution of HR supplies by other PWUD was a universally cited form of health maintenance. Participants expressed interest in low-threshold healthcare, including COVID-19 vaccination, should it be offered in the local HR organization’s office and mobile units.COVID-19 and related public health measures have affected this community in numerous ways. Integrating healthcare services into harm reduction infrastructures and mobilizing secondary distributors of supplies may promote greater engagement with vaccination programs and other healthcare services.NCT04427202. Since 1999, nearly 1 million people have died from a drug overdose –4. The CPublic distribution of COVID-19 vaccines began in early 2021, presenting new opportunities for—and challenges to—addressing the pandemic. Despite widespread availability, vaccine hesitancy poses a major barrier to broad uptake of the intervention . ConcernGiven that PWUD often avoid traditional healthcare settings due to combinations of mistrust, stigmatization and fear of being reported to authorities including law enforcement and child protective services, there is a need for alternative approaches. These approaches include integration of clinical services through peer-oriented harm reduction services and the concentrated expansion of those services through secondary distribution by PWUD of harm reduction supplies  and health-related information to those who do not formally participate in these services . These sThis study was designed to explore the impact of the COVID-19 pandemic on the overall wellbeing and drug use patterns of PWUD in the 16 southernmost counties in Illinois. These counties comprise part of the Delta Regional Authority, a federally designated area with high rates of unemployment and lower per capita income compared to other US counties , though Given these regional characteristics, we aimed to explore attitudes of PWUD living in these counties toward the pandemic and COVID-19 vaccination efforts. Given the strain on PWUD-related service delivery presented by COVID-19, we explored community strategies for maintaining health and safety, such as secondary distribution of harm reduction supplies, especially given the strain on infrastructure that the COVID-19 pandemic presented. We also investigated responses to healthcare and vaccination efforts. Finally, we explored participants’ perceptions of harm reduction organization-based medical care, whereby PWUD can obtain traditional health services in a trusted environment.Outer Setting to evaluate external influences on harm reduction service delivery and patient needs. Questions around the impact of COVID-19, beliefs about healthcare and harm reduction services, and community-level characteristics were incorporated in this domain.This analysis was a part of the Ending Transmission of HIV, Hepatitis C, Sexually Transmitted Infectious and Overdose in rural communities of people who inject drugs (ETHIC) study, the Illinois site of the federally funded Rural Opioid Initiative . Intervi“How, if at all, has your drug use been impacted by COVID-19?” and a probe of this question asked, “Have you noticed any changes to the quality or properties of the drugs? [If yes] what were these changes?” Interviewers reviewed the interview guide together prior to the start of the interview process and piloted the interviews with two PWUD in order to standardize the approach.Participants’ experiences with and perspectives on drug use, harm reduction, healthcare and social service utilization, and the impact of COVID-19 on these factors, were examined using open-ended interview questions with optional probes that explored specific aspects of a question. For example, one interview question asked, Interviews took place between June and November of 2021 in the following Illinois counties: Alexander, Franklin, Gallatin, Hamilton, Hardin, Jackson, Johnson, Massac, Perry, Pope, Pulaski, Randolph, Saline, Union, White, and Williamson. Interview participants were recruited face-to-face and over the phone by a local harm reduction agency using purposive and respondent-driven sampling . ClientsData were collected through semi-structured, audio-recorded narrative interviews conducted by ETHIC team members from the University of Chicago and Southern Illinois University trained in qualitative methods. Some interviews took place in person at a local harm reduction organization, including in its mobile delivery unit, and some over the phone or video call, depending on COVID-19-related risks. Interviews were conducted privately. Once the interview concluded, participants were able to obtain supplies and services from staff at the harm reduction organization.Interviews averaged roughly 45 min per participant. A numeric ID was generated for each participant to de-identify data. Following the interviews, interviewers wrote observational memos to capture immediate thoughts and perceptions of the interview  and updaTwenty individuals participated in qualitative interviews, of whom 13 utilized formal harm reduction services through a local harm reduction organization. The remaining 7 interviewees were PWUD who did not utilize formal harm reduction services and who were referred to interview by their peers. The mean age of interviewees was 38 years. Overall, nine were female, and 19 identified as White and one as Black. All interviewees reported completing high school and two of them completed an associate degree or trade school program. Polydrug use—the concurrent use of multiple drugs—was common among interviewees. Eleven reported that their preferred drug was methamphetamine, while five preferred heroin, and seven preferred fentanyl. Among those who reported preferences for both methamphetamine and opioids, the drugs were reported as being used separately rather than combined.We divided participant insights into the following four themes: (1) the impact of COVID-19 on participants’ quality of life and drug use, (2) attitudes around COVID-19 and vaccination efforts, (3) attitudes toward harm reduction-based healthcare, and (4) secondary distribution of harm reduction services and supplies. Pseudonyms are used throughout.Coupled with a rural backdrop characterized by unique socioeconomic challenges , the panI had a job before COVID hit and then, of course I lost my job because everybody lost – it’s not everybody -- lost their job. And now it’s just harder to even, yeah there's jobs out there, but I don't have a car now, so it's a lot harder to get out there and get a job and stuff like that, because of the whole car situation.Two other interviewees, Rachel (a 38-year-old woman) and Rick (a 35-year-old man) discussed the impact of the pandemic on their ability to perform their job duties, as both worked with older adults who were not comfortable receiving in-person services during the pandemic. Since both were self-employed, there were no accessible supports in place to mitigate this loss of income. Rachel emphasizes that,It sucks. I clean houses to make money. I lost all of them because they’re elderly people I clean for. They’re afraid of catching it, especially with me having all these kids.A mother of six, she discussed the multiplying effects of this income loss. Without her income, Rachel was unable to pay for gas and internet services—barriers which led to no heated water in her home and her 14-year-old daughter being unable to complete her schoolwork virtually. Rachel further said, “It's been a mess. Oh, it's been a mess, but I can't access and I have no internet and I can't go anywhere. It's been a mess because I don't know who can help me, who can't help me.”Despite most interviewees receiving some financial support throughout the pandemic including government-issued stimulus checks, several expressed that these were insufficient. One example was Karen, a 40-year-old woman who lost her job, then lost access to reliable transportation—a particularly acute need in rural areas—because of the pandemic. Of the overlapping barriers to financial stability, she said,an emotional roller coaster,” “miserable,” and “broken,” respectively. Mindy, a 45-year-old woman, dealt with the stress of a volatile break-up during the pandemic and subsequent mental health challenges. She said,And then with COVID, when [my ex] couldn’t work, that really put a financial strain on a lot of things. And like we were having problems in our relationship and -- well, needless to say it didn’t work out and we just ended up splitting up. Now I'm just, basically to be honest with you, homeless and I’ve been staying with a friend. He just told me today that I had to get out. I really don't have nowhere to go… it’s definitely not easy. I’m depressed real bad.For some participants, the pandemic caused substantial trauma and exacerbated other preexisting mental health stressors. Others were less psychologically impacted. Among those who did not feel that the pandemic notably impacted their daily life was Tom, a 41-year-old man. Tom described his resilience in the face of isolation due to experiences with incarceration, saying,No, like isolation doesn't bother me a whole lot because I've been incarcerated, all together it's been about nine years total…so isolation is not a problem to me. I can keep myself occupied.The responses to interview questions around wellbeing during COVID-19 were quite heterogeneous, reflecting the diversity of experiences and effects of the pandemic among this community. However, issues of housing stability and homelessness, coupled with domestic disputes, were major mental health stressors for most interviewees.However, for many interviewees, the impacts of the pandemic on quality of life were significant. Sarah, Rachel, and Josh, a 29-year-old man, described their mental health experiences over the last year as “Prices of drugs been just straight-up bonk[ers]. When you're told a price and you're told what you're going to get and then they show up and then they hand you something and its different…Quality and shit, quality’s went down.Gary, a 30-year-old white man, similarly felt that there were reliability issues with the drug supply. He notes: “Yeah. They’re not the greatest. You never know if there's actually going to be what it's supposed to be or anything.”Several interviewees commented on changes in the drug market during the COVID-19 pandemic. Many remarked that drug prices increased, while quality decreased. Josh explains:We had a very high shortage on it [methamphetamine during the pandemic], and it was in very high demand. And then people started cutting it… It started coming back around, but then it started coming back around with traces of fentanyl.Emily, a 30-year-old white woman whose drug of choice was methamphetamine, discussed the challenges of avoiding inadvertent opioid use in the context of a contaminated drug supply. She reported that she used fentanyl test strips each time she injected drugs, adding,I used to be a heroin addict and that was like five years ago, and I still don't do that and I just do speed but… Some of it, you know, was positive for fentanyl and I don't want to do any type of opiate, no matter how small the amount.Samantha, a 54-year-old white woman, remarked that the increased prevalence of fentanyl in her community was leading to increased overdose rates. She said,I think what came out the most was the fentanyl, is it used to be actual heroin and now it's just fentanyl, these little beans. I didn't even know what a bean was until about a year ago, you know, it’s like a little capsule and it's got fentanyl in it and a lot of people ODed on that stuff because they thought it was heroin. They didn't know it was still an opioid. They didn't know. But a lot of people -- I lost a lot of people period.Many remarked on the increased presence of fentanyl in their drug supply. Sarah remarked on the quality of methamphetamine,Stigmatizing or otherwise uncomfortable experiences with healthcare professionals were cited by many interviewees as reasons to avoid interaction with the healthcare system. Since these experiences typically predated the pandemic, they informed interviewees’ attitudes toward COVID-19, especially with respect to vaccination efforts and mistrust of healthcare providers.“People kind of think that they're going to get in trouble [with law enforcement] if they go to the hospital.”Many participants described situations that drove them away from accessing healthcare, whether as a result of judgement, fear of criminal-legal repercussions, or a sense that their concerns were invalidated by providers. Sam, a 36-year-old white man, described concerns that the hospital was involved with the criminal-legal system. He said, “The nurses made me feel very uncomfortable. Like, they were judging.”Experiences with both enacted and anticipated stigma in healthcare settings presented significant barriers to accessing healthcare among this population. When asked about the healthcare she received, Marissa, a 29-year-old white woman, said, So I went to my doctor. And then when I went to the lab to get my work in, they looked at my arm. I mean, she just, the lab lady just judged me. So, I didn't go back for help… whenever she says, “Oh, well, I'm sure you're not used to a needle this small” …you know, stupid, stupid stuff like that, how are you supposed to feel about that?Karen  also described a particularly salient experience with a lab technician that kept her from returning to see her provider, with whom she had planned to work on reducing her drug use. She said,Well, it’s just another flu virus…They haven’t cured the flu in how many years and they’re gonna cure this overnight? No. That’s all. I think it’s all government. See how far they can push us.Rick  expressed a lack of concern over the severity of the pandemic and indifference towards public health measures such as mask-wearing. He said,I really don't consider it or think about it because if it is supposed to kill me, it’s going to get me. If it was meant to kill me, it's going to get me regardless.Josh, one of the few interviewees who expressed concern over the spread of COVID-19, stated that he did not feel comfortable around many of his friends as they did not uphold public health strategies for preventing infection. He said,I was notified earlier today that I should be, she mentioned something about should be quarantining. And this was literally -- this was before we got vaxxed…She's in the house nonchalantly.It's made pretty hard to even trust…last year or so I started becoming a recluse. I started making it a point to not even let my friends into the house because…it was unknown whether or not they were vaccinated. One of which I guess I had pretty good reason to because I had slipped up one time and a girl was inside the house and was like, When asked about their primary source of information about COVID-19, most individuals replied that they found information on the internet or learned about the virus and vaccine efforts through word-of-mouth. Rob  said: “I live on Google, studying up on all this.” The information they gathered through these searches informed their perception of COVID-19 and vaccination efforts, discussed below.Among interviewees, the health impacts of COVID-19 were often described as less significant than the impacts on other aspects of life, such as financial stability and drug quality. Rob, a 55-year-old white man reflected on his doubts around the severity of COVID-19. He said,Despite public vaccine rollout beginning in early 2021, only 4 out of 20 interviewees (20%) had received a vaccination against COVID-19 at the time of their interviews. Among several interviewees, a distrust of the healthcare system and government were predominant reasons for declining vaccination.“Nope. We've had AIDS for how many years and don't have a cure. COVID just came out and they automatically have a cure for that, a vaccination.”Several interviewees did not believe that the evidence for vaccines was strong enough to warrant vaccination. Rachel compared the pace of vaccine production for COVID-19 with other public health crises, saying, “Give it 10 years and we'll see people growing extra limbs or whatever from it, or they're having deformed babies or babies with disabilities and stuff like that, then we’ll see.”Rick also endorsed uncertainty over the long-term effects of the vaccine, adding, So, the COVID vaccine, I figure I should probably do research on the new vaccines…they had Caucasian male fetus lung tissue in it in the first original vaccine and I didn't see a purpose in that. The 12-week-old fetus lung tissue. Why is that in there?Sarah echoed some of these concerns, and added that she worried about potential adverse effects of the vaccine. She said,I'm not putting baby organs inside me, I'm sorry. They grow inside me…plus, a nurse was the very first person to get a COVID vaccination, 20 minutes after taking her first shot, she died. Hell, no. And there's still people dying from it. And you got to take more than one, sorry. If anybody's going to poke me, it's going to be my damn self. Sorry.Among those who were vaccinated, information from trusted sources and motivation to protect others provided much of the impetus for vaccination and helped to reduce distrust. Emily, a 30-year-old white woman, said,First I was really sketched out…I’m one of those paranoid people. But one of my good friend's husband works for the NSA or has like contracts with NSA, like super smart, and then he said it was like he got it and he just kind of talked me into it…I think it's a very small thing for people to do to in a big scheme of things, possibly saves other people's lives.Greg, a 30-year-old white man whose father was immunosuppressed after a liver transplant, said,I was in a halfway house, and I had to get the vaccine to be able to have any movement whatsoever. But I'm glad I got it. I would have gotten it because of my dad anyway so. I can't really make such a big deal about, you know, being super concerned about what's in it and all that. I mean, I shoot dope, you know what I mean.When asked about his rationale for being vaccinated, Jim, a 51-year-old white man, said, “So, I can have an in-person visit with my friend…in prison. So, there’ll be no screen in front of us.”Several interviewees also cited concerns around the contents of the vaccine, largely in the context of information they had garnered via word-of-mouth or posts on social media. Alice said,Given the appearance of new COVID-19 variants and particular susceptibility of this population to adverse effects of COVID-19, these attitudes toward vaccination efforts were particularly salient. Participants often expressed distrust of healthcare providers, vaccine manufacturers, and government officials. In contrast, many interviewees expressed greater trust in and comfort around harm reduction providers, as well as receptivity to healthcare services offered in a harm reduction context. These findings are discussed below.Participants responded to interview items regarding barriers and facilitators to accessing harm reduction services that they experienced during the COVID-19 pandemic. Interviewees also discussed their openness to potential healthcare services that could be offered through or in collaboration with the local peer-operated harm reduction organization in the future.Not at all because [the harm reduction provider] always comes and gets me and he's really good about doing that. He puts himself out there, so he really does. I enjoy it, like today he came and got me and did all this.Rachel, who was also unable to access transportation during the pandemic, added that she would not have been able to obtain supplies like sterile syringes and naloxone without the harm reduction organization’s home visits. She said,If [the harm reduction organization] wouldn't come here then I wouldn't be able to [access services]. I like it that they deliver... Or you guys come in here and you can pick us up and take us to wherever you're at.Furthermore, the harm reduction organization provided supplies discreetly to PWUD who may not want attention drawn to themselves. According to Wayne, a 47-year-old Black man, supply delivery was “sweet and discreet.” Emily discussed the benefit of having a harm reduction organization to provide supplies for safer drug use among those who may feel stigmatized in other settings, saying,Some people are too embarrassed to go buy new needles and they’ll just use the same packs that they've got for months or end up sharing. And there's a lot of diseases and stuff like that, and people don't really care when they're in it bad. We don't think of it. And it just really does make it easier for us… they're bringing us supplies.Interviewees also noted that their harm reduction provider placed an emphasis on knowing PWUD as people first, rather than immediately attaching a label or stigma to them. Greg summarized this impression, saying,I'm 100% comfortable with [the harm reduction provider]. He's been nothing but a saint to me and [interviewee’s partner]. And I just think like, I have so much respect for him for bringing a harm reduction service to our area, which we had absolutely nothing to speak of. And like the way he went about it, and just doing it himself, like, I can't say enough about how much I respect that.Alice expressed feelings of comfort with members of the harm reduction organization. She said,All the staff, everybody that I've ever been interviewed by, or talked to on the phone has always been very comfortable, very welcoming. No one's ever made me feel unwelcome.Spencer, a 39-year-old white man, added that the humanistic element of the care provided by the harm reduction organization was particularly meaningful to him. He said,I mean, besides all the help [the harm reduction provider] gives…just in general, talking to him as a human being and a friend, I mean, he's a really good guy. So, I mean, it's not all just based on the services he provides, it's, you know, we're -- there's more to it than just that, I guess, so it's kind of nice.While interviewees often associated healthcare experiences with stigma and discrimination, many saw their local harm reduction organization as a trusted source of care and support. One feature of the local harm reduction organization that resonated with interviewees was the focus placed on convenience and accessibility. By delivering supplies in addition to operating at fixed sites and driving participants to service providers when possible, the organization addressed transportation concerns common among rural PWUD. Samantha, who did not have access to independent means of transportation, expressed gratitude for these efforts. When asked if there were any barriers to her accessing services, she said,I know so many people that need a dentist, or just you know, help getting services or something…[Medicaid] is not for teeth. So, a lot of people have a lot of teeth problems and that's painful.Sam  and Rachel  also expressed interest in wound care being offered through the harm reduction organization, largely because of the stigma associated with drug use in wound care settings. In Sam’s words,The wound care…Because that would be one of the main things that people get- abscesses and stuff like that.Rachel agreed, and discussed a friend of hers who could benefit from such offerings. She said,The wound care would be good. An acquaintance, he goes to wound care because from his knees down he shoots up in his legs and he got ahold of that Krokodil shit…He's embarrassed to go to wound care because they're judgmental knowing he shoots up.Josh, one of the four interviewees who had received a COVID-19 vaccination at the time of interviewing, was in support of the local harm reduction agency offering COVID-19 vaccinations to PWUD in a trusted environment. He said, “That would kind of be neat to see…that would be cool.”In addition to expressing support for their local harm reduction organization, many interviewees were enthusiastic about the prospect of accessing healthcare services through the organization . Intervi“[With] this guy. I like [the harm reduction provider]. He’s cool, he’s awesome.” Rick expressed a similar sentiment when asked the same question. He said, “Probably in a place like [the harm reduction organization’s mobile van unit] or at home.”Several interviewees who had not yet been vaccinated stated that, if they were required to receive the COVID vaccine, they would be comfortable receiving it in the welcoming space of the harm reduction organization with trusted professionals nearby. When Samantha was asked where she would be most comfortable receiving the vaccine, she replied, They need all that stuff. I can’t say that personally somebody that I know that has HIV or AIDS, but I know several people that have Hep A, Hep B, Hep C, Hep-15, whatever.Josh agreed and elaborated on the difficulties of obtaining HCV treatment as the system stands. He said,Treatment for Hepatitis C sounds cool. You have to literally like go to the specialist, you have to get referred to them…and you have to have your doctor refer you to them, which is ridiculous.Alice added that she would be more likely to utilize healthcare services including treatment for hepatitis if they were offered in this setting. She said,I would definitely utilize, I would get more medical help myself, which is hard for me to even do, but I would probably actually might even consider doing hepatitis treatment again, consider it maybe but I might consider doing it. I went through interferon, it was horrible.Beyond access to healthcare services via the harm reduction organization, 19 of the 20 interviewees agreed that offering a computer or tablet in the harm reduction organization’s mobile unit for people to engage in telehealth appointments would be valuable. Samantha summarized many interviewees’ sentiments, discussing the lack of access currently facing many PWUD with respect to telehealth. She said,Well, yes because some of us don't have computers at home. I don't have a computer…I mean, you can put it in a little TV monitor in there and get wi-fi hotspot. Yeah. That makes absolute sense to use it for the whole program really, because, really, it's overall health, so makes sense.In discussing the possibility of harm reduction-based healthcare services, many interviewees expressed excitement at the prospect of increased accessibility. Wayne summarized the widespread need for interventions such as these in promoting community health. In his words,I guess one person's needs is someone else's need too. So eventually, you're going to have to see that like, well, maybe they need that.Despite the widespread enthusiasm for the local harm reduction provider and possibilities for accessible healthcare, many interviewees expressed wishes that a greater number of community members would utilize harm reduction services. Various reasons for the reluctance to do so included stigmatization of drug use, fear that there might be criminal-legal repercussions, and unawareness of the presence of the harm reduction organization. One means for addressing this gap in service delivery is through peer networks of PWUD. Among interviewees who did access harm reduction services and supplies from the local harm reduction organization, 12 out of 13 indicated that they engaged in secondary distribution, the process by which one PWUD obtains harm reduction supplies to distribute to other PWUD  if [they] will do it for me, because I supply others…. Every time [the harm reduction provider] would come see me, [they] would bring me double what [they were] supposed to, just because [they] found out that I was just giving.”—Sarah.Without [harm reduction] services, I'm sure more than just he would probably be gone because that was a preventable death. And so, yeah, and I do give out Narcan. And I teach them how to administer it… So, yes, I do provide the services that are provided for me. I readily keep them available for others.Josh, a member of the community advisory board of the harm reduction organization, added that he provides sterile syringes to peers. He said,I always come up to them with the unopened package of syringes, if I am going to give them an entire package. If I feel like I'm low (on syringes) or whatever…I will open it up in front of them and give some out of it, but I'll show them that it’s fresh, new, out of the package… I’m there for anyone.When asked if she provided harm reduction supplies, Rachel said,Narcan and clean needle kits…People come here daily wanting needles…They just pop in or call. “Do you have any clean needles we can get?” “Yeah come and get some.” And I gave them a bag or two depending.When asked about her rationale for distributing supplies, she added,I caught Hep C from using a dirty needle and the lady knew she had Hep C and didn’t even say anything to us. That's how me and [interviewee’s partner] caught it. If I can give somebody clean needles so they do not catch it like I did, I will give them clean needles.Wayne, one of the interviewees who did not report participating in secondary distribution in the past, made a commitment to do so in the future. When asked if he had ever provided sterile supplies to his peers, he said: “No, I haven't but I will. I have a couple friends who come over to do heroin.”Many interviewees engaged in formal harm reduction services expressed a commitment to making sure that other community members were able to access services, even if they did not directly engage with a harm reduction provider. Alice, who had recently witnessed the overdose of a close friend, discussed her decision to become a secondary distributor of Narcan. She said,I mean, for two-and-a-half years I've always made sure I've had or I've gotten naloxone from somebody in general that’s got it from the clean needle exchange I would say… Word of mouth [about formal services] finally spread to us I guess.Cathy, a 33-year-old white woman, reported receipt of sterile syringes via secondary distribution. She said,My friend… never used the needles or anything like that. So, all the ones extra that he had, he ended up giving to us.Mindy also accessed sterile syringes from peers, citing the prohibitive cost of accessing syringes through the local pharmacy. She said,Yes, you can also go to like pharmacies to get them. Sometimes if you don't have the money to do that effectively…[secondary distribution] could be very helpful. Because yeah, everything has got to be sterile for sure.When asked about having supplies delivered from the local harm reduction organization in the future, Mindy added,Yeah, I’d be good with that because they brought it right to [Karen’s] house… you've opened my eyes to a lot of stuff, because I didn't know about that. And I'm definitely going to use that other thing - the mobile [van unit].Cathy summarized the attitude of several interviewees who wished that the local harm reduction organization had more funding and ability to conduct outreach so that services were available to more community members. She said,I just think to be able to branch out more to be able to get more employees or more volunteers that were able to hit more area and to be able to contact more people and get more information across, I guess… Yeah, there really isn't anything like him here. I've heard of it, different places, Canada or different hotspots, cities, I guess, in the United States that offer even places to, I guess, go use drugs in a safe environment…but there's just not things around here, I guess more because it's a rural area. It's just not offered to us down here.Whatever an individual’s reasons for not engaging in formal local harm reduction services, secondary distributors make safe, sterile supplies and community support much more accessible to their peers. In Alice’s words,New cases of STDs and HIV and all that stuff, they got to be going down by even a little- even one number is a big deal. And I know that just for me alone, I feel like I've gotten to touch that number somehow and just by my house, even just the one person, me alone, just giving them new [syringes], encourage them not [use old syringes]. Don't do that. Don't do that- here, take what you need.Among those who did not access formal harm reduction services through the local provider, all reported previous receipt of supplies via secondary distribution. Gary, who was connected with the local harm reduction provider for future services at the time of his interview, said of his previous receipt of harm reduction supplies,Findings from this qualitative investigation of PWUD in rural southern Illinois indicate that the impacts of the COVID-19 pandemic on daily life and drug-related risk factors intersect with stigmatization and negative medical experiences to create a number of overlapping barriers to service access and vaccine uptake. Though participants cited a variety of obstacles to achieving quality healthcare, several also shared their ideas for surmounting these challenges. Ideas for future services supported by interviewees included offering healthcare services  in concert with harm reduction services, facilitating telehealth in the harm reduction organization’s mobile unit for remote doctors’ visits, and increasing the involvement of community members and peers in service delivery to PWUD as well as in advisory bodies for harm reduction organizations.Our study adds to the limited body of research that qualitatively explores the experiences of PWUD with healthcare and harm reduction services during the COVID-19 pandemic. Previous works have explored the impact of the pandemic on mental health and overdose risk , adaptatOur study supports previous work around the disproportionate impact of the COVID-19 pandemic on PWUD. Results support large-scale studies of PWUD indicating that access to financial resources and downstream effects such as housing insecurity have been a significant detriment to the lives of many PWUD. Results also support studies showing that the pandemic has negatively impacted mental wellbeing . ParticiOur findings also reinforce current literature on the relationship between PWUD and the healthcare system as it stands. Our work supports past studies of PWUD in rural settings that found stigma and inappropriate treatment of medical problems significant barriers to accessing healthcare services . This reWe explored the ways in which PWUD collectively promote the health of their community through engagement with harm reduction services, secondary distribution, peer support, and enthusiasm for instituting community organization-based healthcare services. We also explored the ways in which PWUD continue to be marginalized and rejected from societal structures, such as through stigmatization by healthcare professionals, that may lead to hesitancy to access healthcare or receive COVID-19 vaccinations in the future. Utilizing suggestions from interviewees, we suggest several possible interventions for addressing the issues discussed above.First, integrating a wider range of healthcare services into the existing local harm reduction infrastructure would enable PWUD to access important services in an atmosphere viewed as less judgmental and more accessible than typical healthcare settings. Consistent evidence pointing to the efficacy of harm reduction as well as the breadth of health disparities among PWUD supports calls for such integration –36. If iAlong with general expansion of accessible healthcare, harm reduction providers have the potential to become stewards of up-to-date information about COVID-19 and likely future infectious diseases or other emerging health risks for PWUD who may not have access to or trust in healthcare institutions’ recommendations around pandemic response and vaccination. Historic disenfranchisement of PWUD and institutional untrustworthiness warrants their skepticism of institutions such as healthcare, but leaves them with fewer credible sources of information about the pandemic. Many interviewees’ concerns regarding vaccination revolved around fears that vaccine development was rushed and that side effects may occur. Harm reduction providers and allied health professionals are well-positioned to engage PWUD in conversation around these concerns and provide accurate information in a non-judgmental space where PWUD are encouraged to ask questions and learn more about vaccines.Second, for those health concerns that cannot be addressed in the harm reduction organization’s space, PWUD living in rural areas may benefit from telemedicine visits conducted with computer stations available in the organization’s mobile units. Even as in-person visits become the norm once more, technology’s involvement in delivering patient care will likely persist , althougFinally, the importance of secondary distribution of harm reduction services and supplies among this study’s participants highlights the need for continued engagement of PWUD in the development and implementation of future harm reduction interventions. This involvement may help to maximize the network of individuals reached and number of services and supplies delivered. The barriers cited by PWUD to accessing care and the response of community members in promoting access highlight the mobilization of resources among peer networks in response to inadequate institutional support for PWUD health. This response is crucial as secondary distribution recipients may be younger, less experienced, and at higher risk of negative health consequences related to drug use . ResearcOur study has several limitations. These include the lack of racial diversity among our participants, though this reflects the area’s population, and the limited geographic distribution of the study sample, and the small sample size. Results may not be generalizable to all PWUD in the study region or beyond. Furthermore, our study sought to assess the attitudes and experiences of PWUD during the pandemic, and thus we did not interview any other stakeholders. Finally, interviews were conducted in the summer and fall of 2021, a full year after the COVID-19 pandemic reached the United States and prior to the Omicron variant becoming the dominant strain of COVID-19. It is difficult, therefore, to judge whether participants’ experiences have varied over the course of the pandemic and whether responses would have been different a year ago.Distrust of healthcare institutions and lack of credible information about COVID-19 impact the ways in which PWUD perceive the severity of COVID-19 and the potential harms of vaccination. By incorporating community-delivered healthcare services and credible COVID-19 information within an existing local harm reduction framework, as well as integrating peer support and community advising, healthcare and harm reduction providers may have a greater ability to repair trust and address unique health disparities facing PWUD.


Metaphors We Live By in 1980. The present study comprises a pioneering review of publications on Conceptual Metaphor Theory (CMT). It aimed to use the CiteSpace software to provide a clear overview of international research in relation to CMT. In total, 4,458 bibliometric recordings ranging from 1980 to 2022 were collected from the Web of Science (WOS) Core Collection. The descriptive analysis presents the trend of annual publications, the top 10 most prolific journals and the top 10 most productive authors. A document co-citation analysis was conducted via CiteSpace to navigate the key documents in this field. A visualization of keywords and its cluster analysis were conducted to show the research fields and dominant topics. The top 5 keywords with high frequency were language, comprehension, conceptual metaphor, discourse, and figurative language. The most prominent 5 clusters are labeled as right hemisphere, self, time, teacher education, and corpus linguistics. The present review through CiteSpace flags the need for more investigations of CMT from more aspects or interdisciplinary studies, such as metaphor translation, metaphor in literature, metaphor and corpus linguistics, etc.Research on metaphor has gained increasing attention of world’s scholars since the publication of Lakoff and Johnson’s collaborated book  Metaphors We Live By, arguing that metaphor is ubiquitous in everyday life, not just in language, but also in thought and action, that is to say, our conceptual system is fundamentally metaphorical  Core Collection of Thomson Reuters, SSCI, and A&HCI sections for the bibliometric analysis. All collected articles/reviews were written in English, and we retrieved the data using the following fields:1.Title = (“metaphor*”), which means that only articles with “metaphor” in the title will be retrieved.2.Time span = 1980–20223.Document type = article OR review4..7,708 papers in total were obtained from the database distributed in various WoS categories such as “linguistics,” “psychology,” “neurosciences,” “philosophy,” “communication”and “education.” The present study attempted to focus on CMT, but not on traditional view of metaphor. Therefore, the category of “literature (643)” is excluded since its studies are not from the perspective of CMT, but are considered as a traditional literal device. Finally, only 4,458 documents were obtained, which were collected from WoS categories of “linguistics,” “psychology experimental,” “education research,” “communication,””philosophy,” “religion,” “humanities multidisciplinary,” “psychology multidisciplinary,” “social sciences interdisciplinary,” “neurosciences,” “psychology,” “anthropology,” “sociology,” “art,” “history,” “cultural studies” and “political studies.”CiteSpace 6.1 R2, a bibliometric analysis program created by A collection of bibliographic data files in the field-tagged Institute for Scientific Information Export Format constitute the software’s input. The files used in this investigation are taken from the WoS core collection. We select “full record and cited references” as the record content, and CiteSpace tool can directly identify the files. The following procedural processes will be carried out on the files once they are loaded into the software: time slicing, thresholding, modeling, pruning, merging, and mapping  and Cognitive Linguistics (41) ranked the fifth and sixth in the rankings. They did not rank the top three because they only publish about 20 papers each year. Metaphor researchers can refer to The citation frequency of literature is a basic index for academic circles to evaluate the influence of literature. The higher the citation frequency is, the higher the application value and reference value of a literature are, and its research methods or conclusions have exerted an important influence in this field. Document co-citation analysis via CiteSpace can help us find out the key documents in a knowledge domain. We conducted a document co-citation analysis of the 4,458 documents collected from the WoS. The 4,458 bibliographic recordings from 1980 to 2022 were visualized. We chose a three-year time slice and selected the top 50 most cited articles in every 3 years. The results are illustrated in From 1980 to 2022, a total of 27 documents were cited for more than 20 times. The most cited document is a book written by The second most cited document is a monograph by The fourth most cited publication was written by Gibbs’ (2006) monograph ranked the fifth most cited publication on metaphor. This book examines how some of the fundamental underpinnings of human cognition and language are derived from people’s subjective, felt perceptions of their bodies in motion. It is important to study cognition in terms of the dynamic interactions between people and their environment because cognition is what happens when the body interacts with the physical and cultural world. Human mind and language develop from recurrent embodied activity patterns that limit on-going intelligent conduct. We must look for the broad and specific ways that language and mind are intimately impacted by embodied action rather than assuming that cognition is entirely internal, symbolic, algorithmic, and disembodied. The wealth of empirical evidence that supports the notion that the mind is embodied is described by Embodiment and Cognitive Science. This evidence comes from numerous disciplines and includes work on perception, concepts, imagery and reasoning, language and communication, cognitive development, emotions and consciousness.Kovecses’ (2015) monograph is also the fifth most cited one with 31 citations. This book makes the case that “Conceptual Metaphor Theory” has proven to be effective throughout time. At the same time, it also implies that the idea of conceptual metaphor, according to which conceptual metaphors are based on our bodily experience, is enhanced and refined by the notion of metaphorical grounding put forth in the book. The body can thus be seen as just one of the many contexts from which metaphors can emerge , even though it may be the dominant or crucial one. This is true in many instances of metaphor, but the role of the body in metaphor creation can and should be reinterpreted. Such a proposal appears to be more in accord with what has recently been learned about the nature of human cognition, namely that human cognition is anchored in experience in many different ways, with embodiment, strictly speaking, being just one of them. According to the research presented here, this is due to the fact that cognition, including metaphorical cognition, is rooted in a variety of contexts, including the situations in which people act and live, the discourses in which they are constantly interacting and communicating with one another, and the conceptual knowledge they have gained about the world through their experiences there.In a sense, keywords express an article’s main idea and subject matter and act as its central summary. When two keywords appear together in a piece of writing, it shows how closely related they are and how strong their association is. The general consensus is that the more closely connected two or more terms are, the more frequently they will appear together. To define the strength, CiteSpace offers a function called Betweenness Centrality. In other words, it is likely that we will see a keyword even if we discuss other related topics if it frequently appears alongside other different phrases. Therefore, the higher the Betweenness Centrality value this keyword exhibits, the status of the keyword can be more important. The research fields and dominant topics were identified in this study using a keyword co-occurrence analysis.In order to pinpoint the terms or phrases that appeared in at least two different publications, a term analysis of words derived from keywords was carried out. High frequency terms may be used to identify hotspots in a particular research area . LanguagA cluster analysis was conducted based on the keyword co-occurrence analysis. The 4,458 bibliometric recordings generated 27 clusters in total. Cluster #0 is labeled as right hemisphere. Processing of metaphoric language is a very important research topic in neurolinguistics. Hemispheric processing of metaphors has been extensively explored by scholars in neurolinguistics and psycholinguistics during the past two decades. It is suggested by many researchers that the right hemisphere (RH) may contribute uniquely to the processing of metaphoric language.According to behavioral studies using the divided visual field (DVF) paradigm  and neurRecently, scholars begin to explore the differences between hemispheric processing of metaphoric expressions in a native language versus a second language. An experiment study conducted by Cluster #1 is labeled as self. Metaphors “can cast light on why we understand ourselves as we do”  is imprecise and largely belongs to the domain of literature, such as poets and novelists. To be simple, in traditional view, metaphor, whether in linguistics or philosophy, is only a kind of rhetorical flourish which deserves the attention of literature researchers. However, at the onset of CMT, the traditional view is challenged and changed. Cognitive linguist Raymond Metaphor and corpus linguistics. Like CMT, corpus linguistics started to grow quickly at the beginning of 1980s and it is widely used in applied linguistics and related fields (d fields . CMT andd fields  utilizedd fields . How to d fields , or seard fields . The thid fields .CiteSpace is a technique used to identify trends in international scientific research. The global CMT research included in this study covers publication outputs, productive authors, popular articles, popular keywords and research gaps. To the best of our knowledge, our study was the first to use CiteSpace to examine a significant amount of data from CMT publications published during the previous 40 years. Instead than just reviewing articles and studies about metaphor , CiteSpaAlthough within its delineated scope, the present study aspired to be as comprehensive as possible, some limitations were unavoidable. One limitation of this study is that it only searched documents in the Web of Science. Other data sources such as Scopus, Google Scholar, Index Medicus, or Microsoft Academic Search were neglected. The document type labeled by publishers is not always accurate. Some publications that WoS described as reviews, for instance, weren’t reviews at all . AnotherMetaphors We Live By, which proposed the Conceptual Metaphor Theory, that the cognitive function of metaphor has gained much scholarly attention. In contrast to the traditional view, Metaphor and Symbol ranked the top in the number of published articles, with 304 publications related to metaphor. Gibbs is the top author in the number of papers published on metaphor, followed by Faust and Steen. Then CiteSpace software was adopted to visually analyze those bibliometric recordings. The document co-citation analysis showed that a total of 27 documents were cited for more than 20 times, which comprise the key documents in metaphor research. A visualization of keywords and its cluster analysis were conducted to show the research fields and dominant topics in this field. The top 5 high-frequency keywords were language, comprehension, conceptual metaphor, discourse, and figurative language. The most prominent 5 clusters are labeled as right hemisphere, self, time, teacher education, corpus linguistics. These results revealed that metaphor research has largely focused on cognitive processing of metaphors, the influence of metaphors on self identity, the spatialization of time, and second-language learners’ metaphor ability education. Metaphor ability education belongs to one particular strand of applied linguistics, while cognitive processing of metaphors, the influence of metaphors on self identity respectively comprise interdisciplinary studies of language and cognitive science, and metaphor and pathology. The present review through CiteSpace flags the need for more investigations of CMT from more aspects or interdisciplinary studies, such as metaphor translation, metaphor in literature, metaphor and corpus linguistics, etc.From Overall, this study is the first review of linguistic research on CMT via CiteSpace tool and can provide us a sound overview of the landscape of international research on CMT. It is hoped that this study can help researchers to identify subsisting knowledge gaps and a number of future research opportunities.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.


More recently, however, new terms, including enactment and constructed action for (1) and depicting signs for (2) have been introduced. This article provides a brief overview of the history of enactment and depiction in the sign linguistic literature but mainly focuses on issues related to terminology (and terminology shifts). First, we consider the relation between role shifting and constructed action. We question the idea that these terms can be used interchangeably and rather suggest that they capture different, but related functions. Subsequently, we zoom in on the conceptualization of depicting signs, indicating verbs, pointing signs and fully lexical signs and the relation between these signs and the method of depicting. Where earlier research often associates depicting with the use of specific types of structures, we promote the idea that depicting is a semiotic diverse practice. In doing so, we show that the conceptualization of the different sign types and the terms that are used to refer to these phenomena do not accurately capture the way these signs are used in actual signed discourse and propose a reconceptualization of the different sign types in the lexico-grammar of Flemish Sign Language (VGT) as composite signs that can describe, depict and indicate meaning in various ways. In this way, this article illustrates (1) the risks that may come with the execution of terminology shifts and (2) the importance of making a clear distinction between form and function, i.e., we show that it is important to be careful with assuming a (too) exclusive relation between a certain function and one or more particular forms.Already at a relatively early stage, modern sign language linguistics focused on the representation of  referents (1) through the use of the body and its different articulators and (2) through the use of particular handshapes . Early terminology for (1) includes  In doing so, they promote the idea that gesture is an integral part of language  referents (1) through the use of the body and its different articulators and (2) through the use of particular handshapes . Early terminology includes for (1): /playing , role shshifting , body classifier , shifteded locus ; and foredicates , but alslocation , spatialedicates , polymoredicates , productve signs  and polyic signs . As becoconstructed action, previously known as role shift. In this article, however, we suggest that these different terms are possibly being used to capture and describe (slightly) different functions in signed language discourse. In part 3, we continue on this line by focusing on the conceptualization of classifier constructions (or depicting signs)1, indicating verbs and pointing signs, and on the relation between these structures and the method of depicting, i.e., showing. Where researchers traditionally have emphasized a strong relation between depicting and the use of classifier constructions and constructed action, we show that signers have various types of semiotic signs at their disposal when they want to depict meaning. We also question the idea that the main function of a classifier construction or a stretch of enactment is always depiction and we argue that signers can also use these highly iconic structures to mainly describe meaning. In doing so, we show that the theoretical conceptualization of these signs and the terminology used to refer to these mechanisms can be misleading and do not accurately capture how these signs are used in actual signed discourse. In this way, we also show that assuming a (too) exclusive relation between a certain function and a particular form can be problematic. Finally, in part 4 we reflect on the implications of this contribution and put forward some suggestions for future research.In this article, we first provide a brief history of the conceptualization of classifier constructions and role shifting, with a particular focus on the terminology. Subsequently, we highlight that adopting new terminology does not always come without risks. When reviewing literature on role shifting, for example, it becomes apparent that it often remains unclear how older and newer terms relate to one another and whether these terms refer to the same concept or function. In part 2 we therefore go into the relation between role shifting and constructed action. In more recent literature, we regularly find statements such as In this first part of the paper, we provide an overview of literature on role shifting/role playing and classifier constructions. Although this review is not exhaustive, it highlights the most important theoretical evolutions, with concomitant terminology shifts, in the field of Signed Language Linguistics and it will provide the necessary theoretical background for parts 2 and 3 of the paper.2 and is most clearly seen when the discourse concerns more than one 3P referent. She presents an example of a mother-child interaction and points out that the signer not only uses the body and/or head to distinguish between the two referents but that he will also “look up (with his head raised) when he assumes the child’s role, and will look down (with his head lowered) when he assumes the mother’s role” (1975:950).Already in the 1970s researchers working on American Sign Language discuss the use of the signer’s body to refer to somebody else. According to In publications from the 1970s to 1980s, role playing/role taking/role shifting was mainly associated with reported speech/direct quotation. Somewhat generalized, this is how it was presented: Like speakers, signers can opt for direct quotation/reported speech to report what someone else said/signed. This implies that the speaker/signer “shifts” in the role of the original speaker/signer and makes the report from the quoted person’s point of view. Such role shifting usually involves a shift in body position, facial expression and/or eye-gaze e.g.,  for ASL.decided that some other person went to the movies3:he himself would go to the movies. This is an interesting example also because it is not a case of reported speech in the strict sense, i.e., it is not about what Bill said/signed but about what Bill decided/thought. This example is highly similar to Liddell’s example (16) on p. 26, the only difference being that PRO.3 (third person reference) is replaced with PRO.1 (first person reference). In contrast, however, the latter sentence (with PRO.1) means that Bill decided that speech of a referent but also about thoughts, feelings and (for some authors) actions. Despite the frequent linking of role shifting and direct quotation, some of the early publications thus already noted that it is not only about representing the •1. Shifted reference, i.e., the use of pronouns from the quoted sender’s point of view, especially the use of the first pronoun 1. p to refer to somebody other than the quoting sender,•2. Shifted attribution of expressive elements, i.e., the use of the signer’s face and/or body posture to express the emotions or attitude of somebody other than the sender in the context of utterance,•3. Shifted locus, i.e., the use of the sender locus for somebody other than the signer or the use of another locus than the locus c for the signer.dire sans montrer) and telling by showing (dire en montrant). Within the framework of his semiologic model, Ces structures reproduisent, en mettant en jeu tout le corps du locuteur, une ou plusieurs actions effectuées ou subies par un actant du procès de l’énoncé: humain ou animal le plus fréquemment, mais ce peuvent être aussi des non-animés […]. Le narrateur “devient,” pour ainsi dire, la personne dont il parle, jusqu’à, chez certains locuteurs, lui ressembler physiquement. Pour caractériser ces structures, les Sourds utilisent un signe de leur langue signifiant approximativement “rôle” ou “prise de role.”These structures reproduce, by bringing into play the whole body of the speaker, one or several actions carried out or undergone by an actant of the process: human or animal most frequently, but they can also be non-animate [.]. The narrator “becomes,” so to speak, the person he is talking about, to the point where, for some speakers, he resembles him physically. To characterize these structures, the Deaf use a sign in their language that roughly signifies “role” or “role-taking”). or action performatives (1992:100). In a similar vein, The idea that signers want to show  actions when physically embodying a referent is also present in literature on American Sign Language. In contrast with dialogue . Winstondialogue , p. 404,4:Soon after Metzger’s introduction of the term ‘‘constructed action’’ in 1995, more and more researchers started to use this notion, often providing their own definition. Some examples are as follows–“Gestures intended to illustrate the actions of others” , p. 660.–“Constructed action refers to the gestures that imitate the actions of someone other than the signer at the time of signing” , p. 273.–“Becoming an object”; “the use of the signer’s body to depict the actions and movements of an object – whether that object be animate or inanimate” , p. 1285–“Constructed action thus refers to those gestures and bodily behaviors that are used either (i) at the same time as signing or (ii) instead of signing” –“Constructed action , where the signer uses his or her body  to represent the thoughts, feelings or actions of a referent using the surrounding space on a real world scale” , p. 370.–“That Constructed Action is a stretch of discourse  that represents one role or combination of roles depicting actions, utterances, thoughts, attitudes and/or feelings of referents other than the signer (narrator)” , p. 195.constructed action is also often used interchangeably with enacting gestures and enactment, with the understanding that “enactment” includes both constructed dialogue and constructed action (in the narrow sense)  in their multi-modal communicative repertoire is the practice of demonstrating the thoughts, words, or actions of  referents. These enactments occur when a person recruits any number of articulators, e.g., each of the hands, arms, head, face, shoulders, torso, vocal tract, etc., to produce iconic demonstrations.”role-shifting was understood. role” (1986:48). For stretches of discourse or as a certain behavior.From the beginning, there was confusion as to how exactly the term role-shifting/role-taking, (2) constructed action/constructed dialogue as well as (3) enactment are used, sometimes with the same meaning, sometimes not. As shown above, this variety of terms, over the years but also today, is undoubtedly related to different  approaches and interpretations. However, the multiplicity of terms also indicates the great complexity of the phenomenon (or phenomena). In the current Signed Language Linguistics literature, (1) “Terminology used to refer to this phenomenon varies considerably, and it is often unclear if the same assumptions about its nature are being made by different researchers. It is often not even clear whether these terms are used to refer to the same phenomenon, different aspects of the same phenomenon, or perhaps different phenomena altogether.”In the following sections, we follow up on the ambiguous relation between the concepts of role shifting on the one hand, and constructed action on the other hand. We investigate the relation between the two terms and the concepts they refer to.classifier, classifier predicates, or classifier constructions  are mostly seen as components that can complement the movement and handshape. This is in contrast with the conceptualization of classifier constructions as (…) mix “n” match involves selecting the component parts and putting them together in appropriate ways in order to create particular kinds of effect.productive signs, classifier constructions and verb/sign constructions  50 years. We have shown that, although initially the iconic character of these constructions was emphasized, soon more formalist, morphemic approaches became more dominant. As a consequence, the importance of iconicity at this level of signed language discourse was downplayed or even ignored. Researchers adopting more formal approaches rather emphasized the comparability of classifier constructions with classificatory verb systems in some spoken languages. Only toward the end of the 1990s, researchers (re)discovered their iconic properties and also questioned the status of the handshapes as morphemes. Finally, as a result of the increased interest in gesture in the study of language, the “linguistic-only” approaches have been replaced with reconceptualizations of these constructions as partly lexical constructions that exhibit both symbolic and gradient properties ” , p. 50.–“Enactment, also known as constructed action (CA) or role shift; a non-linguistic demonstration of entities and actions; a surrogate real space blend” .The question we ask here is whether this indeed merely is a matter of modernizing terminology or whether it is possible that these different notions are used to capture (slightly) different phenomena in signed language discourse.role taking would be outdated and best replaced by constructed action was also suggested in the early stages (around 2013) of the annotation of the Corpus Flemish Sign Language5. At a certain point, the team of annotators wondered if it would not be better to create a tier “CA” to replace the tier “role taking.” This question was prompted by the adaptation of That the notion of rolnemen (role taking) was introduced in Flanders by rolnemen (as a translation for role-taking) to refer to the ways in which a signer reproduces a previous conversation with someone or reproduces what someone has said. She briefly describes four such “ways”: “role-taking by means of body shift,” “role-taking through facial expressions and body posture,” “role-taking through indexing,” and “role-taking through eye-gaze.”As becomes clear from section “Role Playing” of this article, very different definitions exist for these two terms. Given the Flemish perspective of this article, we take the way the phenomena are usually understood in Flanders as a starting point here. The term rolnemen (role taking) and referentiewissel (shifted reference). Shifted reference here refers to the organization of spatial grammatical mechanisms as if the referent’s location were identical to the signer’s actual location while role taking involves “taking over” the role of a referent by means of non-manual behavior. Furthermore, formal role taking), and the use of non-manual articulators to adopt a role (expressive role taking). She also identifies various degrees of role taking.iconic gestures  discourse at that time . In some cases, these gestures were analyzed as what is now called By the time ASL was demonstrated to be a real human language, virtually all the gesturing done by the hands was considered linguistic and much of the non-manual aspects of the signing were also considered linguistic. Recent analyses of head and body tilts and rotations have also viewed these behaviors as the realization of grammatical elements.constructed action, but exactly how the term was interpreted was not entirely clear. At one point it was suggested to make a distinction between CA at the discourse level, where the signer may imitate the expression and/or posture of a certain referent to indicate role, and CA at a lexical level, where gestures and/or bodily behaviors are used instead of signing, e.g., to enact a certain action or posture of a referent and functioning as a predicate, e.g., G: wink , cartooshifted attribution of expressive elements, i.e., no other non-manual articulators that depict some aspect of the action, one might wonder whether the signer aimed to accurately show the action of “calling” or whether he/she rather wants to describe the action, thereby using both speech and co-speech gesture. In other words, the depictive potential of the gesture might be backgrounded. In the next section, we continue on this line and explore the relation between the methods of describing (telling), depicting (showing), and indicating (pointing and placing) on the one hand, and the different sign types in the lexico-grammar of signed languages on the other hand.Finally, although CA is often used to depict actions, postures, attitudes, …, signers may also use CA as an alternative for lexical or partly lexical signs with the intention to “simply say” or describe, rather than depict. Imagine a speaker saying “And then he contacted me,” while simultaneously imitating holding a phone. Here the gesture adds meaning that is not provided by the spoken message. Especially when there is no simultaneous The previous section has illustrated that terminology shifts can come with certain risks. Whereas some authors have used role shifting and constructed action interchangeably, we have proposed that these might be rather two different functions. In this section, we continue on this line by focusing on the conceptualization of partly lexical classifier constructions as “depicting signs” cf.,  for ASL As highlighted in part 1 of this article, Liddell was the first author to reconceptualize classifier constructions as depicting signs, which differ from fully-lexical signs because “in addition to their encoded meanings, these verbs also depict certain aspects of their meanings” , p. 261.A second important idea in non-illustrative intent, signers mainly draw on fully-lexical signs (which they refer to as standard signs). When telling by showing, however, signers mainly want to show what a particular referent looks like and therefore rather use different types of transferts (transfers), i.e., highly iconic structures through which the signer depicts the referent in the sign space lexicalization processes. It has been argued that classifier constructions and stretches of non-lexical bodily enactment over time can develop into fully-lexical signs (or standard signs), i.e., through repeated use these constructions can acquire an identifiable citation form that prompts the same meaning or set of meanings across different contexts of use e.g.,  for ASL.The existence of lexicalization and de-lexicalization processes might indeed explain the origins of some of the highly iconic fully-lexical signs and the modification of these conventionalized signs for the purpose of depicting in signed discourse. However, it is not always easy – as an analyst – to determine the degree of conventionalization of a particular token, especially when no extensive lexical databases are available. Moreover, very often there is no historical evidence for all these signs, i.e., there is no empirical data that supports the idea that a particular token over time has developed into a fully-lexical sign see also  for VGT.Linguists working on both spoken and signed languages have adopted Peirce’s  semiotics to the study of language use. In doing so, they study language as a form of social action in which people rely on a range of different semiotic resources that differ in degree of conventionalization e.g., . This se6, it has been suggested that people signal meaning through the methods of describing, indicating and/or depicting ng e.g., . When deThe method of indicating entails that people are locating an utterance in space and time by creating an index for the object they refer to Finally, the method of depicting allows people to show their interlocutor what the object looks, sounds or feels like . SpeakerAs describing, indicating and depicting are methods of communication, they can co-occur within a P-sign. Some P-signs integrate, for instance, the methods of describing and depicting [see As highlighted in section “What About Other Sign Types?,” depictions are best considered as iconic renditions of the object they stand for, which allow the interlocutor to imagine what the object looks, sounds, feels like e.g., . A revieIn this section, we illustrate that signers can use different types of signs in the construal of depictions. While reviewing the different sign types, we show that describing, indicating and depicting are properties of different sign types, regardless of their degree of conventionalization.Ferrara and Halvorsen (2017 for NTS) were the first sign language linguists that have adopted the functional, semiotic framework in the analysis of depictions with conventionalized form-meaning pairings. Building on insights from According to Ferrara and Halvorsen (2017 for NTS), iconic fully-lexical signs, like the sign TREE, are composites of depictive and descriptive properties. The descriptive properties can be traced back to the fact that they are conventionalized form-meaning pairings. The depictive properties, on the other hand, lie in the iconic nature of these signs. Within a particular context of use, signers can foreground one of both functions. In the first instance of the sign TREE , for insBuilding on these insights, we suggest that iconic fully-lexical signs that can be placed meaningfully in the sign space are also best understood as composites of descriptive, depictive and indexical properties that can be made manifest to varying degrees cf.,  for VGT.In this excerpt, the signer is setting up the scene. She mentions it is dark outside and subsequently uses the fully-lexical sign MOON in order to say that the moon is already out there. As she thus uses a conventionalized form-meaning pairing and combines the manual production of the sign with the conventional word “moon” in Dutch (maan), the signer accurately describes the meaning of the referent she is introducing. However, the sign MOON is also an iconic sign that also depicts its shape. Just like the fully-lexical sign TREE, the sign MOON is thus best conceptualized as a hybrid of depictive and descriptive properties. Within this particular context of use, the signer modifies the sign and places it higher up in the sign space see . In thisContinuing on this line, we also aim to explore other sign types that signers can draw on when building a depiction. Based on research on the motivated, often topographical use of sign space in various signed languages, we argue that signers can also use indicating verbs and/or pointing signs to depict movements and/or locations. In doing so, we counter the idea that these sign types are merely hybrids of descriptive and indicative properties, an analysis first proposed by The example below illustrates how a signer can use a pointing sign in order to create a depiction.a and HOLEa in relation to the molehill  their meaning. In the following example, the signer is reconstructing the scene where the boy is searching for the frog. In doing so, she also uses a modified token of the indicating verb TO-LOOK-AT.In this example, the signer is enacting how the boy is searching for the frog. During this period of enactment, the signer also produces a modified token of the indicating verb IV: looking-around . Within In the previous section, we have shown that the construal of depictions in signed discourse cannot be captured accurately when looking at the use of partly lexical classifier constructions, i.e., depicting signs, and constructed action or enactment only. Rather, signers have a toolbox with different types of semiotic signs which they can manipulate within a particular context of use in order to foreground the descriptive, depictive and/or indexical reading. This semiotic account of depiction does then also have certain implications for the analysis of partly lexical classifier constructions. Recall from section “Classifier Constructions” that From a functional, semiotic point of view, however, we may ask the question whether this conceptualization accurately captures the variety in the use of these constructions in signed language discourse. First, it is well-known that signers often place classifier constructions meaningfully in the sign space in order to reflect the position of the referent(s) in the original narrative  + constructed action, respectively. Focusing on the relation between form and function, we have argued that depiction is a semiotic diverse practice cf.,  for VGT In that way, this section thus also indicates that it might be misleading to name particular forms after functions. The researcher(s) introducing a term like “indicating verbs” might be aware of the fact that other types of signs can also be used to indicate meaning or that these signs do not always have to indicate. However, this nuance can easily fade away in later publications and what is mainly left is a term that does not always capture the way signers use these signs in actual signed discourse.In this article, we have presented a brief overview of the study of partly lexical classifier constructions/depicting signs on the one hand, and role shifting/constructed action/enactment on the other hand. In the first part of this article, we shed light on the evolutions in the conceptualization of these phenomena and the concomitant terminology shifts. While doing so, we have shown how the symbolic, morphologic conceptualizations of role shift and classifier constructions have been reconsidered and how more recently, especially in work of researchers working from a cognitive, functional point of view, these constructions have been reconceptualized as (partly) lexical constructions. In doing so, they have promoted the role of gesture in language and rediscovered the importance of iconicity in signed discourse. Along with these theoretical evolutions, we have shed light on the terminology shifts in the literature. In more recent studies, classifier constructions are more often referred to with the term “depicting signs” and role shifting with, for instance, “constructed action” and “enactment.” Many authors seem to imply that these older and newer terms can be used interchangeably.In part 2, we have shown that these terminology shifts can come with certain risks. We pointed out that care should be taken when replacing older terms that have often been taken from studies adopting more formal approaches with newer terms that come from Cognitive Linguistics and Gesture Studies. Do the new terms indeed refer to the same mechanisms and/or functions? And are they thus indeed comparable? Or might it be that the terms refer to different mechanisms and/or functions? We have illustrated the importance of these questions in our discussion of the relation between role shifting and constructed action. Whereas it was sometimes assumed in recent studies that these terms concern the same function, we have shown that signers can take on a character role by (1) means of body and/or eye gaze shifts only, or (2) by means of other non-manual articulators depicting the actions, thoughts, feelings or utterances of a referent, i.e., through constructed action. Signers can thus use constructed action to take a role, i.e., to depict the actions of a particular character. This latter practice is very often reported on in studies on CA and is often integrated as a feature of CA in the definitions. However, we have also highlighted that signers can construct action without actually adopting a character role. Therefore, we have argued that CA and role shifting are different, but related functions.Finally, we have explored the relation between the functions of describing, depicting and indicating on the one hand, and prototypical forms that have often been associated with them, i.e., (1) fully-lexical signs, (2) partly lexical classifier constructions  and constructed action, and (3) indicating verbs and pointing signs, respectively. Focusing on the method of depicting, we have argued that signers can use different types of signs in order to depict meaning. In other words, signers can modify fully-lexical signs, indicating verbs and pointing signs in order to foreground the depictive and/or indexical properties in order to show their interlocutor what the (imaginary) event exactly looks/looked like. On top of that, we also showed that the main function of a stretch of enactment or a partly lexical classifier construction does not always have to be depicting. Signers can manipulate these tokens too in order to foreground a descriptive  reading. We thus argue that fully-lexical signs that can be modified for movement and/or location, indicating verbs, pointing signs and partly lexical classifier constructions  exhibit descriptive, depictive and indexical properties that can be made manifest to varying degrees cf.,  on VGT. We have written this article based on our experience with the analysis of Flemish Sign Language data. It remains an open question whether all our ideas are applicable to all other signed languages. We should keep in mind that signed languages may differ here cross-linguistically [see also MV and IB conceptualized the study and wrote part 1 together. MV mainly focused on the literature on role shifting and IB on the literature on classifier constructions. MV took the lead in drafting part 2 of the manuscript. IB took the lead in drafting parts 3 and 4, and conclusion. Both authors have provided feedback on the different parts of the manuscript and worked on the revision.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.