In the past 200 years, urban spaces have been imagined as neatly laid out, well-planned, sanitised and civilised places of dense human habitation with regulated economic activity, where political power, financial capital, the frontiers of knowledge and technology thrive. This has been the urban planners dream, even while it does not reflect the full reality, whether of cities in the LMICs or the HICs. In the face of such homogenising visions arising from Euro-American models, formal urban systems fail to provide adequately for residents' needs, who then carve out their own resources and processes for meeting them, largely within the domain of urban “informality.” While large part of literature presents urban informality as reflected in the slum, others have shown how it is found in relation to all classes . The con While cities have been the locus of urbanisation, over the past century the urban mode of life has penetrated much deeper, changing everything in its wake. The benefits and opportunities have no doubt been astounding, reflected in the rising longevity of human life across the globe. But no less have been the challenges, including environmental degradation and loss of well-being. Having a higher density of population, higher level of consumption and higher number of industries, urban spaces usually exert a greater pressure on natural resources, frequently leading to greater environmental degradation. Cities account for 75% of energy consumption, more than 60% of greenhouse gas emissions, and 67% of the waste generated . South AA large part of the problem seems to lie in the tunnelled vision of urban planning by the state. Over the past century, with colonial hegemony affecting all spheres, the Euro-American model has provided the imagination of the urban landscape and its planned development world-wide. The local historical social and infrastructural specificities, of course, then bring diversity in its translation on the ground. This has been well-demonstrated in land use planning, housing, water and sanitation systems , 6. PlanMuch literature has emerged in recent years on urban “informality,” contrasted with the planners' dream of the manicured formal city. Some scholars view informality as the underbelly of an inequitous development path where large sections of people attempt to find informal means of meeting their basic needs , 8. BuoyIn this paper we examine urban informality related to health through a brief discussion on the implications of peri-urban areas, and to health care service utilisation through empirical data from Delhi, the capital city of India. We hope to demonstrate how crucial recognising the informal is in attempting to build people-centred and sustainable futures through planned development.Challenging the dominant Euro American perspectives on urbanism, such as the “modernist” perspective of the Chicago school or the post-modern urbanism of the Los Angeles school, urban informality has emerged as an exciting analytical framework from the experience of the third world cities . While bHowever, a large body of scholarship from the third world has contested this idea of the informal as unregulated sphere, outside the purview of the state and a refuge of only the poor and marginalised. Scholars like Alsayyad and Roy have shown how governments themselves actively produce informality, by facilitating practices and land use which are contrary to their own regulations and plans. Roy cites the process of rapid peri-urbanisation as an example of informalised process that despite transgressing official plans and norms, often receives tacit sanction from the state. She goes on to identify informality as an idiom of urbanisation in India, as in other countries . For exaFurther, contending the idea that informal cities only represent domains of survival for the urban poor, scholars have highlighted the ingenuous ways in which informality stretches formal limits, opening up newer possibilities for sustainable urban planning. The fluid informal city foregrounds local wisdom in the modern world in opposition to the attempts of its erasure . InformaRegulatory frameworks related to collective resources such as land and employment play a pre-eminent role in designating entitlements and property relations in urban areas. Healthcare lying in the sphere of “the personal that is political” is somewhat different. The health care industry is part of the formal regulated sector, as represented in modern hospitals and health centres, modern health care professionals, pharmaceuticals, and insurance agencies in the public and private sectors . However, a large segment of health care that is undertaken in homes and communities, with traditional and new evolving knowledge in addition to the modern conventional providing the basis, lies outside this formal sector and forms the informal healthcare. Since health care includes “ways of life” and application of specialised knowledge, state support and regulation of only a segment of both these makes what is left out, the “unregulated,” seem “illegitimate.” The plurality of knowledge traditions in health care, included in both the formal and informal segments in countries such as India and China, suffers as the traditions with ontology and epistemology differing from that of modern bio-medicine, get delegitimised over the years. While the codified traditions that have adapted to modern institutional forms, are officially recognised and regulated, the officially unrecognised traditional folk practices and practitioners undergo processes of decline. Yet their use, renewal, and innovation continues in efforts to adapt to the challenges of changing conditions . While tIn the context where urban spaces include a large component of the rural-urban interface , other seemingly rural elements also acquire such an illegitimate characteristic. Studies across third world cities show that peri-urban areas host large concentrations of the rural immigrants in search of livelihoods. In such areas agricultural activity and animal husbandry attracts the poorest and the women, allowing them to find their feet in the urban context with more familiar economic activities and lifestyle. They also provide several other innovative possibilities for urban resilience and sustainability. For instance, peri-urban agriculture has been documented across Asian cities as an informal mechanism devised by local communities to deal with problems generated by an incomplete shift from rural to urban: of mixed land use, unsatisfactory occupational mobility of the local population, domestic waste water disposal, and an influx of rural migrants. Studies show how it allows for retention of green spaces and ecosystem services that provide for increased incomes of the most vulnerable social segments , food security and waste management . HoweverSimultaneously, the peri-urban space acquires an ambiguous administrative identity, and tends to be left out of public services and amenities. The rural agencies withdraw as the area gets declared to be within the urban boundary, and the urban municipalities take time to reach it since it is peripheral and last priority for distribution of scarce resources. However, since it contains a continuity with traditional ways of life and at least some elements of the eco-system, the possibility of practices such as of food production and herbal medicine are preserved more than in the urban core. Thus, “informality” in itself can be a reflection of deprivation and exploitative relations, or an opportunity for assertion of agency and innovation.Perceived as spaces with no legitimate identity, peri-urban areas have been conventionally used for dumping the city's waste or its polluting industries for planned sanitisation of the formal city-space. An alternative view is emerging that considers peri-urban spaces as constituting the diversity of urbanisation and providing possible solutions for urban resilience , 19, 20.Public health has been central to urban planning historically and continues to remain a need just as important in the present day urban scenario. Tracing global epidemiological trends of urban health and disease reveals the seriousness of ill-health generation in these most economically endowed areas. Thereby, focusing on urban health behoves us to examine the pathways through which inequality and ecological unsustainability manifest in urban life and shape health and disease. While inequalities permeate every society, the severe lack of resources make matters far more complicated in the LMICs, and attempting to mimic the development models of the high income countries (HICs) has compounded the problem. Nearly a billion people live in slum conditions, with 90% of the urban slums located in the LMICs .The urban space, layered across different socio-political-cultural-economic axes, is mediated differently by different sections of the population, which in turn also shapes their health differently. For instance, Urban Health Resource Centre in New Delhi, India, drawing on data from National Family Health Survey 2005-06, classified urban populations according to their wealth and observed that for almost all indicators on health, healthcare or key social or housing related determinants of health, the poorest quartile fared far worse than the rest of the urban population. Under-five mortality for the poorest quartile was 73 per thousand live births, significantly higher than 42 per thousand live births in the rest of the urban population. In nutrition too the poorest quartile cut a sorry figure with 54% of children being stunted and 47% underweight, whereas the figures were 33% and 26%, respectively for the rest of the urban population. Women receiving at least three antenatal check-ups among the poorest quartile was only 54% compared to 83% for the rest of the population. In terms of living conditions, 81.5% among the poorest quartile lacked access to piped water supply at home and 52.8% did not use a sanitary flush or pit toilet. By contrast, 62% had access to piped water at home and 96% used sanitary toilets among the rest of the urban population  are also increasingly laying claim to morbidity and mortality among the urban poor. Precarious employments and exploitative employment relations, poor housing conditions, overcrowding, lack of basic amenities, growing inequalities of consumption lead to deteriorating well-being and rising social strife and violence. Fast-paced life, sedentary work, stressful conditions, unhealthy food habits predispose urban inhabitants of all sections to NCDs like obesity, diabetes, and hypertension. Road traffic accidents, diseases due to environmental pollution are also on the rise. LMIC countries such as India are still in the phase of epidemiological transition where the urban better-off are more affected by the NCDs, but the poorer sections are bearing a disproportionate triple burden—communicable diseases continuing, NCDs emerging and injuries rising rapidly. While socioeconomic vulnerabilities expose them to unhealthy conditions, inadequate, fragmented and expensive health systems rob them of the chance of receiving good quality services. The lack of community outreach of health services in urban areas and poor referral services have only compounded the problem.The above description of inadequacy of the formal systems to provide for the urban poor, creating conditions of health inequalities is well-documented across the world. Yet, what is often overlooked in discussions of urban health is the fact of the formal systems being limited by their very centralised, mono-solution based, homogenised, bio-medical imagination in catering to human needs. The ignored plural solutions are then resorted to through informal pathways, supporting the existence of a majority of the urban residents. Underlying this problem is international and local political economies, with industries pushing their technological ware  and real estate making its fast buck. But what is less recognised is an epistemological divide that underlies the modern tools of planning— for assessment, validation and regulation of technologies, models, and systems.India, despite its own experiences in urban planning—for example the city of Shahjahanabad in what is now “Old Delhi”— chose to borrow from western models. Lutyens Delhi in the colonial period or the planned city of Chandigarh post-independence stand testament to that fact. The theoretical assumptions underlying the dominant policy-making knowledge frame, e.g. the Garden Cities of Europe based at least in part on notions of environmental health, led to parks and wide roads at the cost of housing for the poor. Public health needs of the different sections of the population got side lined in the quest for real estate management, often for the benefit of the affluent class. Thus, it has been shown that the inadequacy of urban infrastructure in Independent India, especially for the underprivileged, primarily resulted from the elitist class bias and decontextualised planning of the public administration. Resettling the city's poor from more central locations to the peripheral areas (that had been declared “inhabitable” in the Delhi Master Plan 1962) so as to decongest and beautify the city required official flouting of the masterplan. This led to dismal environmental conditions in these planned colonies of the poor that resulted in endemic water borne diseases and a full blown cholera epidemic in 1988 . Adoptinad hoc regulations, and drawing natural resources such as water from further afield are implemented as solutions. Given that these do not adequately address the problems generated by the decontextualised vision for urban spaces and their inhabitants, their effects also remain limited and temporary at best.The displacement of polluting industries from Delhi to its peri-urban areas in the 1990s has increased pollution of water, soil, and air that is returning to the city through the food produced in the peri-urban area , 18. NowSimilarly, despite a rich heritage of pluralistic health culture, a monolithic health system was imposed upon the Indian people, centred around conventional biomedicine and its doctor and hospital centred institutional model. The system has resulted in a never-ending chase of targets and counting of under-served/un-served population segments. While it responded to the unmet need for services by incorporating para-medical based health centres in rural areas, for urban areas, the imagination remained fixed on hospital and dispensary based medical services until the 1980s. It was in 1983 that a committee recommended urban primary level services with outreach in the community, and even this has been only partially implemented to date . Each has its texts, colleges for professional education, research councils, hospitals, and dispensaries. However, this has been an “undemocratic pluralism,” with dominance of conventional biomedicine such that it gets over 90% of the government allocation for health while the other seven get 3% .At the other end of the health care spectrum is the practice of home remedies and promotive practices, folk healers and faith healers in the community, as well as family lineages of practitioners of the recognised systems who have been trained inter-generationally without going to college or obtaining degrees. These constitute the “informal traditional” forms of health care, using “free gifts of nature” or easily accessible materials. Folk and faith healers generally provide care as a form of non-commercial community service.jhola chaap daktarBetween these two ends of the informal to formal spectrum newer forms of informal health care have evolved, such as the practitioners of conventional modern medicine who have not been formally educated or are at best trained as paramedics and AYUSH doctors, called Rural Medical Practitioners (RMPs) by some scholars, colloquially called Forms of informality are evident within the formal medical institutions, for instance the widespread use of lesser trained nurses and paramedics in private clinical settings with “training on the job” instead of hiring trained professionals who may be in short supply and have to be paid more. Cutting corners or over-prescribing in patient care by private hospitals for enhancing profits often flout professional clinical guidelines. In the over-crowded public sector institutions, scarce resources or time lead to rule-of-thumb practices that do the same . OutreacIt is generally assumed that the urban areas are devoid of informal health care or that it exists only in slum areas. However, studies in different cities find that all forms of informality among health care providers exist and thrive in urban areas, as does the utilisation of herbal medicine. We would argue that this spectrum of informality in health care and the overlaps between the formal and informal processes reflects what recent scholarship on urban systems has started theorising in other spheres. Also that they are not restricted to India, but are ubiquitous in their presence in all continents and countries, to varying extent and in varying forms.Studies conducted in Ahmedabad and Cuttack from India found that in urban areas many people still perceive faith healing as an alternative treatment for psychiatric disorders. Faith healing was available easily and locally, in contrast to psychiatric treatment for which most patients and families had to travel a considerable distance , 29. StuThus, health care planning for the urban setup, just as urban planning itself, needs to account for the wide spectrum of needs and diverse activities that can cater to them. Mere service provisioning of the conventional type or administrative enhancement of the dominant model of services, out of touch with people's contexts, is unlikely to meet the healthcare needs of the population and for all its segments. People's health seeking and health creating practices are shaped by the myriad of identities they embody. Instead of ironing out such plurality the state needs to address the varied needs and practices of populations.In India, as in most parts of the world, this, unfortunately, has not been the case. The state's planning for healthcare has completely ignored the traditional community, family and individual based health care. The codified systems that have been officially recognised have a large network of educational, service delivery and production institutions in both the public and private sectors, including a separate Ministry of AYUSH. Folk health knowledge and practices, however, still remain largely bereft of state support. Devoid of the state's patronage, these non-state, non-modern knowledges, and practices have only been able to sustain because of their continuing utilisation, the experience of benefit., and continuing trust that people have placed in them.If urban healthcare planning wants to be truly informed by people's practices, the health seeking behaviour of people relating to both the formal and informal health services need to be examined, keeping in mind its dynamicity and evolving nature. While there have been several studies exploring urban health seeking in the formal health system and fewer in the informal segment, the continuum of care seeking for different sections of population has rarely been explored in the urban context of India. National household level data gathering on health and health care is conducted by several agencies in multiple forms, such as decadal surveys by the National Sample Survey Organisation  and the The methodology adopted for the study was of a rapid survey across three socio-economic classes, the middle-class, the poor, and the homeless. Residential areas of these socio-economic groups were purposively selected, which included a middle-class colony, a slum area and an area with large number of homeless persons. Systematic random sampling was adopted for sampling at the household level in the purposively selected middle class and slum colonies. For the homeless, convenience and snow ball sampling had to be used as they didn't live regularly in any specific location. In total 125 respondents were interviewed . Majority of the respondents were middle aged women, with diversity in the sampled middle class respondents' educational qualifications while the majority of sampled poor slum residents and homeless were illiterate. A semi-structured interview schedule was used as tool of data collection which was designed to elicit knowledge of all forms of health practices in daily living, including the modern, and traditional modes of care. Previous experience of research among rural and urban communities had shown the importance of the investigator communicating a non-judgemental position on “informal knowledge,” and creating a conversation that encourages respondents to speak about it. Open-ended questions were asked in such a sequence that they allowed the “delegitimised” traditional practice and knowledge to be acknowledged and reported as health seeking actions. The first questions were about what plants and food items the respondent knew had medicinal value and for what health conditions. No checklists were provided from the researcher's side. The information generated reflects the respondent's knowledge of medicinal value of food items in 46 health conditions and plants in 51 health conditions that they themselves cited. One hundred two of the respondents reported any knowledge of food items in health conditions while 113 reported knowledge of medicinal properties of plants. The next set of questions were about their healthcare seeking practice in specific illness events in the past 15 days and over the past 1 year. Given multiple responses from each respondent, the total number of illness episodes for which the respondents sought various modes of healthcare, from home to the outer world, came to 1,114 . Finally, a question was asked about their history of ever visitation to the range of health care providers.jhola chaap” practitioners constituted the informal providers of conventional medical care. Resort to the formal health system constituted of public or private services of conventional medicine and in small measure to the recognised traditional knowledge systems. For a majority of health issues, home remedies were observed to be the first resort.The health care activities reported exhibited a wide range of informal arrangements. Starting with self-care at home , it extended to involve folk healers  and faith healers as informal practitioners of traditional systems of medicine available at the level of the community. The chemists and “Despite the expected erosion of such knowledge within households over the years in the rural and urban populations, the survey found that the general breadth of knowledge on the medicinal properties of food items and medicinal plants was commendably rich. The survey documented that the sampled population is well aware of medicinal properties of food items, 115 of them being reported by respondents to address 46 different health conditions. The survey also listed a total of 91 medicinal plants and their medicinal properties that were known to address 51 different health conditions. Of these food items and medicinal plants, the greatest number was reported by the middle class, then the slum residents and least by the homeless .When the home remedies or diet change alone did not prove sufficient, people usually resorted to other modes of care in different combinations. The survey traced illness in the last 1 month for this movement of healthcare seeking from home to the outer sources. It was observed that across the three different study groups, while about 15% of illness episodes were dealt with by home remedies and diet change alone, a larger section of care seeking involved home remedies and/or diet change in combination with care from outside home (36.44%). This means altogether home remedies and diet change, alone or in combination with other modes of care, constituted the largest proportion of care seeking behaviour (51.16%). This was 60% for the middle class and poor, while only about 33% for the homeless .The specifics of treatment sought outside the home showed a multiplicity of patterns of resort, depending on the problem and their collective experience of various forms of treatment for it. For a case of diarrhoea in a child, the treatment would begin with dietary restrictions and home-made oral fluids, quickly move to accessing informal modern treatment, and upon that failing, go to a formal medical provider/institution. In case of arthritis, however, the sequence may lead from home remedies to traditional folk healers and much later to the formal, traditional, or modern.Figure 3).The three socio-economic groups taken together reveal that, informal health care was resorted to in 67% of illness episodes. This included home remedies and diet change (14.72%), traditional informal (14.18%), and modern informal (38.24%). Disaggregating the data further shows that the modern formal system (public and private) was used most by the middle class (in 72.78% of their illness episodes), followed by much lesser utilisation by the poor households (14.84% of episodes) and the homeless (14.10% of episodes) , followed by the chemist/pharmacy (50%). Almost half of them had also visited Homeopaths (47.5%), and the Ayurveda practitioners/Vaids (37.5%). Most revealing was the finding that 67.5% of the middle class had also resorted to modern informal providers and 45% had sought treatment from informal traditional providers .Of the poor slum resident households 77.5% had ever visited the government dispensary and 50% a government hospital, while 52.5% had gone to the formal private care providers. A much larger proportion  had accessed the informal modern services. It was also observed that reliance on faith healing was the most among the poor (90%) due to the proximity of the slum to a place of worship known for its curative powers. The data also indicates that slum dwellers exercised the greatest “choice” in resort to the range of providers, their number of responses being higher than either the middle class or the homeless, the homeless exercised least choice.Almost all (99.9%) of the homeless group had sought care from the modern informal providers, and 57.7% from informal traditional care. Care sought from the formal private was the least among the homeless (22%).While lack of access and affordability would certainly explain in part the limited use of the sources of formal healthcare by the poorer sections, the not insignificant use of informal health care by the middle class testifies to its inherent value as perceived by all classes. Strengthening the formal public services would, of course, be of benefit to the urban residents especially the poor. However, recent fledgling initiatives at health systems strengthening are unlikely to have impacted treatment seeking behaviours in our study population since 2013-14 when our study was conducted. Delhi government's recent initiative of setting up “Mohalla Clinics” (Colony clinics) for providing free diagnostics and drugs has a very restricted population coverage and the Ayushman Bharat initiative of the national government providing social insurance to the poorest 40% of population is restricted to covering hospital care, with both still facing problems of implementation and fragmented design –41.It is apparent from the data above that a majority of illness episodes are taken care of by informal mechanisms, while the state plans only for the formal health care. Pluralism allows the urban residents to exercise their agency to choose between use of the home remedies they know and the informal and formal sources of healthcare outside the home, in various combinations as they are able to access or think appropriate. The implications of this for urban health care and planning need to be understood.Cities encompass multiplicities within themselves, where various concepts of urbanism coalesce and fragment simultaneously to create ever shifting kaleidoscopic arrangements. In the cities of Latin America, Asia and Africa, the situation gets additionally complicated with their histories of colonisation, underdevelopment and the attempts to develop by adopting the expensive and high consumption models of the first world, as well as the presence of a market dominated economy. An exploitative economic system in conjunction with deeply entrenched social hierarchies have created a landscape of precarious employment and perilous living conditions for the urban underclass, all marking the pervasive poverty by the notion of informality. Rapid globalisation, aggressive marketisation and a receding state have further attributed the cities of the third world with the defining characteristics of increasing inequality, rising violence and an unruly politics. While the “informal” urban processes are a response to such inequality in access to basic resources and services, they are also the means of fulfilling human needs of all sections that the formal system is failing to do., What this paper argues is that it is not only an economic inequality, but also the power equations in the politics of knowledge that denies the more local and rural popular epistemologies and ways of life due consideration in the visions for planning urban spaces, “the urban way of life” and urban health care. Informality reflects not only the solutions of low resource settings in urban areas, but also the marginalised epistemologies that resurface even in better resourced settings, and in people's attempts to conserve or continue to practice what they value in their way of life, and in the cultural-moral underpinnings that accompany them. The wide-spread and increasing informal resort to traditional-complementary-and-alternative medicine (TCAM) in HICs is beginning to be formally factored into their health service systems, for instance by medical insurance paying for TCAM services, the teaching about TCAM in medical schools to sensitise under-graduate medical students as well as in specialisations for post-graduate studies. But the prevailing informal traditional knowledge and practices of the urban poor are likely to be lost to them in the prevailing environment in most LMICs. Traditional folk practices continue to be delegitimised, and with increasing “folkisation” of conventional bio-medicine, forms of self-care and informal providers based on use of modern conventional industrially produced medicine replace the more ecologically sensitive understandings of health as a product of the ecosystem and way of life and health care based on natural materials and processes. Implications of these trends need to be examined.The concept of urban informality that has largely been applied to urban land use as well as to economic activities and livelihoods related to them, has been extended in this paper to the pluralism of health care in people's lives as against the official planning of health care that has ignored such possibilities. The study showed a spectrum of informal and formal-informal sources of health care forming the urban health care system on the ground, even in a metropolis such as Delhi, the capital of an emerging economy. All the sources of formal and informal health care were resorted to by all sections of urban residents, the poor and middle class, in a plural combination of health seeking behaviour varying by socio-economic status. On an aggregate, only 33% of illness episodes led to resort to the formal services  while 67% were dealt with through informal sources of health care. Care seeking for promotion or preservation of health begins from the informal setup of the home across all socio-economic groups. These practices of self or family care, although constituting the largest proportion of healthcare, receive very little attention from the state which arranges all its planning and activities around formal sources of healthcare even when its use is much limited in comparison. Outside care for the poor and the homeless comes mainly from informal health service providers, but they are sought out even by the middle class. Clearly people make choices across the wide spectrum of informal to formal depending on the nature of their ailment and experience with different systems, influenced by their location and belief systems. The exclusivity of what is legitimised as valid knowledge and its practitioners by the state's vision of health care , is rarely observed in real life practice.The way formal urban health care is planned in India carries common attributes with urban planning in general, The models tend to get adopted uncritically from international contexts. While there is a diverse set of health services and practices available in the urban culture of Delhi, the state reserves its support for only institutionalised biomedicine, which has become the standard the world over, or that part of traditional medicine that has moulded itself into the dominant model of doctor-and-institution centred health care. Solely a disease centred approach limits the biomedical system to primarily curative services and that gets reflected in the state supported health services as well. A more democratic and comprehensive approach to health planning in the urban setup would make use of not only the plurality of knowledge and practices available, but also link health with its various other determinants, such as employment conditions for the urban worker, livelihood and food security, living conditions etc. Urban planning, instead, driven by the desire to implement universal solutions, creates an abstract homogenisation of urban life, mostly out of touch with reality of the majority of the citizens. Rather than learning from local wisdom of diverse people and communities, “the formal” attempts to centralise systems of knowledge and of production and application, clearly evident in water supply, sewage and institutionalised healthcare provisioning in the urban areas. This creates inappropriate services and wastage of valuable resources. Being far removed from the local context the models adopted are more aspirational of the “development standards” of the global north rather than mindful of ecological sustainability, economic viability, and social justice.The observation of widespread resort to informal modern conventional health care in cities, towns and villages has led to the proposal to officially institute 3-year courses for training “community-level accredited practitioners—not full-fledged doctors” who can practice independently and provide basic health care at low cost . HoweverMoreover, the dominant politics of knowledge overlooks, even delegitimises, these alternative sources of knowledge coming from the common people of all sections. Thus, even though the most marginalised of the population primarily depended on informal sources and the public services for their healthcare needs, there's little reflection of that in existing plans that favour promotion of private medical services. People taking care of themselves, with locally available resources, is a reality that is usually ignored in our formal health services planning. The whole articulation is geared only towards medical service provisioning and demand generation for the products of the medical industry, creating dependency rather than facilitating people's own health creating practices.It must be admitted that folk medicine like any other system of medicine has its own strengths and limitations. While it is mainly used in present times for promotion of health and treatment of common everyday health problems, its value as beneficial for health promotion, prevention, palliation and cure has been well-recognised by pharmacology since the discipline has evolved on the basis of traditional medicinal plant knowledge found especially in the “developing” world. The pharmaceutical industry too has depended on it as the source for leads to identify medically effective molecules for its research and development activities, and continues to do “bio-prospecting” even in the present . In receOur study shows the possible benefits of providing urban populations access to traditional medicinal plants by promoting urban forests and herbal gardens in public spaces as well as encouraging cultivation and use of medicinal plants and herbs by all sections. Urban/peri-urban agriculture and cultivation of medicinal plants in public spaces for citizens to access is possible with a vision of urban green spaces that may not be neat or sanitised but are of use in the way of life of all, and especially of the poor and migrant. Learnings can come from initiatives such as undertaken in Cape Town, South Africa that brought together disparate groups who share interests in the city's biodiversity—formal economy, predominately middle class conservation managers and policy makers, and informal economy, predominately working class Rasta herbalists—to develop herbal gardens in public spaces .State can play an important role therefore in reviewing the popular practices and facilitating those that prove beneficial. In terms of strengths beyond biological efficacy, it is important to note that folk traditions are commonly an integral part of the social and physical environment of the communities, making them more conducive for adoption and treatment adherence. Facilitating home remedies which are usually low cost, prepared from locally available materials, and constituting a significant proportion of care seeking, could have not only brought down the cost of care but also taken the load off the formal public services, allowing them to improve their quality of services. In the face of exorbitant rise of medical care cost, increasing incidence of antimicrobial resistance and deaths due to iatrogenesis globally, as well as the polluting nature of the pharmaceutical industry, the traditional systems of medicine and folk medicine do hold promise of contributing to evolving more democratic, plural and sustainable health systems.An integrated, comprehensive, and ecological planning would have optimised the existing resources and practices in providing people good quality care that is need based and sustainable on a longer term. Epidemiological logic in consonance with people's need and service provider's opinion, should inform decisions regarding provision of institutional care. An earlier study covering rural populations spanning 18 states of India had found that 80% items listed as self-reported household level knowledge of medicinal value of plants and food items was verified and validated to be rational by the codified knowledge and scientific principles of the recognised AYUSH systems . BuildinThe challenge to such folk knowledge and practices that tend to be location specific can pose challenges when practitioners migrate to urban areas. Our study found that there is continuity of the regional flora across rural and urban, which gets eroded as construction and concretisation of open spaces increases. While this problem can be resolved, the issue of folk healers is more complex. The folk healers were traditionally regulated by the norms and ethics of their community of healers. As they migrate to the city, they can get cut off from their community and its regulatory system. That is why wider propagation of the peer assessment based certification mechanisms for folk healers becomes important even in urban areas. Further, their skill upgradation through senior healers would ensure survival of such valuable knowledge and its practice brought to better benefit larger numbers. Inter-disciplinary and trans-disciplinary research could also provide systemic mechanisms to rationally increase the element of self-care and community level care so as to decrease resort to institutional care, thereby decreasing costs and time of both the users and institutional providers. Further, based on studies of the urban poor in different parts of India and a wider literature review, it has been argued that their perceptions of quality of care, understandings of the social determinants of health and ways of dealing with them can provide learnings for more appropriate assessment criteria and designing of health systems , 55. In Thereby, the informal can (i) be analysed to understand what features suit people in diverse conditions and build them into system or intervention designs, (ii) demonstrate pathways to sustainability in diverse contexts, and (iii) be analysed for evolving normative principles for planning. All these are valid activities even while they need to be undertaken with the recognition that the informal mechanisms may not always be the “best solutions” of the elite, but responses for coping with situations full of constraints. The constraints themselves have to be recognised as those of societal resources, as relevant considerations for any efforts at sustainable development encompassing all socio-economic sections and thereby questioning the criteria for assessing optional solutions including those of the elite. The interface between the informal and the formal is the junction we are hoping to address for examining and contributing to building sustainable systems.People's health seeking practices show that there is place for both the formal and informal. The how, where and what of that gets reflected in the choices that people make which vary by specific contexts. Making the process of urban planning people centred should therefore create conditions that empower people's solutions emerging from the ground. This can help capture the complexities of real life, as well as show us how to make the urban environment healthier by ensuring fulfilment of basic needs and promoting resilience  and the health care system more responsive to people's needs and suitable to local context . Sustainable cities, while upholding the three pillars of social equity, economic prosperity and environmental integrity, need to place democratisation of knowledge and people's practices upfront as the fourth pillar. Exploring urban informality can provide us with some clues on how to do that, so as to reflect the diversity within urban areas and provide more sustainable options for organising the high urban densities into more livable spaces for health and well-being of all.The datasets generated for this study are available on request to the corresponding author.The empirical study was conceptualised by RP. Methodology and tools prepared by RP and RS. The survey was coordinated and data managed by RS. Data analysis was done jointly by RP and RS. RP and SD jointly conceptualised and wrote the paper based on an earlier draft by RP and RS.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.


To measure and compare musculoskeletal pain in patients with juvenile fibromyalgia (JFM) and polyarticular juvenile idiopathic arthritis (JIA), and to evaluate and compare pain perception and pain coping mechanisms in these patients. In this cross sectional study, we evaluated 150 children and adolescents, and their respective parents, from 3 different groups: JFM, polyarticular JIA, and healthy controls. Pain intensity and pain coping mechanisms were measured using specific questionnaires. Pain perception was evaluated according to three illustrations simulating situations that might cause pain: a shot, a bicycle fall, and social isolation. The patients’ parents also filled out the questionnaires and provided a pain score that matched their child’s perception of pain for each illustration. The highest pain scores, the lowest pain coping strategy scores, the highest pain perception scores for all three illustrations, and the worse health related to quality of life indicators were observed in the JFM group, when compared to the JIA and control groups. The same pattern was observed with their parents. Patients with JIA and JFM behave differently in relation to pain perception and the development pain coping mechanisms. Pain should be evaluated from different perspectives for an individualized and efficient treatment of patients. Musculoskeletal pain is one of the most common complaints from the pediatric age group. Many patients have idiopathic musculoskeletal pain (IMP), which does not necessarily have an apparent cause, is intermittent, and can be disabling, for a minimum period of three months.,,Some case series show that 25-40% of children and adolescents with chronic musculoskeletal pain syndrome meet the criteria for juvenile fibromyalgia (JFM).,,Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease characterized by arthritis that lasts at least six weeks in at least one joint. Pain is common in patients with JIA, especially in those with polyarticular impairment (five or more inflamed joints). Previous studies have shown that 86% of children with JIA present mild to moderate pain,,Pain, regardless of its cause, is perceived, tolerated and dealt with differently by patients. However, these aspects are rarely studied when JFM and JIA are analyzed.The present cross-sectional study was carried out in a specialized outpatient clinic of a tertiary hospital. One hundred patients aged 8 to 18 years old were included consecutively: 50 patients with JFM and 50 patients with polyarticular JIA. Patients with JFM met the criteria for fibromyalgia as established by the American College of Rheumatology in 1990.The control group consisted of 50 randomly selected children and adolescents, chosen in order of when they joined a leisure club. This group was paired off by gender and age, and they had no history of inflammatory disease or previous chronic musculoskeletal pain.Data was collected with regard to the age of onset, intensity, duration of the pain, and previous painful experiences that were related or unrelated to the disease  and use of analgesic and/or anti-inflammatory medication. For JIA patients, the disease activity and the number of active joints at the time of the interview were evaluated. We used the numerical visual analogue scale (VAS)Patients reported the intensity of their pain at the time of the interview and the average pain they felt during the previous week. The parents indicated the pain score that they believed their children felt on the day of the interview.To evaluate pain perception, we developed three vignettes related to situations associated with physical or psychological pain:physical pain related to a traumatic experience ;pain related to a medical procedure (shot); andemotional pain, due to social deprivation (excluded from a group of children).A designer drew up the vignettes after a consensus meeting among the researchers . The chaTo assess pain coping mechanisms, the Waldron/Varni Pediatric Pain Coping Inventory (PPCI) questionnaire, translated into Portuguese, was used.Patients with JIA were evaluated regarding the clinical activity of their disease according to the criteria from Wallace et al.Patients, controls and their respective parents signed consent forms. The study was approved by the Research Ethics Committee of the Universidade Federal de São Paulo (CEP-UNIFESP 0309/10).Initially, the data were analyzed descriptively. For the categorical variables, absolute and relative frequencies were calculated. For the numerical variables, summarized measurements were calculated . The means of the two groups were compared via Student’s t-test for independent samples. To perform an analysis for more than two groups, the means were compared using a variance analysis (ANOVA), followed by multiple comparisons  in order to pinpoint the differences. To verify the normality of the data, the Kolmogorov Smirnov test was used. In the case that there was no normality, the nonparametric Kruskal Wallis test was used, followed by the Mann Whitney test (if there was evidence of different means) with a Bonferroni correction. For the comparison of paired sample means, Student’s t-test was used. To verify associations between the categorical variables, the chi-square or Fisher’s exact tests were used if the samples were small. Linear associations between numerical variables  were analyzed using Spearman’s correlation. The internal consistency of the items that make up each of the five PPCI aspects was evaluated using Cronbach’s alpha. A significance level of 5% was used for all statistical tests.Three hundred interviews were performed with 150 patients and their parents. The clinical and demographic data of the patients and the demographic data of the controls are shown in Among the 50 patients with polyarticular JIA evaluated (seven had positive rheumatoid factor), the disease was active in 29 (58%) of them at the moment of the evaluation.Twenty-six patients with JFM (52%) and 11 patients with polyarticular JIA (22%) had severe pain (pain score > 8) in the week preceding the interview . Nine of the 50 patients in the JFM group (18%) had used painkillers in the week prior to the interview, while eight of the 50 patients with polyarticular JIA (16%) were on pain medication at the time of the interview. In the group of patients with JIA, we did not observe a statistical difference between the pain score on the day of the interview and the score from the week prior to the interview between the patients who were actively suffering from the disease (arthritis) and those who were not.There was a difference between the mean age of onset of pain in children in the JFM and JIA groups. The onset of pain began in JIA patients at a younger age  and their pain lasted longer  .We calculated the intraclass correlation coefficient between the pain scores provided by the children and adolescents of the JFM group and their parents. The value found was 0.716, with a 95% confidence interval (95% CI) ranging from 0.550 to 0.828. In patients with JIA, we found a value of 0.658, with the 95% CI ranging from 0.468 to 0.790.When analyzing each pain situation presented in the vignettes separately, the control group obtained higher scores than the patients with JIA in the social deprivation situation  and the pain related to a medical procedure situation .The Spearman correlation coefficient between the pain scores given by parents and by children after seeing the vignettes is presented in In the present unprecedented study, we evaluated and compared two aspects that are relevant for clinicians who follow up with children and adolescents with musculoskeletal pain: pain perception and pain coping mechanisms.Pain perception is the process by which an organism interprets and organizes sensations in order to give it meaning. Pain perception is not directly related to an active disease (the presence of arthritis or painful spots the body), but rather to a number of factors, such as the individual’s previous experience, social context, emotional state, gender, race, age and culture.The pain perception evaluation, which was performed through the presentation of simulated situations in the form of vignettes, showed that the JFM group had the highest scores (the highest pain perception) for the three situations presented, when compared to the other groups. The perception was greater for both the patients and their parents. The correlation between parents and children’s pain perception was low in all three groups. As such, the patients’ point of view should be considered.In the comparison of the three vignettes within the same group, we can see how previous lived situations can influence pain perception. Evaluating each group separately, we observed that, in the JFM group, the highest scores for pain perception were given in reference to the social deprivation simulation, a situation that these patients know well due to the limitations imposed by their pain.With the vignettes we were able to observe two aspects:the pain perception scores in the JFM group were much higher than in the other groups in all of the simulated situations;pain perception, when analyzing each individual group, is strongly influenced by the personal experience of each person.In the JIA group, the highest score obtained from the vignettes was for the social isolation simulation, followed by physical trauma and then, receiving a shot. All of the children and adolescents who made up the JIA group received shots regularly to inject medication, controlling disease activity, and for laboratorial exams. Because injecting medication may be a positive experience for these patients, it could have influenced the lower pain perception score. Similarly, the situations of isolation and physical restraint that are caused by JIA in certain moments may have influenced the higher score for the social deprivation vignette.The control group had the highest scores for pain perception from the shot simulation, followed by social deprivation and then, bicycle trauma. Healthy children and adolescents are not constantly subjected to experiences such as injectable medication. Many of these children were only given injections during their routine vaccination. We emphasize that this finding is unprecedented, since we did not find other articles aimed at measuring the perception of pain in hypothetical situations. The use of the vignettes designed in our study is still not well established in daily clinical practice. We believe that with the implementation of this instrument in the everyday routine of our outpatient clinic, we can obtain useful information to better design individual treatment plans.,The study by Varni et al.JIA, despite being an inflammatory disease, can structurally comprise the joints, tendons and muscles, making remission difficult. Illowite et al.It is commonly known that pain is a preponderant factor in patients with musculoskeletal pain that is associated with amplification, as in the case of FMJ. In our study, the JFM group had the highest pain scores when compared to the other groups. More than 50% of the members of the JFM group reported intense pain, with a pain score higher than 8 in the week prior to the interview. On the other hand, for the JIA group, this figure was lower (22%). This difference in the proportion of patients with intense pain between the groups confirmed our impressions formed in day-to-day practice: patients with JFM complain more of intense and persistent pain that interferes in daily activities in comparison to patients with JIA.Our data show that the parents of patients with JFM are able to measure the pain reported by their children better than the parents of patients with JIA. Pouchot et al.,Sawyer et al.Thastum et al.One of the limitations of our study is the fact that we evaluate subjective and personal data - pain - for which the gold standard is through self-reporting. Throughout the study we were careful to avoid external interference. All interviews were conducted by the same researcher (MMF), and the order in which the questionnaires were applied and vignettes were presented stayed the same for all the participants. The entire study was performed in the same physical space (the pediatric rheumatology clinic).Patients with JIA and JFM behave differently in relation to pain perception and the development of pain coping techniques. In our study, patients with JIA had experienced pain longer than patients with JRM, since the pain started earlier in the JIA group. This group developed a greater number of mechanisms for coping with pain. The more time exposed to pain could have contributed to the development of more coping skills.Pain originates from many factors and is influenced by several aspects while it lasts. We must evaluate the patient in pain from different perspectives. We have shown in our study that it is not enough to only measure pain intensity, we also need to deeply evaluate other aspects such as pain perception and pain coping mechanisms. Once each patient’s profile has been identified, it is the responsibility of all of the members of the multidisciplinary team to design an individualized therapeutic plan capable of relieving pain in its multiple form, with an emphasis on the physical, emotional, social and cognitive aspects.


The goal of this study is analyze the influence of perceived supervisor support (PSS) by employees at a micro level and the role of the cultural values of “power distance” and “masculinity” at a macro level on direct employee participation in decision-making (PDM). Furthermore, the influence of the gender of managers and employees is taken into account. The analysis is based upon the Sixth European Working Conditions Survey carried out by Eurofound in 2016. The results of a Hierarchical linear model indicate that all predictors significantly influenced PDM; PSS positively and cultural values negatively. When the gender of managers and employees is considered, the findings suggest that PSS has a larger impact on PDM when male managers address female employees. Regarding the moderating effect of PSS on cultural values, it is shown that masculinity and power distance lose importance when employees have the support of their supervisors. Competitiveness, the uncertainty of the economic environment, and socio-cultural changes have resulted in modern, diverse and flexible organizations. In this context, new management styles characterized by the participation of employees in the decision-making process have emerged.There is a growing consensus among HR researchers and professionals that a participative environment can enhance employees’ job satisfaction, commitment, motivation and productivity  and creaThe role of the manager as a starting point for the inclusion of employees in PMD has been demonstrated . PreviouIt is known that national cultural values have an influence over organizations . This paMost relevant studies on cultural values and participation focus on power distance and uncertainty avoidance. In contrast, few empirical studies have been done on masculinity and employee participation. Assuming the relevance of gender, the current study aims to fill this gap in the literature. Masculinity, one of the culture dimensions studied by Hofstede, is a value that affects the relationship between roles at work and gender. Women are warm, sensitive, and caring in their domestic role, even though they are increasingly demanding occupational roles. Correspondingly, men are considered assertive and competitive, and they tend to demand leadership roles . ConsistThe analysis of the direct influence of cultural values in the PDM, as well as the moderating role of the PSS in this relationship, is another contribution of this paper. In addition, this allows identifying which European countries promote more (and less) the direct employee participation in making decisions and comparing this ranking with that regarding the analyzed culture dimensions of Hofstede.The empirical analysis is based upon the Sixth European Working Conditions Survey EWCS;  carried The article is structured as follows. After the introduction, the second section defines the concept of direct employee participation (PDM). The third section provides the theoretical arguments that ground the expectations and hypotheses on PDM’ micro- and macro-level determinants. The data and the definition of the dependent and independent variables of the fitted hierarchical regression model are included in the fourth section. Next, the fifth section analyses the results, and, finally, the sixth section includes the discussion of the results and the limitations of the study.Employee participation includes all the practices developed in organizations that allow employees to participate in the decision-making process . It can per se is a process linked to authority and power in organizations, so whoever has the power is the person who ultimately exercises decision-making. According to Decision-making The main driver of this change is trust. As Simultaneously, based on social exchange theory, employees value recognition and fair treatment, whereas supervisors value performance and loyalty . Given tTherefore, PSS is considered by the current study as a micro variable that determines direct employee participation.As a result, the following is expected:H1: PSS by employees is positively related to their direct PDM.The gender perspective is included in this study at two different points of view. On one hand, direct PDM is analyzed from the perspective of the employees’ gender. This analysis will allow us to verify whether the participation of women in making decisions at workplace is lower than that concerning men, which would corroborate the existence of a situation of inequality even in the 21st century. This measurement of inequality between men and women is a novelty in the literature and one of the contributions of this study. The gender gap in a workplace context is usually related to differences in wages (gender pay gap)  and the H2: Female employees have lower direct PDM than men.On the other hand, the influence of the manager’s gender is studied assuming its role as a promoter of direct employee participation. This perspective is also of interest for two main reasons. The first is the relevant papers on women in management. According to a study from H3: Employees managed by women have a higher direct PDM than those managed by men.Previous studies analyze the relationship between managers and employees in terms of gender. H4: Perceived Supervisor Support (PSS) has a different impact on direct employee PDM according to the manager-employee gender dyad.Research on cross-cultural management  indicatePower distance is defined as “the extent to which the less powerful members of the institutions and organizations of a country expect and accept that power is unevenly distributed” . That isIn organizations with a low power distance, communication between manager and employee is more open, which translates into a high level of participation and therefore joint decision-making. This is because employees of low-power organizations are more likely to have direct contact with their managers. Conversely, if the distance becomes greater, employees will work independently of the managers. With this, contact is reduced, and the possibilities of co-decision tend to decrease . FurtherFollowing gender differentiation, countries with a high level of masculinity make differentiation between male and female responsibilities. In this sense, women are related to house responsibilities and men are able to develop a career . MasculiThe present study aims to understand if direct employee PDM promoted by organizations is linked to the cultural dimensions of the country in which they are located. Thus, the following hypotheses are established:H5: The greater the power distance in the culture where the organization is located, the lower the level of direct employee PDM.H6: The higher the level of masculinity in the culture where the organizations is located, the lower the level of direct employee PDM.In the literature, some studies analyze the cultural values at the individual level as a moderator variable of POS . ConsideA study on the Chinese hotel industry  indicateH7: Perceived supervisor Support has a moderating effect on the influence of the power distance dimension on direct employee PDM.Apparently, women and men are very similar in their leadership styles, but females often have a larger supporting role . The genH8: Perceived supervisor support has a moderating effect on the influence of the masculinity dimension on direct employee PDM.The testing of previously formulated hypotheses involved a three-stage process. First, a factor analysis was carried out to obtain the values of the variables related to employees (direct PDM and PSS). Second, descriptive and inferential statistics analysis were carried out in order to justify the selection of the variables used to predict the PDM. In addition, thirdly, hierarchical linear modeling (HLM) was applied to explain direct employee PDM by PSS at a first level (employee) and the national cultural values (Power distance and Masculinity) at a second level (country). The gender of the employees and their managers was included in the analysis as a control variable. The data analysis procedure was conducted using the 25th version of SPSS statistic software.The analyses are based upon the Sixth European Working Conditions Survey EWCS;  carried p-value = 0.000 when testing the null hypothesis that the proportion of men in management positions is 50% against the alternative that it is greater). These figures are close to the information published by Since the objective of this study is to analyze direct PDM by employees (no managers), as well as the role of their supervisors’ supporting in this participation, the cases related to managers were identified and later removed from the original database. The final sample includes 26,079 employees with information about the gender of them and of their bosses. According to the contingency table , the prop-value = 0.000, so the null hypothesis of independence between the gender of employees and their managers was rejected). Moreover Phi coefficient was computed (0.42) showing a moderate and significant (sig. = 0.000) relationship between both genders.If the gender of both employees and their managers is considered, 65% of male managers work with male employees . Regarding employees managed by women, only 19% are men (compared to 80% of women). Therefore, in most of the cases observed, the gender of employees and bosses coincides. This relationship was ratified with a Chi-square test . Concretely, employees are asked about eight questions related to their participation in making decisions about the order of their tasks, their methods of work, the speed or rate of work, improving the work organization, choosing their work colleagues, applying their own ideas, influencing important decisions and being consulted before objectives are set. Cronbach’s alpha was computed in order to measure the internal consistency of these eight items used to measure the construct “Participation.” The value of alpha was 0.814 so it ratifies a good internal consistency. In addition, the Cronbach alpha coefficient was reduced if any of the elements considered was removed from the reliability analysis. A factor analysis was carried out based on these eight survey questions, specifically, principal component analysis. The results ratified that factorial analysis was appropriated . Two components were found that explained 63% of the total variance. This fact ratifies the theoretical classification of direct PDM into two categories: individual task discretion and organizational participation . The firPerceived supervisor support by interviewed employees was considered the independent variable in the hierarchical regression model in the first stage at the company level. Later, at the country level, indexes regarding power distance and masculinity were added.Perceived supervisor support can be defined as employees’ general opinion concerning the degree to which supervisors value their contributions and care about their well-being . It was 1.For the country level, the indexes of the cultural values of power distance and masculinity provided by Several authors have suggested that the gender of one’s boss is an important control variable in direct participation research . It has t-test).Direct employee PDM and PSS values obtained by factor analysis were ranked between 0 and 1 to make its interpretation easier. Descriptive statistics (Mean and Standard Deviation) for both variables are reported in p-value is 0.228), the null hypothesis of equality of the two means of male and female employee PDM is rejected . Therefore, female employees have lower direct PDM than male employees . This result supports hypothesis H2, which predicts a lower direct PDM from women employees. Concerning the values of PSS, female employees perceive greater support from her supervisor (0.6847), on average, than men (0.6785). In this case, the t-test ratifies this difference  under the assumption of inequality of the variances . Therefore, if women participate less but perceive greater support from their supervisor, the higher PSS perceived by female employees does not always translate into higher direct PDM. This result highlights the need to delve into the relationship between PSS, PDM and gender through regression analysis.For example, regarding direct employee PDM, the statistics indicate that female employees participate less, on average, than male employees (0.5528 vs. 0.5826). After the acceptance of equality of the variances (Levene’s test H3 is not supported by data). According to PSS, it was significantly greater for employees with female managers.When the gender of managers is analyzed without consider the gender of the employees see  direct et-test for independent samples was carried out considering all the possible gender combinations  is different according to the gender of both employees and managers. This result justifies the inclusion of gender as a control variable that influences the relationship between PDM and PSS.Moreover, a correlation analysis was analyzed to justify the inclusion of the independent variables in the regression model see  as well To study in deep the influence of the gender combination (manager-employee) in the linear relation between PSS and PDM, an analysis of linear correlation coefficient was made for each subgroup. Then a hypothesis test about the difference of these coefficients was carried out using Fisher’s Z transformation in order to detect if these differences were significant or not . ResultsAs the predictor variables are at two different hierarchical levels , HLM was applied to analyze variance in direct employee PDM using the whole sample see  Model 1.The standardized values of the regression coefficients (showed in ∗∗∗) has a higher impact on employee participation when male managers address female employees. The difference between this coefficient and the rest of the cases would be significant according to the results of the hypothesis test of the difference between correlations coefficients previously made ; however, it has no significant relationship when the manager is male. Thus, PSS moderates masculinity level in organizations where managers are women.As expected in Hypothesis 1, and according to the correlation coefficient previously computed , PSS is sly made . In this∗), and loses significance in the gender classification . The moderating effect of PSS over power distance means Hypothesis 7 is not totally support. Only when female managers lead female employees is the moderating effect significant. The relationship between the analyzed variables and the tested hypothesis are included in In addition, PSS has a low moderating effect in power distance in the general model . On the other hand, to further clarify the debate on the effect of PSS in the aforementioned participation, as well as the effect of national cultural values and the gender of both managers and employees in such a relationship.Concerning the first objective, the study reveals that currently, in the European context, the number of women in management positions is still considerably lower than that of men. In addition, direct participation in decision-making is also lower in the case of women. Therefore, we can affirm that today, in the European company, women are still in a situation of inequality with respect to men in terms of participation in decision-making and in the performance of leadership positions.Regarding the second purpose, the research shows that PSS has a direct relationship with employee PDM, whereas cultural dimensions such as masculinity and power distance have a negative effect. Additionally, the current study confirms that the gender of managers affects direct employee PDM in different ways based on the gender of the employee. Concretely, direct employee PDM is, on average, greater in the case of female managers, especially with male employees  but the difference is not significant. It has been found, that PSS has a greater influence on direct PDM when the manager is a man and the employee is a woman. Therefore, when a male manager gives his support to a female employee, this support is transformed into a higher PDM than in other gender combinations.It has also been found that female managers tend to mitigate the effect of the masculinity of the country where the organization is located.Previous researchers suggest that a participative environment can enhance employees’ job satisfaction, commitment, motivation and productivity . ManagerIn general, all hypotheses were supported. Consistent with previous research, PSS plays a crucial role as a promoter of employee participation in organizations. These results lend further support to the notion that employees feel supported by managers when they encourage them to participate in the decision-making process . EvidencWomen in management position are also more supportive in organizations located in countries where the masculinity value is predominating; they are considered agents of change for gender integration . In othePrevious studies proved that PSS delivered more quality service in cultures with traditionally high power distance . HoweverBased on these findings, it can be concluded that gender differentiation is a crucial feature in the analysis of participation in Europe organizations.Although previous studies indicated that gender diversity and a balanced number of women and men in PDM can lead to positive outcomes in the organization, inequalities between gender in PDM remain a large concern and an unresolved problem in most companies around the world due to the huge gap between the number of women and men in PDM positions. This could be precisely the cause of one limitation of this study, the smaller sample of female managers in comparison to that of male managers. This could affect the capacity to generalize some of the findings. Additionally, the cases of female employees leaded by female managers are astonishingly lower in comparison with those leaded by male managers. This makes difficult the comparison of the results for both groups.Another weakness of this study is that it is based solely on the perceptions of the workers, so it would be appropriate to take into account the opinion of the managers and compare the results.In future research, it would be interesting to analyze in more depth the difference by countries in direct employee PDM as well as the influence of other cultural dimensions proposed by Hofstede not included at this study.Finally, it is necessary to highlight that right now, this paper has an extraordinary opportunity to promote the role of women in the economic sphere, which is indispensable to entails fostering gender equality in education, employment and leadership positions, so we should take advantage of the moment.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.