The aim of this study is to investigate the factors influencing consumer willingness to accept the use of insects to feed poultry, cattle, pigs, and fish. To reach this objective, we conducted an online survey with Brazilian consumers. 600 questionnaires were collected. We analyzed data using descriptive statistics and logistic regression models. In general, the use of insects to feed poultry, pigs and cattle was not widely accepted. A more widely acceptance was found for the use of insects to feed fish. The results of logistic regressions models show that positive attitudes are associated with a higher probability of accepting the use of insects to feed poultry, pigs, cattle, and fish. Perceived benefits were associated with a higher likelihood of accepting the use of insects to feed fish. However, perceived benefits were also associated with a lower likelihood of accepting the use of insects to feed poultry. Perceived challenges were associated with a higher likelihood of accepting the use of insects to feed poultry. However, perceived challenges were associated with a lower likelihood of accepting the use of insects to feed pigs. The increase in the world’s population will cause a higher demand for animal-source food, which will require a boost in the production of proteins, because proteins are important components of animal feed . A higheHermetia illucens, HI) has been included as an ingredient in animal feed, and its use is restricted to aquaculture [The regulatory system on the use of insects in animal feed differs between countries. The European Union currently authorizes the use of processed animal proteins (PAP) derived from insects in aquaculture , but Euraculture . In Canaaculture . Brazil aculture .Regarding consumer reactions to the use of insects in animal feed, a major concern is that in general humans avoid unfamiliar foods , particularly from animal origins , 11. TheSpecifically, studies on consumer preferences and barriers for the use of insects in animal feed are scarce , 9. VerbBrazil is one of the main producers and exporters of animal-source food and the greatest feed protein supplier in the world. Most of the protein used to feed animals comes from common sources  . TherefoConsidering the foregoing, the aim of this study is to investigate the factors influencing consumer willingness to accept the use of insects to feed poultry, cattle, pigs, and fish. Such factors include consumer attitudes towards using insects in animal feed, perceived benefits, perceived risks, perceived challenges about the use of insects in animal feed, and socio-demographic characteristics. We believe that such a study can provide insights to policy makers and private companies that can be used to develop strategies to increase the acceptance of the use of insects to feed poultry, cattle, pigs, and fish.We developed four similar questionnaires. Each questionnaire focuses on a specific animal . The questionnaires consisted of four groups of questions adapted from Verbeke et al. . In the To collect data, we conducted an anonymous online survey. The survey was distributed in all regions of Brazil. The sampling and the application of the survey were performed using a specialized market research company, which has its own panel of respondents. Registration in the panel is voluntary and recruitment of participants occurs by advertisements in social media by people who find the company’s website themselves or by people who are referenced to by other users. In our research, respondents were randomly selected in the panel and received an invitation to participate in the survey. Upon acceptance, they received incentives . To ensure the necessary level of rigor, we monitored and commented on each step of the sampling and survey implementation. 600 questionnaires were collected, 150 for each of the four animals. The data collection took place in March 2018.Statistical analysis was conducted in three steps. In the first step, we used descriptive statistics to characterize the respondents and the main measures. In the second step, we used factor analysis to reduce the number of items that represent consumer attitudes, perceived benefits, perceived risks, and perceived challenges about the use of insects in animal feed. Principal component analysis was used as the extraction method. The criterion to define the number of factors was an eigenvalue greater than one . Items wIn the third step, we ran four logistic regression models. The dependent variable was consumer willingness to accept the use of insects in animal feed. We tested the impacts of five groups of independent variables: socio-demographic characteristics, attitudes, perceived benefits, perceived risks, perceived challenges about the use of insects in animal feed. The significance level was p<0.05. We assessed multicollinearity by running multiple regressions, each with a different item as the dependent variable and the rest of the items as independent variables, and then verifying the tolerance and variance inflation factor (VIF) . We founDescriptive statistics are presented in The results of factor analysis showed an eigenvalue above 1.0 for the items measuring attitude, perceived benefits, perceived risks, and perceived challenges. The same pattern occurred in the analysis of data from the four questionnaires. We decided to remove one item measuring perceived risk due to its cross factor loading. The item was excluded from the analysis of data of the four questionnaires. The item was ‘The use of insect-based meal in animal feed can increase competitiveness with other agricultural activities.’By adapting from Verbeke et al. , we creaDescriptive statistics of the statements used to measure attitudes, perceived benefits, perceived risks, and perceived challenges are presented in We tested whether socio-demographic characteristics, attitudes, perceived benefits, perceived risks, and perceived challenges could affect consumer willingness to accept the use of insects to feed poultry, cattle, pigs, and fish. The socio-demographic characteristics gender and educational level did not affect consumer willingness to accept the use of insects to feed poultry, cattle, pigs, and fish. A one-year increase in age was associated with a 10% decrease in the likelihood of accepting the use of insects to feed fish. Living in the Midwest, Northeast and North of Brazil was associated with an 80% decrease in the likelihood of accepting the use of insects to feed cattle. A one-unit increase in income was associated with a 73% decrease in the likelihood of accepting the use of insects to feed fish. Consumers who indicated previous contact with pig farms were 3.8 times more likely to accept the use of insects to feed pigs than those who did not indicate a previous contact. Positive attitudes were associated with a higher probability of accepting the use of insects to feed poultry, pigs, cattle, and fish. Consumers who perceived higher benefits were more likely to accept the use of insects to feed fish than those who perceived lower benefits. However, consumers who perceived higher benefits were less likely to accept the use of insects to feed poultry than those who perceived higher benefits. Consumers who perceived fewer challenges were more likely to accept the use of insects to feed poultry than those who perceived more challenges. However, consumers who perceived more challenges were more likely to accept the use of insects to feed pigs than those who perceived fewer challenges.This is the first study investigating consumer willingness to accept the use of insects in animal feed in Brazil. Our results contribute to the existing literature because previous studies have shown that consumer willingness to accept new food technologies, such as the use of insects in animal feed, depends on the country where the study is conducted –26.We found a higher acceptance of the use of insects to feed fish compared to poultry, pigs and cattle. The use of insects to feed cattle presented the lowest acceptance rate. These results are somehow in line with Verbeke et al. , who alsInterestingly, the average scores for all items measuring attitudes, perceived benefits, perceived risks, and perceived challenges are in a central position  for the four animals analyzed. There are some possible explanations for these results. First, when a Likert-scale with a neutral response option is used people might choose the neutral point to avoid the cognitive effort required to pick a satisfactory answer, which is called satisfice . SecondlThe results of the logistic regression models were slightly different, indicating that the factors influencing consumers’ willingness to accept the use of insects in animal feed depend on animal  that will feed on insects. In general, socio-demographic characteristics seem not consistent to explain consumer willingness to accept the use of insects in animal feed because no socio-demographic variable that we tested had a significant impact in all four logistic models. Instead, age and income were significant in explaining consumer willingness to accept the use of insects to feed fish, with an increase in age and an increase in income being associated with a lower likelihood of accepting the use of insects to feed fish. These results might be explained because older individuals with a lower income are more neophobic; they are more prudent and seek safer and known foods . ConsumeThe results of the logistic regression models showed that consumer attitude towards the use of insects in animal feed consistently explain consumer willingness to accept the use of insects in animal feed. These results are in line with previous literature that found that individuals holding more positive attitudes were more willing to accept new food technologies , 9, 26. The results of the logistic regression models also showed that perceived benefits affect consumer willingness to accept the use of insects to feed poultry and fish. Surprisingly, consumers who perceived more benefits were less willing to accept the use of insects to feed poultry. This result is hard to explain. A possible explanation is that the use of insects as an alternative source of protein is new and unfamiliar, therefore consumers might not have a clear picture of the possible benefits presented in the questionnaire. Indeed, according to Napier et al. , most coIn logistic regression models we also found that perceived challenges affect consumer willingness to accept the use of insects to feed poultry and pigs. Once again, results for poultry are difficult to interpret because consumers who perceived more challenges were more willing to accept the use of insects to feed poultry. A possible explanation is that individuals who are presented to unfamiliar food technologies might not understand them, causing some resistance and challenges . HoweverFrom a private and public policy perspective, our results provide insights that can be used to design strategies to increase the acceptance of the use of insects in animal feed. The strong and consistent impact of attitudes on consumer willingness to accept highlights the importance of design strategies to disseminate the benefits of using insects to feed animals. For instance, we believe that important benefits disseminated by information campaigns are, for instance, ‘the use of insects in animal feed decrease environmental impacts of food production’ and ‘the use of insects in animal feed increases animal productivity.’ In addition, the academia and industries should collaborate closely to develop further research and technology related to the use of insects in animal feed and the population should be engaged in this process, which might increase the willingness to accept this technology.A potential limitation of our study is that online representativeness is not similar as the representativeness of the whole Brazilian population. Hence, our sample cannot be considered fully representative of the Brazilian population. Therefore, our findings must be considered primarily as exploratory. Another limitation was that consumers might not have enough information to evaluate the use of insects in animal feed. Therefore, it is possible that respondents faced difficulty in predicting their willingness to accept, their attitudes, perceived benefits, perceived risks, and perceived challenges about the use of insects in animal feed.Because we found contradictory results about the impacts of perceived benefits and perceived challenges on consumer willingness to accept the use of insects in animal feed, we recommend that future studies further explore these issues. We believe that a clearer picture should emerge when information about the use of insects in animal feed becomes widely available for consumers in Brazil. Future studies might also benefit from the use of recent standardized questionnaires developed to measure consumer attitudes towards the use of insects in animal feed .S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.


Background: Mental illness, multi-morbidity, and socio-economic inequalities are some of the main challenges for the public health system nowadays, and are further aggravated by the process of population aging. Therefore, it is widely accepted that health systems need to focus their strategies for confronting such concerns. With guaranteed access to health care services under universal coverage in many health systems, it is expected that all services be provided equally to patients with the same level of need. Methods: In this paper, we explore the existence of inequalities in the access to services of patients with mental illness taking into account whether they are multimorbid patients, their socioeconomic status, and their age. We take advantage of a one-year (2010–2011) database on individual healthcare utilization and expenditures for the total population  of the Basque Country. Results: More comorbidity leads to greater inequality in prevalence, being the poor sicker, although with age, this inequality decreases. All health services are more oriented towards greater utilization of the poor and sicker, particularly in the case of visits to specialists and emergency care. Conclusions: Mental health inequalities in prevalence have been identified as being disproportionally concentrated in the least affluent areas of the Basque Country. However, inequalities in the utilization of publicly-provided health services present a pro-poor orientation. As this region has adopted a system-wide transformation towards integrated care, its mental health delivery model offers excellent potential for international comparisons and benchlearning. Mental illness, multi-morbidity, and socio-economic inequalities are some of the main challenges for health systems nowadays and are further aggravated by the process of population aging. Therefore, it is widely accepted that health systems need to focus their strategies for confronting such concerns.Mental disorders are among the major causes of ill-health and disability worldwide ,2, accouDuring the last decades, the change in the burden of disease evidenced by the increase in the prevalence of chronic diseases has become a major concern for health systems ,12,13,14Universal health systems aim to provide equity in access to health insurance and health provision. Different notions of equity in access have been discussed traditionally in the literature , such aLow socioeconomic status affects different aspects of social life, health status, and health care utilization among them. Dimensions of social inequalities in health are commonly measured by SES indexes or various indicators defined by individuals’ level of education, labor market status, income, or material wealth. Socioeconomic status is especially important for the elderly because they conform to a vulnerable group, being at higher risk of social and family isolation and loneliness, which may explain anxiety and depression in older age . FeelingWe focus our analysis on the prevalence of mental illness and study the existence of inequalities in multimorbidity and the use of health care resources by SES and age, which has an increasing relevance because of the aging process in our society. Although the literature, as presented, has extensively analyzed the impact of mental health on those variables separately, we contribute to the literature by focusing on the presence of mental illness but looking at the distribution of all other variables. If there are inequalities in the presence of mental disorders with other conditions due to socioeconomic status for the elderly, that will come with a greater relevance given their greater exposure to vulnerability and unfavorable socioeconomic circumstances.Eckersley (2015)  explainsWe take advantage of our analysis with a rich dataset containing clinical and administrative records from the Basque Country, a northern region in Spain. The Basque population, like the rest of the population in Spain, has universal health coverage, access to publicly-funded health care services is free at the point of delivery, with patients paying copayments only on prescribed medicines, the retired and some chronically ill being excluded ,40. We aWe utilized a database elaborated by the population stratification program (PREST) of the Basque Country, owned by the Basque Health Service and whose access is restricted. It included every individual covered on 31 August 2011 by the public health insurance in the Basque Country and who had been covered for at least 6 months in the previous year, regardless of whether they used the Basque Health Service or not. Hence, with universal health insurance, the dataset included practically the entire population of the Basque Country. This dataset had been used previously in the literature (see for instance  or 41]))41]).PREST dataset combines all clinical and administrative information available to the regional public health authorities, and thus, we had individual-level data on age, sex, health care use by type of services and diagnosis, small area of residence indicator, and socioeconomic status. The analyses presented here covered one year, from 1 September 2010 to 31 August 2011. The total sample included 2,262,698 individuals; slightly more than half of them were women (50.9%). The average age was 42.2 and 45.1 years for men and women, respectively. Children and adolescents (aged 16 years and below) represented 13.5% of the sample, while the elderly represented almost 20% of the population.Following the national health policy guidelines set by the Ministry of Health, Social Services and Equality of Spain, Basque Health authorities codified diagnoses on hospital discharge forms, emergency department and primary care medical records according to ICD-9-CM , while tOur choice of mental health indicators was based on relevance, as measured by prevalence in the study population greater than 0.5%, and was consistent with different studies in Spanish ,46 and iMultimorbidity was defined as the coexistence of two or more chronic conditions in the same patient. As we focused our attention on patients with mental health conditions, multimorbidity was defined as the presence of at least one additional chronic disease to the existing mental health condition. We followed the methodology proposed by Barnett et al. (2012)  and OrueIndividual SES is based on the deprivation index (DI) elaborated by the MEDEA project in 2008 . The DI Health care is measured based on the cost-weighted actual use of health care services over a year. Our dataset contained information on the following types of services: primary care , specialist care , emergency care, use of pharmaceuticals , and inpatient stays in general hospitals. Hospitalizations in monographic psychiatric hospitals were not included in our analysis as they were not available in the dataset. We used all the contacts within the health system, coded, as mentioned before, according to ICD-9-CM , and allThe primary and specialized care expenditures were calculated by multiplying the number of services used by each individual by a standardized cost, calculated as the average cost per visit or use of those health services among their total cost. The cost of inpatient care in general hospitals was determined according to its weight in the corresponding Diagnosis-Related Groups (DRGs). Finally, the cost of prescribed pharmaceuticals was based on market prices following the registry of pharmaceutical expenditures through prescriptions in the Basque Health System during the length of our study. We estimated a linear regression to assign the cost associated to each individual because of the provision of health services from several providers to all the different diagnoses registered by each patient following the conventional risk adjustment methodology .CI) [CI allowed measuring the distribution of one variable of interest  against the ranking of another, usually socioeconomic variables , and ranges were between −1 and +1. When the variable of interest was the presence of a mental chronic condition, negative (positive) values of the CI indicated that there was socioeconomic inequality in favor of the worse-off (better-off). If the CI equaled 0, there was no evidence of inequality in mental health that could be attributed to socioeconomic status.To assess socioeconomic inequality in mental health in this study, we calculated the concentration index (CI) . The CI CI. The one that was most convenient for our analysis was the one proposed by Wagstaff (2002) [n is the sample size; hi is the mental health indicator; μ is the mean of mental health in the population; and Ri is the relative rank in the socioeconomic distribution of the ith individual, being the 1st person, the poorest one (i = 1) and the nth person, the wealthiest one (i = n).There are different ways of formally expressing the f (2002)  and it cAlternatively, the concentration index could be calculated using the ‘convenient regression’ expression based on the covariance between CI is a widely used measure of socioeconomic inequality in health and health care because it satisfies a number of desirable properties [CI may depend on the mean of the health variable; not allowing for comparisons across population groups with different mean heath levels [CI separately for men and women and for all age groups, to be able to compare the status of the elderly with respect to the population.The operties . Its majoperties . Neverthh levels . In ordeh levels . Thus, wHI) as the difference between the actual health care utilization inequality (observed CI) and the estimated inequality associated to need [Concentration indices for actual health care use reflected inequalities in the amount of care different individuals got. However, in order to assess the degree of inequity in the use of health care, we needed to adjust for the varying needs among individuals. Therefore, we calculated the horizontal inequity index  was 57.08%. Depression hit 35.284 individuals out of every 1000 and the prevalence increased with age. The prevalence of depression was nearly three times higher in women than in men . Interestingly, deprivation was positively related to depressive disorders only for women, while the rates of prevalence only slightly varied by socioeconomic status for men.Average total health expenditures and costs by type of health services, calculated on the basis of actual health services utilization, by mental health disorder and age groups are shown in The results regarding socioeconomic inequality in multimorbidity by mental health problem are shown in CI of pharmaceutical expenditures among those who suffered from dementia), which indicated that individuals living in less affluent areas were more likely to use these services  with mental illnesses is much more severe in poor than in rich neighborhoods. As in Schiøtz et al. (2017) , we inteEven in countries where access to health services is guaranteed and does not seem to be a major concern, the diversity of health policies at a regional level can explain these inequalities on the pro-poor or pro-rich orientation of the publicly–funded mental healthcare provision. For instance, the Basque Country Health System has been a pioneer in the adoption of chronic care strategies and the emerging healthcare delivery model offers excellent potential for international comparisons, given its specific characteristics: a relatively homogeneous system providing universal coverage; a model based on primary care in the community; good integration of primary care and mental health; and successful implementation of a model of comprehensive care for chronic conditions ,71. At tAnyway, this final element is a limitation of our study as the available dataset does not contain information regarding social services for patients with mental health problems. Two other limitations related to the dataset should be noted, the lack of data on hospitalizations on monographic psychiatric hospitals and the absence of information on privately-funded healthcare utilization. Regarding the psychiatric hospitalizations not included in our dataset, they are related to patients with serious mental illness and publicly-funded, as privately-funded services for this severe profile of patients are almost non-existent in the studied region.Mental illness, multimorbidity, and socioeconomic inequalities represent important challenges for the public health system in many countries, even more so due to the aging of the population. In this paper, we examine the prevalence of mental illnesses and the use of public health services by their patients, taking into account whether they suffer multiple chronic conditions, their socioeconomic status, and their age. We take advantage of data from the regional Basque Health System for practically the entire population (over two million) of the Basque Country.We find inequalities in the prevalence of mental illness, which is significantly greater in more deprived economic areas, although with age, this inequality decreases. Even more, when taking into account the existence of other chronic conditions in mental health patients, it is in more deprived areas where we find more multimorbid patients with mental illness conditions. We also find some inequalities in the use of resources, in all types of health services, they are more oriented towards greater utilization of the poor and sicker, particularly in the case of visits to specialists and emergency care. Belonging to the National Health System in Spain, our results are consistent with the guaranteed equity in access to public health services. But, even if access is not a concern, socioeconomic inequalities in the prevalence remain that are space- and time-dependent and are multiple rather than singular. Managers and decision-makers should not take them as ‘given’ but as something that can be tackled with policies and well-targeted interventions, resulting in a pro-poor orientation like the case of the Basque Country has shown. This Region has adopted a system-wide transformation towards integrated care , oriente


Purpose This study describes the development of an evidence-based intervention to create a supportive work environment for employees with chronic conditions. Occupational physicians (OPs) play an important role in guiding organizations in this process of organizational change. Supportive work environments can aid in preventing work-related problems and facilitate sustainable employment. Current workplace interventions for employees with chronic conditions are mainly focused on return to work or a reduction in sick leave at the individual worker’s level. This study contributes to the literature an organizational-level intervention which utilizes a preventive approach. Methods Intervention mapping (IM) is a six-step, structured protocol that was used to develop this intervention. In step 1, a needs assessment was conducted to define the problem and explore the perspectives of all stakeholders involved. The program outcomes and the performance objectives of employees with chronic conditions and occupational physicians were specified in step 2. In step 3, appropriate methods and practical applications were chosen. Step 4 describes the actual development of the intervention, consisting of (1) a training for occupational physicians to teach them how to guide organizations in creating a supportive work environment; (2) a practical assignment; and (3) a follow-up meeting. The intervention will be implemented in a pilot study in which occupational physicians will put their acquired knowledge and skills into practice within one of their organizations, which is delineated in step 5. Conclusions IM proved to be a valuable and practical tool for the development of this intervention, aiming to facilitate sustainable employment for employees with chronic conditions.The online version of this article (10.1007/s10926-020-09885-z) contains supplementary material, which is available to authorized users. The number of people in the working population with one or more chronic conditions is increasing , 2. WorkMuch research has been conducted on factors associated with sustainable work participation for employees with chronic conditions, showing that personal, disease-related, as well as work-related factors are of importance –6. In thIn recent years, people with chronic conditions have been encouraged by the Dutch government and society to take control over their lives, including their work . Self-cocapacity to exert self-control or on changing the context in which self-control is exerted [Interventions aimed at increasing the exertion of self-control can focus on an individual’s  exerted . Based o exerted . However exerted . Changin exerted . This imOccupational health professionals could play a key role in increasing the exertion of self-control of employees with chronic conditions, both by supporting individual employees and by helping to create these supportive work environments. In the Netherlands, occupational physicians (OPs) have the task of supporting and advising employees and organizations on issues related to work and health to facilitate sustainable employment . In receBased on the importance of the context in which self-control is exerted, it can be inferred that it is essential that an intervention for employees with chronic conditions should focus on changing the work environment. These interventions aimed at organizational change can result in creating supportive environments, thereby providing employees with chronic conditions with the right conditions to exert self-control and leading to the prevention or early identification of work-related problems. By changing the OP’s role and making OPs an essential part of organizational-change interventions, they are able to use their expertise on work and health to guide organizations in creating supportive work environments for employees with chronic conditions. This role enables OPs to collaborate closely with organizations, reducing the distance between employer and OP and supporting and guiding preventive measures within an organization. To the best of our knowledge, no intervention has been developed aimed at increasing the exertion of self-control for employees with chronic conditions by changing the work context. The aim of this study is to develop an intervention for OPs with the purpose of creating supportive work environments for employees with chronic conditions by guiding organizations in making these changes. For the development process, we used intervention mapping (IM), which “provides a framework for effective decision making during planning of intervention programs, including the planning of implementation and evaluation” .IM is a stepwise protocol used for planning and developing effective behavioral and environmental change interventions, consisting of six steps  and the needs (‘what should be’) of all the stakeholders. The needs assessment consisted of a qualitative synthesis to gain insight into the concept of self-control and the influence of the environment on the exertion of self-control for employees with chronic conditions . In addiSelf-control is defined as “the capacity for altering one’s own responses, especially to bring them into line with standards such as ideals, values, morals, and social expectations, and to support the pursuit of long-term goals” (p. 351) . In our During the interviews, OPs expressed the importance of early identification of work-related problems. Currently, OPs do not have a clear overview of all employees with chronic conditions within the organization, as most employees with chronic conditions consult their OP only in cases of already existing work-related problems or sick leave. Support from and collaboration with the work environment were described by OPs as important prerequisites for sustainable employment for employees with chronic conditions. OPs also stated the importance of a positive organizational attitude towards employees with chronic conditions and a supportive workplace culture. In a study by Abma et al., OPs also stated the importance of clear communication and a supportive organizational culture on sustainable employment. In addition, OPs described their desire to have a more preventive role, instead of focusing a large proportion of their time on return to work or sick leave .During the interviews, employers and human resource managers highlighted the importance of collaborating with OPs and employees and making sure that mutual expectations are clear. Currently, employers and human resource managers mainly focus on looking at an individual employee’s work capacity and, in case of need, facilitating work adjustments. Work adjustments can, however, only be implemented to a certain extent. Adjustments such as task redistribution or shifting work tasks to colleagues is not always possible. OPs and organizational representatives pointed out the importance of having a clear organizational policy for working with a chronic condition and preventing work-related problems within an organization. Literature on the needs and perspectives of organizational representatives has shown the important role of employers and human resource managers when it comes to supporting employees with chronic conditions , 32. At The results of this first step provide clarity on the behaviors of an employee with a chronic condition, the influence of the environment (work environment and current support from OPs) and perspectives of OPs and organizational representatives on sustainable employment. It is clear that preventing work-related problems and sustainable employment requires the commitment of all stakeholders involved. Employees exerting self-control means executing the abovementioned desired behaviors. However, employees must be enabled and supported by the work environment to actually execute these behaviors. Organizational policies could thereby facilitate sustainable employment for employees with chronic conditions. OPs can fulfil their preventive tasks by offering advice on organizational policy development and guiding organizations towards more supportive work environments.the employee with a chronic condition will exert self-control) of the intervention to be developed was identified, after which the performance objectives were specified. The performance objectives operationalize what needs to be done in the behavior of the employee with a chronic condition in order to accomplish the behavioral outcome. The performance objectives associated with the behavioral outcome of the employees with chronic conditions are listed in Table In this second step, a logic model of change was created (see online resource 1), visualizing the effects of the intervention on behavior and the environment. As a starting point, the behavioral outcome (OPs collaborate with the work environment in supporting employees with chronic conditions to exert self-control), which was considered the most relevant environmental outcome level. Performance objectives were identified for the environmental outcome, with OPs being the environmental agents of importance at the organizational level , attituThe intervention was conceptualised and designed in step 3, based on the logic model of change created in step 2. In this step, an initial program plan was conceived with the program components, scope, and sequence. Additionally, theory- and evidence-based methods and practical applications were chosen to influence the change objectives.The design of the intervention and selection of chosen methods and applications were extensively discussed within the project team to make sure that appropriate methods were used to influence the relevant determinants. As the work environment is crucial for employees with chronic conditions to express the desired self-control behaviors in the workplace (e.g. disclosure and requesting accommodations), the scope of the program was to develop an organization-specific policy and to create a supportive environment for these employees. By changing the role of OPs, they are able to focus more on prevention of work-related problems and support of organizational preventive actions. OPs can fulfil their preventive tasks by guiding and advising organizations in the process of organizational policy development and creating a supportive work environment. Online resource 3 shows examples of the theoretical methods and practical applications chosen for changing the attitudes, skills and self-efficacy, and perceived norms among the OPs, enabling them to guide organizations in developing an organizational policy and creating a supportive work environment.When developing an organizational policy and creating a supportive work environment, it is important to include all stakeholders within an organization in the process. The participatory approach (PA) is an effective evidence-based approach for addressing and tackling existing barriers in an environment where different stakeholders could have varying perspectives regarding these barriers. The PA is a structured six-step process: (1) creating the right conditions, (2) analysis of barriers, (3) analysis of solutions, (4) plan of action, (5) implementation, and (6) evaluation. It can be used at both the individual or the organizational level to facilitate sustainable employment and the health of employees in an organization –39. In tHaving a process leader to guide all the stakeholders through the different steps is essential when applying the PA. As OPs are considered suitable professionals to guide an organization into a supportive work environment for employees with chronic conditions, the plan was to train OPs in serving as a process leader when applying the PA in an organization. In addition to the knowledge and skills of the PA, it is also essential for the OPs to understand the concept of self-control and the associated self-control behaviors. An understanding of the influence of the work environment on the expression of self-control behaviors by employees with chronic conditions is also essential. OPs can use this knowledge to create awareness within the organization and to provide organizational representatives with information during the PA process.The methods and practical applications chosen in step 3 were operationalized into the final program in step 4. The structure and organization of the program were explained in a protocol, program materials were developed, and existing materials were reviewed and adapted as needed to address the change objectives.The program we developed consists of a training, a practical assignment, and a follow-up meeting for OPs. It is suitable for all OPs, whether they are self-employed, working for an occupational health services agency, or working within the occupational health services department of an organization. The training provides the OPs with (a) theory and evidence on the self-control behaviors of employees with chronic conditions and the importance of a supportive work environment in expressing these self-control behaviors, and (b) information on how to apply the PA and act as a process leader in an organization in order to help the organization create organizational policy and a supportive work environment. During the training, theory on self-control behaviors and the PA will be alternated with short exercises, giving the OPs the opportunity to practice certain steps of the PA. Additionally, these exercises offer ways to reflect on the level of exertion of self-control behaviors in the organization the OP is working in. The training will be given by two members of the project team. At the start of the training, the participating OPs will receive a training manual containing (1) practical information, (2) the slides of the PowerPoint presentation to be used during the training, (3) information on the practical assignment, and 4) background information. At the end of the training, the OPs will receive further instruction on the practical assignment.In the practical assignment, the OPs will need to apply the six steps of the PA in one of the organizations they are working for. OPs will start with creating the right conditions for applying the PA in the organization, one of which is creating a working group with employee and organizational representatives. The OP will serve as a process leader to guide this working group during three meetings. During the first meeting, the workgroup members will analyze and identify existing barriers inhibiting the execution of self-control behaviors within their organization. The second meeting will be used for brainstorming solutions for the identified barriers and a plan of action for the implementation of these solutions. OPs will thereafter monitor the implementation of these solutions within the organization. These solutions provide input for organizational policy and contribute to the creation of a supportive work environment. During the third meeting, the implemented solutions will be evaluated. Forms have been developed for guiding the PA process during the practical assignment. These forms are included in the manual (see online resource 4 for examples). Six months after the training, a follow-up meeting will be planned in which experiences with the practical assignment will be shared between the OPs.Considering program implementation began in step 1 and extended to step 5. In step 5, a plan for the implementation of the program was developed specifying the potential implementers of the program. Program outcomes and performance objectives for adoption, implementation, and maintenance were written, after which matrices of change objectives for implementation were constructed. After selecting the proper change methods and applications, a strategy for adoption, implementation, and maintenance was designed.Implementation of the program will occur in a pilot study in which the practical assignment will be used to explore the usability, practicality, and effectiveness of the program. OPs who participated in the training will put their knowledge and skills from the PA into practice in one of their organizations. Two important program outcomes were identified prior to the start of the pilot study: (1) the organization is positive about developing an organizational policy and creating a supportive work environment with use of the PA and (2) OPs are able to carry out the PA for the development of this organizational policy. Since this program aims to include all relevant stakeholders in the process, OPs as well as the organizations  are important to the successful implementation of the program. However, OPs and employers are considered the most relevant implementers because of their responsibility for initial implementation actions. Therefore, performance objectives for both these environmental agents (OPs and employers) are specified .In the final step of the IM protocol, a plan for evaluating the effectiveness of the program on the change objectives and the actual behavior was developed. Results of this evaluation are expected in 2021.This study describes the systematic development of a program for OPs using the IM protocol. The program consists of a training, a practical assignment, and a follow-up meeting for OPs. The program aim is to develop an organizational policy and create a supportive work environment for employees with chronic conditions thereby enabling them to exert self-control.Targeting the workplace has been a focus of many interventions aimed at maintaining health and employment among employees, either on the individual employee level or on the organisational level. Workplace interventions have been developed focusing on issues such as improving employees’ lifestyles (e.g. sitting time or nutrition) or preventing work-related stress and injuries –43. In tWith the growing number of employees with chronic conditions, a greater focus on prevention and sustainable employment within organizations is essential. Organizations differ in their ways of dealing with employees with chronic conditions with regard to the level of support offered, including the realization of work accommodations . A negatThe use of OPs as process leaders in this intervention also has limitations. Firstly, the intervention was tailored to the role of OPs in the Dutch context. In various other countries, the role of OPs differs from the role of Dutch OPs , 59. In Workplace interventions are complex, with numerous stakeholders involved. IM proved to be a valuable tool for the systematic development of this intervention, with several underlying reasons for the practicality of this approach. IM provided us with a structure to start sorting out the causal relationships of the problem and finding out the needs of all stakeholders involved. Based on the causal relations and stakeholders’ needs identified in the IM steps, it was clear what changes were necessary. Evidence-based decisions could thereby be made to focus the intervention to match the context in which it must be implemented. Since the program was initiated to support the development of knowledge and skills of OPs, our initial thought was to develop an intervention focusing on the OP. However, the evidence gathered in the IM steps shifted the focus of the intervention and its implementation to the work environment in which OPs would need skills as process leaders. Additionally, IM also provided an understanding of the complexity of the context, guidance on deciding what methods to use, and subsequent practical applications. However, although IM was used to optimize the development of the intervention, some drawbacks of this method could be identified. Following all the steps of the protocol is a time-consuming process. Furthermore, although IM aids in optimizing the effect of the intervention, using IM is not a guarantee for success, as pointed out by the review of Fassier et al. . In thisChanging employees’ behavior is difficult, especially when optimal conditions for carrying out certain behaviors are absent. The same applies for self-control of employees with chronic conditions. Creating a supportive and understanding work environment provides these employees with the ability to exert self-control, while an organizational policy will provide the organization with clear procedures for employers and employees on addressing the prevention of work-related problems. The intervention developed in this study provides OPs with the necessary skills to serve as process leaders in the development of organizational policy and creating supportive and understanding work environments. An optimal work environment for the expression of self-control behaviors can lead to early identification or prevention of work-related problems among employees with chronic conditions and sustainable employment. This will benefit both employees with chronic conditions as well as employers. Once proven effective after the pilot study (expected results in 2021), this program could be imbedded in educational programs for OPs.It is to be expected that the effectiveness of the intervention will vary for different work settings. Aspects such as the size of the organization, the number of management layers and types of employees (e.g. white or blue collar) could influence the effectiveness of the intervention. Further research should be conducted to investigate contextual factors and the optimal conditions for implementing interventions in the workplace. The possibility of targeting organizations instead of OPs could also be explored.Supplementary file1 (PDF 213 kb)Supplementary file2 (PDF 274 kb)Supplementary file3 (PDF 182 kb)Supplementary file4 (PDF 349 kb)Below is the link to the electronic supplementary material.


In the face of growing modernity and the coronavirus disease 2019 (COVID-19) pandemic, open and distance learning (ODL) is considered to play an important role in increasing access to education worldwide. There is a robust evidence base demonstrating its cost effectiveness in comparison with conventional class-based teaching; however, the transition to this new paradigm of learning for nursing and midwifery courses has been difficult in low-income countries. While there are notable efforts to increase internet and education access to health care professionals, not much is known about ODL for nurses and midwives in East African countries.The objective of this scoping review is to understand whether ODL programs for nursing and midwifery education exist, the drivers of their adoption, their implementation, the topics/courses covered, their acceptability, and their impacts in East African countries.The scoping review methodology employs the framework developed by Arksey and O’Malley. Using an exploratory approach, a two-stage screening process consisting of a title and abstract scan and a full-text review will be used to determine the eligibility of articles. To be included, articles must report on an existing ODL initiative for nurses and midwives in Uganda, Tanzania, and Kenya. All articles will be independently assessed for eligibility by pairs of reviewers, and all eligible articles will be abstracted and charted in duplicate using a standardized form.Details of ODL for nursing and midwifery education initiatives and study outcomes will be summarized in a table. The extracted data will undergo exploratory descriptive analysis, and the results will be classified into learner and clinical outcomes.Evidence on ODL for nursing and midwifery education will inform the ongoing development and restructuring of health care professional education in East Africa amidst the COVID-19 pandemic.PRR1-10.2196/17765 In the face of modernity, the coronavirus disease 2019 (COVID-19) pandemic, and increased access to the internet, telecommunication, and related technologies, there is growing interest in open and distance learning (ODL) as a promising entry point to address the challenges of access to educational opportunities worldwide . ODL entThe world continues to face challenges regarding human resources for health. Concerns of low production from health training institutions and consequently inadequate number of health care workers, as well as gaps in knowledge and skills are large particularly in sub-Saharan Africa -16. The Various evidence synthesis approaches were considered for this review; however, the scoping review methodology was seen as the most appropriate, especially since the complex area of ODL in East Africa has not been reviewed comprehensively before. To the best of our knowledge, there has been no prior attempt to establish a baseline of knowledge regarding ODL initiatives for nursing and midwifery education in the study setting. Given this knowledge gap and that literature may be diffuse owing to the multidisciplinary nature of ODL implementation, a scoping review is ideal for taking stock of the volume and nature of the existing literature . The useThe scoping review methodology employs the framework developed by Arksey and O’Malley from the Centre for Reviews and Dissemination at the University of York . The fraWhat is the extent of published evidence in East Africa relating to the existence of ODL programs for nursing and midwifery education and their drivers, implementation, topics covered, acceptability, and impacts? The rationale behind this broad question was the lack of harmonized evidence about ODL practices for nursing and midwifery education in East Africa. By identifying the current educational initiatives, this review seeks to establish a foundational understanding of how ODL programs for nursing and midwifery education, if any, are implemented and glean the critical impact factors and recommendations of these experiences. Based on a combination of informal discussions and a preliminary review of published topics, we developed the following specific questions for our exploratory scoping review: (1) What ODL interventions exist for nursing and midwifery training programs in East Africa? (2) What are the key drivers for adoption of ODL interventions for nursing and midwifery in East Africa? (3) What aspects of nursing and midwifery education are taught using the ODL strategy? (4) How are the ODL interventions for nursing and midwifery education delivered? (5) What are the existing policy and institutional frameworks that guide and promote quality of ODL interventions? (6) What is the documented impact of ODL interventions for nursing and midwifery education in East Africa?Arksey and O’Malley  recommenThe optional stakeholder consultation phase is meant to be an ongoing interaction throughout the review process . Thus, wStakeholders of interest represent fellow researchers, instructors, and decision makers involved in nursing and midwifery education in East Africa. Individual stakeholders will be identified through professional networks and contacted via email. We will brief them on our research question and focus areas, as well as approach to searching the literature, and solicit their feedback on our approach. Only their titles and/or positions will be used to ensure anonymity.To be comprehensive, Arksey and O’Malley recommended searching several literature sources, including electronic databases, reference lists of relevant literature, key journals (hand searching), existing networks, relevant organizations, and conferences . For ourWe will enlist the services of a library scientist to conduct the electronic database search. The research team will devise a broad list of terms pertinent to ODL in nursing and midwifery education, including ODL initiatives, ODL implementation, and ODL benefits/impacts. These terms will be combined to create keywords that could be used to search electronic literature databases. Keywords will then be mapped to database thesaurus search terms, where available, and also searched as text word terms in all databases. The goal is to conduct a sensitive rather than specific search of the literature; thus, search terms are kept very broad, resulting in many irrelevant studies being eliminated at the study selection. All literature database searches will be limited to the English language and publication from inception to December 2020.open and distance, nursing and midwifery education, nursing education, midwifery education, and East Africa OR Tanzania OR Kenya OR Uganda. For websites that are not specifically health care focused, we will add the word “health” to the specific term. A log of the website searches will be kept, and links to relevant pages will be saved.Once relevant studies are selected from the literature database search, we will carry out a selective search of relevant websites. Through consultation with our stakeholders and members of the research team and colleagues, we will compile a list of relevant websites in East Africa to search. We will attempt to search websites in a systematic manner, allowing for some variation in search strategies in response to varied website structures. Once hand searching a website’s links is complete, we will use the website’s search engine to attempt to uncover additional materials. Once again, different types of search engines require different search tactics. For all websites, we will search the terms In an attempt to be as comprehensive as possible in our search, we will also collect literature from reference lists of relevant articles, master’s and PhD theses, specific journal issues with related material, technical reports from health care organizations, and suggestions from colleagues.A two-stage screening process consisting of a title and abstract scan and a full-text review will be used to determine the eligibility of articles. Both stages will follow the same process, where every article will be independently reviewed in pairs and the results will be documented on the spreadsheet. At the end of each round, the ratings will be compared and resolved by two reviewers or a third reviewer, when consensus is not achieved. Any ambiguities regarding the eligibility of a citation (or article) will be flagged and discussed.Does the article describe/discuss the ODL initiative/intervention/program for nursing and midwifery education in Tanzania, Kenya, and Uganda?The citations will be assessed for relevance based on a title and abstract scan. To be relevant for full-text review, articles must report on an existing ODL initiative for nurses and midwives in Kenya, Uganda, and Tanzania. The full-text review form will ask reviewers to assess each article using the following questions: This review is inclusive of all types of literature, thus including commentary articles, technical reports, case studies, and empirical studies employing all types of methodologies  and study designs. Viewpoint articles on how ODL education programs should be implemented outside of the context of an existing program will be excluded.The criteria will be piloted by the reviewers to refine and establish a common understanding of the inclusion criteria. About 10% of the selected citations from a single database will be independently reviewed by four reviewers to establish interrater reliability (IRR). The results of the review will be compared, and the IRR will be calculated. The threshold for IRR is set at an average Cohen kappa of 0.70, indicating substantial agreement ,32. The Arksey and O’Malley indicated that the charting process is multistaged, involving extraction of information from individual articles . A PRISMThe purpose of this final stage of the scoping review is to provide a structure to the literature uncovered. The extracted data will first undergo a simple quantitative analysis using descriptive statistics  to provide numerical summaries of the education initiatives and article or study characteristics . MultiplThe results from selected publications will undergo exploratory descriptive analysis and will be classified into learner and clinical outcomes -34. The The purpose of this review is to gain an understanding of the existence of ODL programs for nursing and midwifery education, the drivers of their adoption, the extent of their implementation, the courses covered, and their acceptability and impacts. The discussion of the findings will be contextualized based on previous studies and their implications for the ongoing development of ODL initiatives for nursing and midwifery education in East Africa  in the face of the COVID-19 pandemic.This scoping review is not without limitations. The review only focuses on nursing and midwifery education. This means ODL interventions on other aspects of health care professional education will be excluded. However, a snapshot of ODL interventions beyond the nursing and midwifery sphere will be offered to partly overcome this exclusion. The review only focuses on Tanzania, Kenya, and Uganda. While this is driven by the researchers’ institutional affiliation presence, further reviews may extend beyond these countries.Research ethics approval is not required for this scoping review. This protocol reports a comprehensive, rigorous, and transparent methodology. This review contributes to the advancement of research on this subject and comments on the maturity of the body of literature by identifying gaps in knowledge and research. Through the publication of the results and their dissemination at relevant conferences, the findings of this review could guide the direction of future research and implementation of ODL initiatives for nursing and midwifery by health care institutions in East Africa amidst the COVID-19 pandemic. The results will also be presented at relevant national and international conferences and published in a peer-reviewed journal. The results of this review may inform the design of new initiatives and the policies that support them; moreover, future implementation teams can learn from the experience of others to avoid potential barriers and focus on enablers to increase the chances of success of their ODL programs (existing or new).


Factors increasing pain after tattooing include: time B: 0.21; 95% CIs: 0.15–0.27; p = 0.001; bleeding B: 0.47; 95% CIs: 0.20–0.72; p = 0.001; level of stress B: 0.15; 95% CIs: 0.04–0.26; p = 0.001. Conclusions: There was no difference between females and males in pain intensity during tattooing. Directly after the procedure, however, pain intensity was higher in women when compared to men. The most important factors increasing pain were time, bleeding, and the level of stress.Background: The aim of the research was to analyse the impact of gender on pain perception during and directly after tattooing, with the following predictors as covariates: the body area chosen for a tattoo, the character of the pain, the time it takes to complete the tattoo, bleeding, the level of stress, analgesics taken before the tattooing procedure, and the cycle phase. Methods: A total of 1092 participants took part in this study . A proprietary survey was used in the research, including patient characteristics and questions relating to the above-mentioned variables. Multiple regression analyses were used for continuous outcomes and multiple logistic regression analyses for binary outcomes. Results: Factors increasing pain during tattooing include: time B: 0.35; 95% CIs: 0.27–0.43;  Tattooing, which involves creating a permanent skin pigmentation, has become a common phenomenon that has evolved from a cultural taboo related to ostracizing tattooed individuals into a way of expressing oneself and a sign of individualism ,2. TattoPain is a complex process that involves the integration of sensory and emotional information. Experiencing pain is linked to both the action of an injuring stimulus that affects tissues and the awareness emerging based on the mental interpretation of those occurring phenomena, additionally modified by past experiences and psychosomatic predispositions. The awareness of pain occurrence triggers a whole chain of reactions and methods of pain response, from proper recognition of the pain stimulus to appropriate emotional assessment. All painful experiences trigger emotional reactions, as information about pain is transmitted to the limbic system .The unpleasant pain sensation during tattooing is linked to the presence in the human skin of free nerve endings, nociceptors, reacting to tissue damaging stimuli, which in the case of this procedure are understood as the piercing of the skin with a needle and the mechanism of pain sensation. This sensation makes an individual aware of the pain and enables them to subjectively assess it and undertake preventive action ,12. The Experiences that accompany humans throughout their lives, especially pain, are linked to various external and internal factors, and the determinants of pain that may impact its sensation, interpretation, and modification. Due to this, pain intensity and quality are subject to various conditions. The same stimulus can be perceived differently by various—or even the same—people in diverse external conditions, somatic and mental states. Pain perception, a sensual impression based on the subjective assessment of a stimulus affecting the human body, depends on many factors, such as sociological and cultural factors , psychological  and biological factors, such as gender, genetic and hormonal predisposition, or the activity of endogenous opioids ,12,13. AIn recent years, the particular role of gender in the perception of individual perception of pain has been noted. For many years, clinical trials more often involved male subjects than females due to hormonal changes related to women’s menstrual cycle, which may potentially significantly influence the perception of pain . NumerouIndividual differences influencing the perception of the pain stimulus definitely involve hormonal balance in females and males. The available scientific literature yields scarce and ambiguous—or even conflicting—views on the influence of hormonal changes occurring in females during consecutive menstrual cycle phases on the perception of an external stimulus. While some authors  claimed This research undertakes to assess the differences in pain intensity in males and females during tattooing and directly upon the completion of the procedure. Moreover, the authors inspected the continuity of pain or its increasing nature, radiating to body areas other than the tattooed place, as well as bleeding during the procedure. The aim was to provide a wider analysis of gender differences regarding the age of tattooing, location and duration of the procedure, stress preceding tattooing and intake of analgesics before the appointment. An additional objective involved the analysis of pain sensation in connection with particular phases of the menstrual cycle in females, which also alter the hormonal balance and various factors independent of gender that may impact the severity of pain during and after tattooing.The study involved 1092 participants, consisting of 863 women (79%) and 229 men (21%). The research was conducted at professional tattoo studios in Katowice, Silesian Voivodeship, as well as nationwide in Poland with the use of an online survey. The research lasted one year, from June 2019 to June 2020. At first, it was conducted at the Horkruks Tattoo studio in Katowice and other partner studios. However, after 5 months it was noticed that the previous recruitment method was ineffective, mainly due to the reluctance of the tattooed persons to complete the survey following a one-hour or longer painful tattoo session. The persons reported fatigue and a need to rest. Using this method, about 60 females and 10 males were surveyed, with about 30 persons refusing to complete the questionnaire. Subsequently, in November 2019, the authors contacted the Bioethics Committee again, asking for a change in the recruitment method from a direct survey into an online survey. The author of the project ensured full anonymity of the surveys. It was created in a digital form and sent to various Polish groups associated with people with a passion for body adornment. The link to the survey included its description with a special annotation to female participants. Only those females who were tattooed during the same month as they were completing the survey were asked to submit the questionnaire. The authors aimed to precisely define the day of a woman’s menstrual cycle when she was tattooed. The menstrual cycle was understood as repetitive, monthly hormonal changes in the female body, aimed at preparing the oocyte for fertilisation or leading to the shedding of the uterine lining in cases when no fertilisation occurred [A proprietary survey was used in the research, which included questions regarding parameters such as the age, height, body weight and education of the participants. Subsequent questions regarded maximum subjective pain perception during and after the completion of the tattoo, tattooed body area, the time required to complete the tattoo and the character of experienced pain, including the potential increase in pain intensity occurring with the passing of time during the procedure and pain radiating to further body areas, other than the one affected directly by the procedure. Moreover, the participants were also asked about their pain experienced prior to the procedure and the use of analgesics. Females were also asked about the day of the menstrual cycle on which they were tattooed. Due to significant hormonal differences, menstruation was isolated from the follicular phase into a separate stage. Females were asked to provide the day of the procedure, counting from the last day of menstrual bleeding.In order to assess the pain, the Numerical Rating Scale (NRS) was used, which comprised 11 degrees of pain intensity from 0 to 10, where 0 indicated a total lack of pain and 10 marked the highest degree of pain sensation, meaning the most severe pain the respondent has ever felt in their life. The participant was asked to select a number, which according to their subjective assessment, reflected the maximal pain occurring both during and directly after the procedure.Inclusion criteria included: a lack of any pain on the day of tattooing, including, e.g., headache or menstrual pain. No regular use of any over-the-counter medicines, including analgesics, antihistamines, and anti-inflammatory drugs. No consumption of alcohol and energy drinks 24 h prior to the research. In females, additional inclusion criteria included: regular menstrual cycles, understood as occurring every 28 to 32 days and not using hormonal contraception. Exclusion criteria included persons with sensory disorders and chronic pain. In the case of females, additional exclusion criteria included: irregular menstrual cycles of undetermined cause and female diseases that could negatively impact normal menstrual cycle, including hormonal disorders diagnosed by a doctor. Out of all submitted surveys, around 170 were removed from further analysis. Most often, these were completed by women with irregular menstrual cycles or using hormonal contraceptives. A few surveys were also completed incorrectly and did not include the necessary data.All analyses were performed using SPSS 21 software.Gender differences were calculated for dependent variables as well as for predictors. Given the large difference in the sample sizes of men and women and the fact that the assumption of homogeneity of variances was not met in some cases, nonparametric Mann–Whitney U tests were used to determine gender differences for continuous variables. For categorical variables, chi-square tests were used to analyse gender differences. In the case of significant results for multicategorical variables, additional z tests were performed to determine which category is different between men and women.2), which indicate the percent of the variance of the dependent variable explained by all predictors, and standardised regression coefficients (betas), indicating the strength of association between a given predictor and the dependent variable. In the case of categorical predictors, p values for differences between groups were reported. In addition, p values for all parameters were calculated, together with confidence intervals generated by bootstrapping in order to avoid problems with the distribution of errors and other assumptions of multiple regression analyses.To analyse the impact of predictors , a series of multivariate regression analyses were performed. For the dependent variables—NRS during tattooing, NRS after tattooing, and increasing pain—multiple linear analyses were performed, in the case of which the following parameters were reported: multiple determination coefficients .The descriptive results for the dependent variables and predictors are presented in There were significantly more women than men in the sample. In the case of dependent variables, in univariate analyses, NRS after tattooing proved different between men and women, with women declaring higher levels of pain. Increasing pain was more frequently present in the case of men. As for predictors, men were significantly older and had higher BMIs than women. Education varied between genders, with men having a vocational education more often than women and graduating high school less often. Body area proved different between genders: the upper extremity was chosen more often in the case of men, and the torso was more often chosen among women. The time required to complete the tattoo was generally longer in the case of men. Bleeding occurred more frequently in men. Women experienced more acute stress in comparison to their male counterparts.For the dependent variable “NRS during tattooing”, there were five statistically significant predictors: education, time, bleeding, stress level and analgesics taken before the procedure . All of For the dependent variable “NRS after tattooing”, the following predictors were significant: gender (with women experiencing higher pain), the time required to complete the tattoo, bleeding, stress level. All of them were positive. Time required to complete the tattoo, the presence of bleeding and stress level also constituted significant positive predictors for “Increasing pain”. The same was true for the dichotomic dependent variable “Pain during tattooing”.In the case of “Radiating pain”, a longer time of tattooing increased its presence. In addition, the categorical predictor “Body area” was significant for this dependent variable: radiating pain was more often present in the case of an upper extremity in comparison with a lower one. When compared to the torso, radiating pain was also more often present in the case of an upper extremity.p = 0.003), with radiating pain occurring more often in the upper extremity than the lower one (83% vs. 72%). In addition, the pain sensation in the upper extremity differed from the one affecting the torso .The results of multiple comparisons in the case of the categorical variable body area, for the dependent variable radiating pain, are as follows: the differences between the categories upper extremity and lower extremity was statistically significant  were all positive predictors of NRS during tattooing . The samBody tattooing is a form of body adornment, standing out in society or seeking a symbol of individuality. The conducted research has shown that after the tattooing procedure, females experienced pain more acutely than males. However, no statistically significant differences in pain intensity were found between men and women. This could, however, be caused by the fact that most women had chosen rather small tattoos, thus requiring a shorter time to complete, while men had decided on larger designs, in which case the procedure was longer. A certain type of “equalization” of pain experiences could have occurred, as the duration of tattooing might have impacted it. Females experienced a relatively short and strong pain, using a scale to determine their subjective impression. Since the procedure was longer and the pain increased with every passing hour in male participants, they had the impression that the pain is comparable to the one experienced by their female counterparts. Differences in the type of experienced pain described by the respondents could also be associated with different body regions selected by the participants for their tattoo. The areas more frequently selected for tattooing were the torso in the case of women, and an upper extremity in the case of men. A different body region also means a different thickness of the skin and a different density of nerve endings, and these factors may contribute to differences in experiencing and describing pain.Inter-individual variations that impact the way we experience pain stimuli, understanding the complex nature of pain, and personal differences that may influence nociceptive processes are still of interest to scientists. However, despite noticing the influence of gender that determines the personal perception of pain, some authors claimed that differences in susceptibility to pain between genders are scarce, while others highlighted their importance ,18,19,20The conducted research did not show a statistical significance of the influence of the menstrual cycle phase in women on the perception of external stimulus, in this case puncturing their skin during tattooing. This could stem from the fact that menstrual cycle phases were divided only on a basic level, into three stages. Moreover, differences in cycle length and the length of particular cycle phases occur even in women who menstruate regularly. Mistakes could have occurred, even though only females with regular menstrual cycles were chosen for the study. Such a result, however, inspires further research and more detailed division into menstrual cycle phases and even the performance of hormonal tests. Such tests will enable precise determination of the menstrual cycle phase and give the opportunity to establish the current level of sex hormones and the exact day of ovulation.Pain is an intrinsic element of body tattooing, as puncturing human skin with needles is a painful experience. It stems from both anatomical and physiological features of skin structure and the transmission of pain impulses from the receptor to the cerebral cortex. Despite the fact that during the procedure the skin is punctured at a quite shallow level, it is deep enough to stimulate nociceptors. A quite startling result of our research was the fact that around 10% of people in both study groups claimed that receiving a tattoo did not cause them any pain. While it is clear that every human being has a different pain threshold, which is affected by a plethora of factors that have already been mentioned here, as well as the fact that every person experiences pain in a personal way, it is challenging to explain such a result in a straightforward way. These participants might have had a particularly high pain threshold, the density of pain receptors was lower within the affected area or the skin was thicker, as this value may vary from 0.5 to 1.0 mm. The tattooed area might not have had contact with a bone, and adipose tissue may have created enough of a buffer between the needle and the nociceptor. Given the fact that the human brain interprets information about pain and compares it to former painful sensations and experiences, the brain itself could have acted as a “suppressant” to the actual interpretation of pain ,31. MaybAnother attempt at explaining the “lack of pain” in a small number of participants could encompass their mental attitude towards the process itself. For them, getting a tattoo could have been a certain kind of sacrifice and involved particular engagement in the procedure to achieve a higher idea. Pain was accepted to such an extent that it was mentally “blocked out” and made “non-existent”. There is also a group of people who highlight their resilience to pain by speaking about a “lack of pain sensation”. By doing so, they present themselves as stronger and healthier than the rest of society, pointing out their evolutionary superiority, including when presenting themselves as the right choice while choosing a life partner. Maybe exactly this mechanism was triggered among graduates of junior high, who declared lower pain intensity than those with higher education?A phenomenon of not experiencing pain during the tattooing procedure may also be interpreted through the human ability to achieve certain states of mind during which the human brain is able to alleviate the pain ,33. HereEven though the process of tattooing is generally linked with pain, it is not recommended to take analgesics prior to the procedure, as it has been found that such medicines may increase bleeding ,35 durinThe results show that stress experienced before tattooing is an important factor increasing the pain sensation both before and after the procedure and that it favours pain escalation during tattooing. This is consistent with Peters’  observatTattooing is always accompanied by bleeding; 69% of persons observed bleeding due to the performance of a tattoo, while the remaining participants reported bleeding so light that it was unnoticed. Bleeding is linked with an increase in pain intensity both during and after tattooing. This connection might be caused by the depth of punctures and/or skin properties, including the thickness of particular skin layers.The occurrence of pain radiating to body parts other than the tattooed area is not dependent on the presence of bleeding and stress; it does, however, depend on the location of the tattoo. Radiating pain is more common in the upper extremities than the lower extremities, and also upper extremities differed from the torso. Further research is required to prove which location-related factor determines such spreading of pain. It can be presumed, however, that the density of nerve endings within a particular body area is of particular importance.During our research, we attempted to determine the degree of pain perception in males and females undergoing the process of tattooing. Moreover, we strived to assess whether factors associated with certain individual characteristics and the specificity of the procedure impact the modification and interpretation of painful experiences. During the research, however, we encountered certain limitations. Scholars sharing our scope of academic interest should pay attention to them and shape the future direction of scientific research within these areas. Statistically significant differences in the number of tattooed men and women, their age and education were found. Unfortunately, the method of recruitment does not allow us to determine how this effect depends on the actual phenomenon of tattooing in Poland and to what extent it depended on the willingness to complete the survey in groups of males or females of different ages and education. The participants were not asked whether this was their first or subsequent tattoo. Some of the respondents might have been so-called “collectors” , which cThe participants’ marital status was not revealed. Such knowledge would not influence the general results, but it would enrich the description of the study group and show whether it impacts the frequency of tattooing in society. The respondents’ motivation for getting a tattoo was also unknown. It could possibly provide an explanation for a “lack of pain” declared by a certain percentage of those tattooed. The size of the performed tattoo was unknown. This information does not significantly influence the results, as each participant was surveyed only once. Even if their tattoo required a few sessions to complete, the survey was completed only once. The time required to complete the tattoo or its part on a given day was known, which enabled the authors to compare the level of perceived pain to the duration of the procedure. This seems to be an important aspect of the research which also influenced the results.The presented research raises issues that may be of interest to specialists representing various scientific disciplines. The publication is interdisciplinary, thus setting new directions for exploring knowledge in various areas. It raises numerous issues within the field of psychology, such as a person’s motivation to have a tattoo, tattoo symbols, concerns regarding experiencing stress prior to the procedure and individual sensitivity to pain linked with the mental attitude towards the process of tattooing. Subsequently, it also presents sociological concerns, including the education of the tattooed persons, their age, gender, material and marital status, occupation and so on. The publication can also serve as a stimulus for further exploration of medical issues, including a comparison between the overall health condition and pain experienced by a person undergoing the procedure, investigating skin properties of the tattooed person  and pain experienced during tattooing as well as the durability of the tattoo. In future research, it would definitely be beneficial to perform laboratory tests and determine the level of hormones, namely oestrogen and progesterone in female participants and testosterone in males, and subsequently assess the level of experienced pain. The assessment of the tattooing technique also proves to be an interesting issue. The question is whether it can in some way reduce painful experiences, for example, by choosing a given type of tattoo machine, particular needle thickness, skin penetration depth and tattoo ink types. Eventually, it should be investigated whether topical anaesthesia methods used in cosmetics and aesthetic medicine might be recommended and effective in the process of tattooing, and assess their impact on reducing pain, bleeding, and tattoo quality.The results of the study are based on the survey, which demonstrates the opinion of all respondents willing to participate in the study. In the case of each of the above-mentioned problems, one might attempt to make them objective, apply appropriate measuring tools in reference to, e.g., the same body area being tattooed, and employ a targeted, randomised group selection in order to fully explain these compelling issues. The subject of such research would certainly find many supporters, especially given the fact that tattoos have become a popular body adornment method.After being tattooed, women experienced more intense pain than men. However, no differences in pain perception were noted during the procedure. Compared to men, female participants reported higher stress before the procedure, but they also more frequently decided to tattoo their torso, while their tattoos required less time to complete and caused lighter bleeding.The factors that most significantly increased pain perception during the process of tattooing included: the time required to complete the tattoo, the presence of bleeding, stress, and the intake of analgesics.


Background: Violence or violent imagery, defined as any image that conveys an imminent physical or existential threat to person(s), property, or society, with or without weaponry, is often featured in advertising. However, the effects of exposure (sporadic or chronic) to such imagery are not fully understood. The objective of this study was to describe the prevalence and types of violence portrayed in advertising on public buses in New York City (NYC). Methods: In this cross-sectional study, from April to July 2019, researchers catalogued and coded the print advertising images present on the passenger entry side of all Metropolitan Transit Authority (MTA) bus lines in Manhattan to determine whether images of violence or violent acts were present. Unlike images of alcohol and tobacco products , there are no similar restrictions on violence or violent imagery. Results: A total of 23 out of 136 (17%) observed advertisements included images of violence and/or actual or imminent violent acts. One hundred percent of images involving violence were embedded in advertisements for mass media/entertainment purposes often featuring well known and favorably regarded actors and entertainment personalities or companies. Conclusion: People of all ages and backgrounds are passively exposed to bus advertisements in a variety of settings. This study contributes to the literature regarding the extent to which the public is passively exposed to violent advertising. Additional study is required to further understand the link between violent imagery and attitudes toward/tolerance of violence. Given that average weekday ridership is approximately two million people,4 the purpose of this study was to describe the prevalence and types of violence portrayed in advertising on public buses in NYC.Violence is a devastating public health problem with consequences for individuals, families and communities. Interpersonal violence is a widespread issue in the United States. For example, in 2017, the death rate from guns in the United States was 4.43 per 100 000 people, notably higher as compared to other countries.5 These effects may last over several days, or are perhaps more durable under certain circumstances. The temporal aspects of desensitization are not well understood, however there are assumed to be aggregated effects of exposure across brief periods of time as well as over an individual’s lifetime.5 Furthermore, Jones and colleagues6 argue that because ads must capture attention, images are designed to be compelling, affecting the emotions, thoughts, and behaviors of viewers.7 In other words, there may be negative psychological effects of even the briefest exposures to violent images on buses.One argument in favor of efforts to control the prominence of violence in public settings can be found in the literature of desensitization, a process whereby emotional responses  gradually or abruptly diminish or change across repeated exposures to violent content. It has long been recognized that desensitization has at least two possible emotional outcomes: reduced negative responses to violence (and sometimes enhanced enjoyment of violence) and reduced empathy for victims.There is a paucity of research regarding the extent to which violent advertisements appear on city buses. Therefore, the objective of this study was to describe the prevalence and types of violence portrayed in advertising on public buses in NYC. This will allow an estimate of the rate of passive societal exposure, information that is needed before estimates of the effects of such exposure can be estimated. If it discovered that violent bus ads are prevalent or memorable enough to affect individuals, then removal or restriction of violent images on buses could be a relatively simple and cost-effective method of reducing exposure to and thus, minimizing harmful effects of such violent images.8 This study was ancillary to a study exploring alcohol imagery on buses, and is described in greater detail elsewhere.9 For each of the Metropolitan Transit Authority’s (MTA) 42 Manhattan bus lines, researchers observed and documented the advertising on the passenger side of the bus  did not have any advertising; these were excluded, leaving a sample of 136 buses and advertisements.Researchers adapted a cross-sectional approach that was used in their prior studies of advertising imagery on NYC subways.Because buses travel significant distances along their routes, researchers determined that just one observation point per route would be sufficient. At each observation point, a researcher photographed the advertisement on the side of the given bus and stored the data for coding and analysis. In addition, researchers recorded the distinctive identification number for each bus observed to ensure that each observation was of a unique bus. Buses were observed and data collected at various times of day, days of the week, and locations across Manhattan from April to July 2019.4 Existential threat was defined as an image, idea, action, or event that instills or invokes feelings of personal or societal peril, either immediate or at some undetermined future time. These feelings could be strong or weak, and the perceived threat real or imagined; existential threats are defined by a personal feeling, not by an outside objective standard. Violent wording were words that communicated - either directly or indirectly - actions or ideas relating to harm to persons or property (e.g. hitman). Presence of a weapon indicated an object that could be used to inflict pain, injury, harm, or death on a person or object . Intent to strike was coded when a person was holding an object in such a way that the next action would be using the weapon to strike, harm, or otherwise injure a person or object. Destruction was defined as the act of conducting damage to property. The gender of the people in the advertisements were also coded. Multiple categories could be coded for each advertisement.Data was collected and coded using a spreadsheet instrument that was designed to capture relevant content characteristics of each advertisement. This instrument allowed the researchers to code and capture the object of each advertisement, to document whether images of violence or violent acts were present, and if so, what type of imagery was involved. When present, violent imagery was coded into one or more (where applicable) of five categories: Existential Threat, Violent Words, Weapon, Intent to Strike, or Destruction. These categories were based on our prior research on advertising present in publicly-owned/controlled spaces.The researcher (CHB) reviewed all photographs to complete the initial coding; a second individual, researcher reviewed and coded a subset of 13 randomly selected advertisements to determine inter-rater reliability. There was 94% agreement. Descriptive statistics, including frequencies and percentages of the various categories of violent images were calculated using Microsoft Excel.A total of 23 out of 136 (17%) of advertisements, including duplicates, with violence were observed in this study . The overwhelming number of advertisements with violent images were for television shows  with the remaining 22% (n = 5) for movie advertisements. The most common type of violent content displayed on city buses was presence of a weapon, followed by existential threat and intent to strike . The maj10 as was seen in all of violent bus ads studied herein.We found that violent images on buses are prominent in NYC, appearing on 1 out of every 6 buses. This rate of exposure to violent ads may be sufficient to affect attitudes of those who view them. Moreover, the majority of ads featured a weapon and/or an allusion to existential threat, defined as feelings of personal or societal peril, either immediate or at some undetermined future time. The impact of the current ads remains unclear, however certain factors facilitate the process of desensitization to violent images, such as explicitly contextualizing the images in a story,th Street in midtown Manhattan, NYC is populated by at least 100 buses per hour. Considering that 17% of bus ads display violent content, it can be deduced that individuals will be exposed to an ad featuring violence once every 3 to 4 minutes on 34th Street. While certainly not as intensive as the rate of exposure to violent images one might experience in a laboratory, this overall amount of exposure would be equivalent to laboratory studies that used repeated short film clips (30 seconds to 2 minutes) to test desensitization in college students.5It can be argued that the effects of repeated exposure to violent images in advertisements are cumulative, thus contributing to a longer-term process of desensitization, This can take place outside of conscious awareness, in everyday, seemingly mundane settings. For example, the crosstown bus route along 34per se , or toward the subject of the ad  that are most affected. There is also the matter of the impact of violent ads on the larger environment. Who pays the price of violent images found in the NYC transit system? It may be those with the most exposure to buses: their drivers. Between January and July of 2018, 962 incidents of aggression were reported by bus drivers.11 Partly in response to rising numbers of assaults on bus drivers, in June of 2019, the MTA, in conjunction with the Governor of New York announced that they would add 500 extra uniformed officers to the NYC Transit system. This was “part of a comprehensive action plan to improve safety across New York City’s mass transit system, address the rising number of assaults on transit workers and combat the growing problem of fare evasion.”12 It may be that advertising revenues are ironically undercut by the need to implement violence prevention for MTA workers.Clearly more research is needed to determine the ultimate effects of violent bus advertisements, and whether it is attitudes about violence 13This study had a number of limitations. We viewed buses in different neighborhoods at different times of day, most typically during business hours. Thus, we did not sample the range of ads occurring over consecutive 24 hour periods. Certain ads might be more likely to be on buses that arrive at locations at specific times, and there might be systematic differences in which ads appear on which buses at specific times of day. We sampled only on the passenger sides of buses, and passers-by might be more exposed to ads on the opposite side. Whether or not individuals are vulnerable to the psychological effects of incidental exposure to violent images is a complex issue. There are controlled intentional processes that can counteract such effects . Evidence suggests that controlled processes moderate brief exposures to ads even in the case of preconscious exposure. Therefore, it may be the case that only those who have pre-existing violent motives experience psychological effects of violent ads.Additional research is urgently needed to determine the type and severity of these effects, whether or not violent ad exposure should be considered a public health issue, and if regulating or banning violent ad content stands to benefit individuals and communities.The Institutional Review Boards (IRB) at Teachers College, Columbia University determined that this study was exempt (Protocol # 19-328), while the IRB at William Paterson University does not review studies that do not involve human subjects.The authors of this study do not report any conflicts of interest.None declared.CHB and CEB conceptualized the study. CHB collected the data. JM and CHB analyzed the data. All authors contributed to writing and revising the manuscript.The authors would like to acknowledge Kristina Berger for her contributions to this work.