Artigos de revistas sobre o tema "Association of Academic Health Centers (U.S.)"

School readiness during early childhood establishes the fundamental basis for prospective academic achievement, emphasizing the necessity for a comprehensive preparation that encompasses both mental and physical readiness. The current study examines the impact of child well-being and family support on school readiness among young learners. This Study used a correlational quantitative approach, the research involved 139 children between the ages of 4 and 7, along with their parents and 30 teachers selected through purposive sampling based on their socioeconomic status. The participants included 54.7% boys (n=76) and 45.3% girls (n=63) from families with varying income levels – low-income (25%), middle-income (29%), and upper-middle-income (46%). The results of the regression analysis indicated that both family support and child well-being have a significant influence on children's school readiness. Particularly, there is a notable positive association among all factors, a correlation between school readiness and child well-being at 42% (r = 0.420, p < 0.001), highlighting that higher levels of child well-being are linked to increased school readiness. Furthermore, family support exhibits a positive contribution to school readiness at 37% (r = 0.370, p < 0.001). The findings suggest that preparing children for school should extend beyond academic and motor skills development to include substantial psychological support, thus enhancing their ability to thrive in an academic environment. Keywords: early childhood, Emotion, Emotion regulation, parenting, happiness References: Atkins, R., Deatrick, J. A., Bocage, C., Huc, R., Aromolaran, D., Besseir, E., Hinckson, A., Joseph, M., Kim, D., Lagman, D., Gladsden, V. L., & Lipman, T. H. (2022). School Readiness and Social Determinants of Health: A Collaboration with Community Teachers and Parents. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.4090268 Ayriza, Y., Setiawati, F. A., Nurhayati, S. R., Gumelar, S. R., & Sholeha, E. P. D. R. (2019). Does sleep quality serve as a mediator between well-being and academic achievement? Cakrawala Pendidikan, 38(1), 63–74. https://doi.org/10.21831/cp.v38i1.22181 Azra, A., Risnawati, E., Hermaini, B., Hendra, M., Kartikawati, E., Buana, U. M., & Terbuka, U. (2023). How family communication pattern affect a family ’ s capacity for resilience during covid-19 pandemic. 11(1), 117–137. Barnett, M. A., Paschall, K. W., Mastergeorge, A. M., Cutshaw, C. A., & Warren, S. M. (2020). Influences of Parent Engagement in Early Childhood Education Centers and the Home on Kindergarten School Readiness. Early Childhood Research Quarterly, 53, 260–273. https://doi.org/10.1016/j.ecresq.2020.05.005 Borualogo;, Ihsana Sabriani, F. C. (2020). Subjective Well-Being of Indonesian Children:A Perspective of Material Well-Being. ANIMA Indonesian Psychological Journal, 44–47. https://doi.org/10.1515/9783111634487-006 Borualogo, I. S., & Casas, F. (2022). The children’s worlds psychological well-being scale: Adaptation and fit in the Indonesian context. Cogent Psychology, 9(1), 1–17. https://doi.org/10.1080/23311908.2022.2053377 Cress, C. J., Synhorst, L., Epstein, M. H., & Allen, E. (2012). Confirmatory factor analysis of the preschool behavioral and emotional rating scale (PreBERS) with preschool children with disabilities. Assessment for Effective Intervention, 37(4), 203–211. https://doi.org/10.1177/1534508411433499 Cress, C., Lambert, M. C., & Epstein, M. H. (2016). Factor Analysis of the Preschool Behavioral and Emotional Rating Scale for Children in Head Start Programs. Journal of Psychoeducational Assessment, 34(5), 473–486. https://doi.org/10.1177/0734282915617630 Diener, E., & Ryan, K. (2009). Subjective Well-Being: A General Overview. South African Journal of Psychology, 39(4), 391–406. https://doi.org/10.1177/008124630903900402 El Zaatari, W., & Maalouf, I. (2022). How the Bronfenbrenner Bio-ecological System Theory Explains the Development of Students’ Sense of Belonging to School? SAGE Open, 12(4), 1–18. https://doi.org/10.1177/21582440221134089 Golshirazi, F., & Sadeghi, A. (2021). The Effect of Home-to-School Transition Program on Social-Emotional Readiness of Preschool Students. Journal of Counseling Research. https://doi.org/10.18502/qjcr.v20i77.6147 Gómez-Leal, R., Holzer, A. A., Bradley, C., Fernández-Berrocal, P., & Patti, J. (2022). The relationship between emotional intelligence and leadership in school leaders: a systematic review. Cambridge Journal of Education, 52(1), 1–21. https://doi.org/10.1080/0305764X.2021.1927987 Gregory, T., Dal Grande, E., Brushe, M., Engelhardt, D., Luddy, S., Guhn, M., Gadermann, A., Schonert-Reichl, K. A., & Brinkman, S. (2021). Associations between School Readiness and Student Wellbeing: A Six-Year Follow Up Study. Child Indicators Research, 14(1), 369–390. https://doi.org/10.1007/s12187-020-09760-6 Halimah, N., & Kawuryan, F. (2010). Kesiapan Memasuki Sekolah Dasar Pada Anak Yang Mengikuti Pendidikan Tk Dengan Yang Tidak Mengikuti Pendidikan Tk Di Kabupaten Kudus. Jurnal Psikologi Universitas Muria Kudus, I(1), 1–8. http://www.pustaka.unpad.ac.id Harrington, E. M., Trevino, S. D., Lopez, S., & Giuliani, N. R. (2020). Emotion regulation in early childhood: Implications for socioemotional and academic components of school readiness. Emotion (Washington, D.C.), 20(1), 48–53. https://doi.org/10.1037/emo0000667 Holzer, J., Bürger, S., Lüftenegger, M., & Schober, B. (2022). Revealing associations between students’ school-related well-being, achievement goals, and academic achievement. Learning and Individual Differences, 95(March), 102140. https://doi.org/10.1016/j.lindif.2022.102140 Hughes, C., White, N., Foley, S., & Devine, R. T. (2018). Family support and gains in school readiness: A longitudinal study. British Journal of Educational Psychology, 88(2), 284–299. https://doi.org/10.1111/bjep.12188 Jung, S., & Choi, N. (2020). Effect of Family Functioning on Preschoolers’ School Readiness: Mediating Effects of Mothers’ Affective Parenting and Preschoolers’ Self-regulation. Family and Environment Research, 58(1), 1–12. https://doi.org/10.6115/fer.2020.001 Kokkalia, G., Drigas, A., Economou, A., & Roussos, P. (2019). School readiness from kindergarten to primary school. International Journal of Emerging Technologies in Learning, 14(11), 4–18. https://doi.org/10.3991/IJET.V14I11.10090 Lazarus, R. S. (1991). Emotion and Adaptation. Oxford University Press. https://doi.org/10.2307/2075902 Lin, M. L., & Faldowski, R. A. (2023). The Relationship of Parent Support and Child Emotional Regulation to School Readiness. International Journal of Environmental Research and Public Health, 20(6). https://doi.org/10.3390/ijerph20064867 Lombardi, C. M. (2023). Early Maternal Employment And Children’s School Readiness: Changing Associations Over Time? Journal of Child and Family Studies, 32(4), 1032–1047. https://doi.org/10.1007/s10826-022-02357-3 Lombardi, C. M., & Dearing, E. (2021). Maternal Support of Children’s Math Learning in Associations Between Family Income and Math School Readiness. Child Development, 92(1). https://doi.org/10.1111/cdev.13436 Luby, J. L., Barch, D. M., Belden, A., Gaffrey, M. S., Tillman, R., Babb, C., Nishino, T., Suzuki, H., & Botteron, K. N. (2012). Maternal support in early childhood predicts larger hippocampal volumes at school age. Proceedings of the National Academy of Sciences of the United States of America, 109(8), 2854–2859. https://doi.org/10.1073/pnas.1118003109 Mariyati, L. I. (2017). Usia dan Jenis Kelamin dengan Kesiapan Masuk Sekolah Dasar. Prosiding Seminar Nasional Psikologi UMG, 095, 331–344. Mashar, R., & Pudji Astuti, F. (2022). Correlation between Parenting Skills, Children’s Emotional and Intelligence Quotient with School Readiness. JPUD - Jurnal Pendidikan Usia Dini, 16(2), 215–223. https://doi.org/10.21009/JPUD.162.02 Nurmaria, H., & Risnawati, E. (2022). The Relationship of Loneliness and Internet Addiction To Psychological Well-Being in Adolescents. Biopsikososial: Jurnal Ilmiah Psikologi Fakultas Psikologi Universitas Mercubuana Jakarta, 5(2), 509. https://doi.org/10.22441/biopsikososial.v5i2.14644 Rahmawati. (2018). Kesiapan sekolah merupakan kesiapan anak untuk memasuki sekolah . Di Indonesia istilah kesiapan sekolah lazim digunakan untuk merujuk kesiapan anak masuk Sekolah Dasar ( SD ), sebagai sekolah f. Jurnal Pendidikan Usia Dini,12(November), 201–210. http://journal.unj.ac.id/unj/index.php/jpud Risnawati, E., Meiliyandrie, L., Wardani, I., Saputra, A. H., Pramitasari, M., Mercu Buana, U., Pendidikan, J., & Dini, U. (2023). Theory of Mind, Roles, and the Development of Emotion Regulation in Early Childhood. 17(2), 1693–1602. https://doi.org/10.21009/JPUD.172.01 Risnawati Erna, Arisandi Alfida, D. R. (2019). Peran Religiusitas dan Psychological Well-Being terhadap Resiliensi Korban KDRT. Journal.Univpancasila.Ac.Id, 10(2), 67–77. http://journal.univpancasila.ac.id/index.php/mindset/article/view/836 Ryff, C. D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57(6), 1069–1081. https://doi.org/10.1037/0022-3514.57.6.1069 Ryff, C. D., & Keyes, C. L. M. (1995). The Structure of Psychological Well-Being Revisited. Journal of Personality and Social Psychology, 69(4), 719–727. https://doi.org/10.1037/0022-3514.69.4.719 Seran, T. N., Haryono, & Anni, C. T. (2017). School Readiness: Readiness Children Seen from The Whole Aspect of Early Childhood Development Article Info. Journel of Primary Education, 6(3), 224–232. http://journal.unnes.ac.id/sju/index.php/jpe St. Laurent, C. W., Burkart, S., Andre, C., & Spencer, R. M. C. (2021). Physical Activity, Fitness, School Readiness, and Cognition in Early Childhood: A Systematic Review. Journal of Physical Activity and Health, 18(8), 1004–1013. https://doi.org/10.1123/jpah.2020-0844 Turner, K. M. T., Dittman, C. K., Rusby, J. C., & Lee, S. (2017). Parenting Support in an Early Childhood Learning Context. In M. R. Sanders & T. G. Mazzucchelli (Eds.), The Power of Positive Parenting (pp. 242–251). Oxford University Press. https://doi.org/10.1093/med-psych/9780190629069.003.0021

Summary Background: The role of the Chief Research Informatics Officer (CRIO) is emerging in academic health centers to address the challenges clinical researchers face in the increasingly digitalized, data-intensive healthcare system. Most current CRIOs are the first officers in their institutions to hold that role. To date there is very little published information about this role and the individuals who serve it. Objective: To increase our understanding of the CRIO role, the leaders who serve it, and the factors associated with their success in their organizations. Methods: The Clinical Research Informatics Working Group of the American Medical Informatics Association (AMIA) conducted a national survey of CRIOs in the United States and convened an expert panel of CRIOs to discuss their experience during the 2016 AMIA Annual Symposium. Results: CRIOs come from diverse academic backgrounds. Most have advance training and extensive experience in biomedical informatics but the majority have been CRIOs for less than three years. CRIOs identify funding, data governance, and advancing data analytics as their major challenges. Conclusion: CRIOs play an important role in helping shape the future of clinical research, innovation, and data analytics in healthcare in their organizations. They share many of the same challenges and see the same opportunities for the future of the field. Better understanding the background and experience of current CRIOs can help define and develop the role in other organizations and enhance their influence in the field of research informatics.Citation: Sanchez-Pinto LN, Mosa ASM, Fultz-Hollis K, Tachinardi U, Barnett WK, Embi PJ. The Emerging Role of the Chief Research Informatics Officer in Academic Health Centers. Appl Clin Inform 2017; 8: 845–853 https://doi.org/10.4338/ACI-2017-04-RA-0062

Abstract Background Overuse of cardiac telemetry monitoring (telemetry) can lead to alarm fatigue, discomfort for patients, and unnecessary medical costs. Currently there are evidence-based recommendations describing appropriate telemetry use, but many providers are unaware of these guidelines. Objectives At our multihospital health system, our goal was to support providers in ordering telemetry on acute care in accordance with evidence-based guidelines and discontinuing telemetry when it was no longer medically indicated. Methods We implemented a multipronged electronic health record (EHR) intervention at two academic medical centers, including: (1) an order set requiring providers to choose an indication for telemetry with a recommended duration based on American Heart Association guidelines; (2) an EHR-generated reminder page to the primary provider recommending telemetry discontinuation once the guideline-recommended duration for telemetry is exceeded; and (3) documentation of telemetry interpretation by telemetry technicians in the notes section of the EHR. To determine the impact of the intervention, we compared number of telemetry orders actively discontinued prior to discharge and telemetry duration 1 year pre- to 1 year post-intervention on acute care medicine services. We evaluated sustainability at years 2 and 3. Results Implementation of the EHR initiative resulted in a statistically significant increase in active discontinuation of telemetry orders prior to discharge: 15% (63.4–78.7%) at one site and 13% at the other (64.1–77.4%) with greater improvements on resident teams. Fewer acute care medicine telemetry orders were placed on medicine services across the system (1,503–1,305) despite an increase in admissions and the average duration of telemetry decreased at both sites (62 to 47 hours, p < 0.001 and 73 to 60, p < 0.001, respectively). Improvements were sustained 2 and 3 years after intervention. Conclusion Our study showed that a low-cost, multipart, EHR-based intervention with active provider engagement and no additional education can decrease telemetry usage on acute care medicine services.

609 Background: Black patients with pancreatic ductal adenocarcinoma (PDAC) are less likely to have major pathologic response (MPR) following induction chemotherapy compared to non-Black patients. Rare reports have suggested that Black patients are more likely to be CA 19-9 non-producers. We aimed to determine if disproportionate rates of CA 19-9 nonproduction underlie racial differences in neoadjuvant chemotherapy response in patients with localized PDAC. We also explored differences in somatic mutations between CA 19-9 producers (CAprod) and non-producers (CAnonprod). Methods: Black and White patients with localized PDAC receiving ≥ 2 cycles of neoadjuvant chemotherapy followed by pancreatectomy (2010-2019) at 7 high-volume centers were reviewed. Patients were categorized as CAprod (CA 19-9 > 5 U/mL) or CAnonprod (CA 19-9 ≤ 5 U/mL). Uni- and multi-variable models evaluated differences in rates of CAnonprod by race, and the association of CAnonprod with MPR (CAP 0/1). The Pancreatic Cancer Action Network (PanCAN)’s SPARK health data platform which contains clinical and multi-omic data from the PanCAN Know Your Tumor program was queried to identify patients with CA 19-9 and genomic data. Fisher’s exact test was used to compare differentially mutated genes between CAprod and CAnonprod patients. Results: Our cohort included 385 (93.3%) CAprod and 30 (6.7%) CAnonprod. CAnonprod patients were more likely to be Black than CAprod (50.0% vs 12.5%, p<0.01). There were no other differences in demographic or clinical features between CAnonprod and CAprod. Most patients received FOLFIRINOX vs Gemcitabine based chemotherapy (60.3% CAprod vs. 56.7% CAnonprod, p=0.27) with a median number of 4.0 vs 5.0 cycles (p=0.83), respectively. Rate of MPR was significantly higher in patients with CAprod compared with CAnonprod patients (26.3% vs 7.7%, p=0.03). No CAnonprod patient had a complete pathologic response vs 28 (7.3%) of CAprod (p=0.12). CAnonprod was independently associated with decreased odds of MPR (OR 0.21, CI [0.04-0.99]). Black race was independently associated with increased odds of CAnonprod (OR 8.66, CI [3.81 – 19.7]). When stratified by production of CA 19-9, there was no significant difference between rate of MPR between Black and White patients. In the PanCAN KYT analysis, CAnonproduc had higher rates of SWI/SNF alterations (50.0% of CAnonprod vs 30.1% of CAprod, P<0.01;P-adj=ns; ARID1B was the most frequently mutated SWI/SNF gene in CAnonprod (31.0% vs 9.0% CApos, p<0.01; P-adj=ns). Conclusions: CAnonprod were more likely to be Black and have significantly worse rates of MPR following neoadjuvant chemotherapy in patients with localized PDAC. Moreover, CAnonprod was associated with higher rates of SWI/SNF alterations, noting a potential biologic basis for racial differences in chemotherapy response to curative-intent treatment for PDAC.

Meeting Centres (MC) are a flexible, hyper-local model for dementia post-diagnostic support, which create engaging, enabling, and empowering spaces for families affected by dementia. MCs offer ongoing warm and friendly expert assistance, including peer support, for people and families affected by dementia. The model originated in the Netherlands, led by Professor Rose-Marie Dröes at the Amsterdam University Medical Centers. Meeting Centres UK was established in 2018 and led by the Association for Dementia Studies (ADS), University of Worcester. In 2019 Kirrie Connections set up the first Scottish MC. Prior to the COVID-19 pandemic, there were 13 MCs in the UK. Despite the pandemic, there are now 32 funded MCs in England and Wales and 14 in Scotland with the likelihood of another 10 being funded before the end of 2023. Significant national and regional developments have taken place over the last three years. This has been driven by different policy decisions and funding opportunities across the three nations and has involved a variety of partnership working between academic, local authority, third sector, government and lived experience partners. The Scottish Government is supporting the development of a national MC network because of the recognition that capacity can be built, best practice shared, and communities empowered. In addition, the involvement of people affected by dementia is of paramount importance. In Scotland, this is being driven forward with a strategy board made up of a third people living with dementia, a third family carers and a third dementia professionals. This is being replicated in the new UK National MC Consortium. In the presentation, the different contexts and approaches to MCs will be described and compared. The audience will gain an understanding of the flexibility of the MC model in meeting the needs of people affected by dementia in different communities; the MC grassroots community development approach; and the impact of the involvement of people affected by dementia in the meaningful ongoing coproduction of MCs. Brooker, D., Evans, S., Dröes, R. M., (2016), Framing outcomes of post-diagnostic psychosocial interventions in dementia: The Adaptation-Coping Model and Adjusting to Change. Working with Older People. Vol 21: Issue 1 Evans, S., Bray, J. and Brooker, D. (2021), ""How Meeting Centres continue to support people affected by dementia: report on UK COVID-19 impact"", Working with Older People, Vol. 25 No. 4, pp. 283-293. https://doi.org/10.1108/WWOP-12-2020-0060 Evans, S., Bray, J., Brooker, D. and Stephens, N. (2022), ""The essential features of Meeting Centres: development of the UK criteria for community support for people affected by dementia"", Working with Older People, Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/WWOP-03-2022-0009

This study aims to analyze the level of psychological well-being of ex-drug addicted counselee in post-rehabilitation education. The study was conducted in 2 communities of post-rehabilitation education providers in Semarang city. The level of psychological well-being of 40 respondents was measured by filling in the 18-item psychological well-being scale developed by Ryff (r = 0.83; v = 0.97). Measurement includes indicators: (1) self-acceptance; (2) positive relationships with others; (3) autonomy; (4) environmental mastery; (5) purpose in life; and (6) personal growth. Hypothesis test results indicate that the level of psychological well-being of ex-drug addicted counselee in post-rehabilitation education is significantly greater or equal to 80 (t = 49,140; sig = 0,000). Based on the results of this study, it is recommended to further researchers to further explore certain differences in the level of psychological well-being of the counselee by the factors of age, demographics, educational background, and length of abstinence. In addition, further studies with a larger number of samples and questionnaire items are needed so that study results can be generalized to a wider population.Ardiantina, D. (2016). Studi Kasus Kehidupan Remaja Mantan Pecandu Narkoba. Jurnal Bimbingan dan Konseling, 5(1), 1-12.Astuti, R., & Ismandari, F. (2014). Gambaran Umum Penyalahgunaan Narkoba di Indonesia. Buletin Jendela Data dan Informasi Kesehatan. I, pp. 1-52. Jakarta: Kementrian Kesehatan RI.Aztri, S., & Milla, M. N. (2013). Rasa Berharga Dan Pelajaran Hidup Mencegah Kekambuhan Kembali Pada Pecandu Narkoba Studi Kualitatif Fenomenologis. Jurnal Psikologi, 9(1), 48-63.Bhandari, S., Dahal, M., & Neupane, G. (2015). 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Research between physical activity and cognitive work in children is still relatively rare and inconsistent, even though children's motor development and cognitive learning are related to positive effects on academic work. This study aims to determine the increase in mathematical logical intelligence of early childhood through physical activity. This is action research. This type of research was a sequential exploratory design. Data analysis in this study used a combined quantitative and qualitative analysis (Mix Method). The results showed increasing logical mathematics intelligence in DKI Jakarta's childhood. The initial assessment results showed that the average value of the child's logical mathematics intelligence was 28 and then increased to 57 in the final assessment of cycle 1 and continued to increase to 78 in the final assessment of cycle 2. Physical activity learning with games strategies increasing the logical mathematics intelligence in childhood in Jakarta Kindergarten. Future research is expected to examine more childhood intelligence with many respondents. Keywords: early childhood, physical activity, logical-mathematics intelligence References: Andriyani, FD, Biddle, SJH, Arovah, NI, & de Cocker, K. (2020). Physical activity and sedentary behavior research in Indonesian youth: A scoping review. International Journal of Environmental Research and Public Health,17(20), 1–15. https://doi.org/10.3390/ijerph17207665 Aubert, S., Brazo-sayavera, J., González, SA, Janssen, I., Manyanga, T., Oyeyemi, AL, Picard, P., Sherar, LB, Turner, E., & Tremblay, MS (2021). Global prevalence of physical activity for childhood and adolescents; inconsistencies , research gaps , and recommendations : a narrative review. 1–11. Azman, KF, & Zakaria, R. (2022). Recent Advances on the Role of Brain-Derived Neurotrophic Factor (BDNF) in Neurodegenerative Diseases. 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NOTICIAS / NEWS (“Transfer”, 2016) 1) CONGRESOS / CONFERENCES: 1. Languages & the Media – Agile Mediascapes: Personalising the Future, Hotel Radisson Blu, Berlín, 2-4 Nov. 2016 www.languages-media.com 2. Third Chinese Drama Translation Colloquium Newcastle University, UK, 28-19 Junio 2016. www.ncl.ac.uk/sml/about/events/item/drama-translation-colloquium 3. 16th Annual Portsmouth Translation Conference – Translation & Interpreting: Learning beyond the Comfort Zone, University of Portsmouth, UK, 5 Nov. 2016. www.port.ac.uk/translation/events/conference 4. 3rd International Conference on Non-Professional Interpreting & Translation (NPIT3) Zurich University of Applied Sciences, Suiza 5-7 Mayo 2016. www.zhaw.ch/linguistics/npit3 5. 3rd Postgraduate Symposium – Cultural Translation: In Theory and as Practice. University of Nottingham, UK, 18 Mayo 2016. Contact: uontranslation2016@gmail.com 6. 3rd Taboo Conference – Taboo Humo(u)r: Language, Culture, Society, and the Media, Universitat Pompeu Fabra (Barcelona) 20-21 Sep. 2016. https://portal.upf.edu/web/taco 7. Postgraduate Conference on Translation and Multilingualism Lancaster University, UK, 22 Abril 2016. Contacto: c.baker@lancaster.ac.uk 8. Translation and Minority University of Ottawa (Canadá), 11-12 Nov. 2016. Contacto: rtana014@uottawa.ca 9. Translation as Communication, (Re-)narration and (Trans-)creation Università di Palermo (Italia), 10 Mayo 2016 www.unipa.it/dipartimenti/dipartimentoscienzeumanistiche/convegni/translation 10. From Legal Translation to Jurilinguistics: Interdisciplinary Approaches to the Study of Language and Law, Universidad Pablo de Olavide, Sevilla, 27-28 Oct. 2016. www.tinyurl.com/jurilinguistics 11. Third International Conference on Research into the Didactics of Translation. Universitat Autònoma de Barcelona, 7-8 Julio 2016 http://grupsderecerca.uab.cat/pacte/en/content/second-circular-1 12. EST Congress – Expanding the Boundaries or Strengthening the Bases: Should Translation Studies Explore Visual Representation? Aarhus University (Dinamarca), 15-17 Sep. 2016 http://bcom.au.dk/research/conferencesandlectures/est-congress-2016/panels/18-expanding-the-boundaries-or-strengthening-the-bases-should-translation-studies-explore-visual-representation/ 13. Tourism across Cultures: Accessibility in Tourist Communication Università di Salento, Lecce (Italia). 25-27 Feb. 2016 http://unisalento.wix.com/tourism 14. Translation and Interpreting Studies at the Crossroad: A Dialogue between Process-oriented and Sociological Approaches – The Fourth Durham Postgraduate Colloquium on Translation Studies Durham University, UK. 30 Abril – 1 Mayo 2016. www.dur.ac.uk/cim 15. Translation and Interpreting: Convergence, Contact, Interaction Università di Trieste (Italia), 26-28 Mayo 2016 http://transint2016.weebly.com 16. 7th International Symposium for Young Researchers in Translation, Interpreting, Intercultural Studies and East Asian Studies. Universitat Autònoma de Barcelona, 1 Julio 2016. http://pagines.uab.cat/simposi/en 17. Translation Education in a New Age The Chinese University of Hong Kong, Shenzhen, China 15-16 Abril 2016. Contact: Claire Zhou (clairezhou@cuhk.edu.cn) 18. Audiovisual Translation: Dubbing and Subtitling in the Central European Context, Constantine the Philosopher University, Nitra (Eslovaquia). 15-17 Junio 2016. https://avtnitraconference.wordpress.com 19. Cervantes, Shakespeare, and the Golden Age of Drama Madrid, 17-21 Oct. 2016 http://aedean.org/wp-content/uploads/Call-for-papers.pdf 20. 3rd International Conference Languaging Diversity – Language/s and Power. Università di Macerata (Italia), 3-5 Marzo 2016 http://studiumanistici.unimc.it/en/research/conferences/languaging-diversity 21. Congreso Internacional de Traducción Especializada (EnTRetextos) Universidad de Valencia, 27-29 Abril 2016 http://congresos.adeituv.es/entretextos 22. Translation & Quality 2016: Corpora & Quality Université Charles de Gaulle Lille 3 (Francia), 5 Feb. 2016 http://traduction2016.sciencesconf.org/?lang=en 23. New forms of feedback and assessment in translation and interpreting training and industry. 8th EST Congress – Translation Studies: Moving Boundaries, Aarhus University (Dinamarca), 15-17 Sep. 2016. www.bcom.au.dk/est2016 24. Intermedia 2016 – Conference on Audiovisual Translation University of Lodz (Polonia), 14-16 Abril 2016 http://intermedia.uni.lodz.pl 25. New Technologies and Translation Université d’Algiers (Argelia). 23-24 Feb. 2016 Contacto: newtech.trans.algiers@gmail.com 26. Circulation of Academic Thought - Rethinking Methods in the Study of Scientific Translation. 11 - 12 Dec. 2015, University of Graz (Austria).https://translationswissenschaft.uni-graz.at/de/itat/veranstaltungen/circulation-of-academic-thought 27. The 7th Asian Translation Traditions Conference Monash University, Malaysia Campus, 26-30 Sep. 2016. http://future.arts.monash.edu/asiantranslation7 28. “Translation policy: connecting concepts and writing history” 8th EST Congress – Translation Studies: Moving Boundaries Aarhus University (Dinamarca), 15-17 Sep. 2016 http://bcom.au.dk/research/conferencesandlectures/est-congress-2016/panels/13-translation-policy-connecting-concepts-and-writing-history 29. International Conference – Sound / Writing: On Homophonic Translation. Université de Paris (Francia), 17-19 Nov. 2016 www.fabula.org/actualites/sound-writing-on-homophonic-translationinternational-conference-paris-november-17-19-2016_71295.php 30. Third Hermeneutics and Translation Studies Symposium – Translational Hermeneutics as a Research Paradigm Technische Hochschule, Colonia (Alemania), 30 Junio-1 Julio 2016 www.phenhermcommresearch.de/index.php/conferences 31. II International Conference on Economic Financial and Institutional Translation. Université du Québec à Trois-Rivières (Canadá), 17-18 Agosto 2016. www.uqtr.ca/ICEBFIT 32. International Congress - liLETRAd 2016-Cátedra LILETRAD. Literature Languages Translation, Universidad de Sevilla, 6-8 Julio 2016. https://congresoliletrad.wordpress.com 33. Transmediations! Communication across Media Borders Linnæus University, Växjö (Suecia), 13–15 Oct. 2016 http://lnu.se/lnuc/linnaeus-university-centre-for-intermedial-and-multimodal-studies-/events/conferences/transmediations?l=en 34. Translation Education in a New Age, 15-16 Abril 2016. School of Humanities and Social Science, The Chinese University of Hong Kong, Shenzhen. Contacto: chansinwai@cuhk.edu.cn 35. Translation and Time: Exploring the Temporal Dimension of Cross-cultural Transfer, 8-10 Diciembre 2016. Departamento de Traducción, The Chinese University of Hong Kong. Contacto: translation-and-time@cuhk.edu.hk. 36. Du jeu dans la langue. Traduire les jeux de mots / Loose in Translation. Translating Wordplay, 23-24 Marzo 2017, Université de Lille (France) https://www.univ-lille3.fr/recherche/actualites/agenda-de-la-recherche/?type=1&id=1271. Contacto: traduirejdm@univ-lille3.fr, julie.charles@univ-lille3.fr 37. Translation and Translanguaging across Disciplines. EST Congress 2016 “Translation Studies: Moving Boundaries”, European Society for Translation Studies, Aarhus (Dinamarca), 15-17 Sep. 2016 http://bcom.au.dk/research/conferencesandlectures/est-congress-2016/panels/12-translation-and-translanguaging-across-disciplines/ Contacto: nune.ayvazyan@urv.cat; mariagd@blanquerna.url.edu; sara.laviosa@uniba.it http://bcom.au.dk/research/conferencesandlectures/est-congress-2016/submission/ 38. Beyond linguistic plurality: The trajectories of multilingualism in Translation. An international conference organized jointly by Bogaziçi University, Department of Translation and Interpreting Studies, and Research Group on Translation and Transcultural Contact, York University, Bogaziçi University, 1-12 Mayo 2016. Contacto: sehnaz.tahir@boun.edu.tr, MGuzman@glendon.yorku.ca 39. "Professional and Academic Discourse: an interdisciplinary perspective". XXXIV IConferencia Internacional de la Sociedad Española de Lingüística Aplicada (AESLA), 14-16 Abril 2016. Interuniversity Institute for Applied Modern Languages (IULMA) / Universidad de Alicante. http://web.ua.es/aesla2016. Contacto: antonia.montes@ua.es. 2) CURSOS, SEMINARIOS, POSGRADOS / COURSES, SEMINARS, MASTERS: 1. Seminario: Breaking News for French>English and English>French Translators King's College Cambridge, UK, 8-10 Agosto 2016 Contacto: translateincambridge@iti.org.uk 2. Curso on-line: Setting Up as a Freelance Translator Enero – Marzo 2016. Institute of Translation & Interpreting, UK https://gallery.mailchimp.com/58e5d23248ce9f10c161ba86d/files/Application_Form_SUFT_2016.pdf?utm_source=SUFT+December+Emailer&utm_campaign=11fdfe0453-Setting_Up_as_a_Freelance_Translator12_7_2015&utm_medium=email&utm_term=0_6ef4829e50-11fdfe0453-25128325 3. Curso: Using Interpreters for Intercultural Communication and Other Purposes (COM397CE) http://darkallyredesign.com/what-we-do/using-interpreters-for-intercultural-communication 4. Workshop: How to Write and Publish Your Scholarly Paper In cooperation with the European Association of Science Editors (EASE) New Bulgarian University, Sofia (Bulgaria), 21-23 Marzo 2016 www.facebook.com/events/1511610889167645 http://esnbu.org/data/files/resources/ease-nbu-seminar-march-2016-fees.pdf 5. Posgrado: II Postgraduate Course on Spanish Law Taught in English "Global study". Universidad Internacional de Andalucía / Colegio de Abogados de Málaga. www.unia.es/cursos/guias/4431_english.pdf 3) CURSOS DE VERANO / SUMMER COURSES: 1. STRIDON – Translation Studies Doctoral and Teacher Training Summer School, Piran (Eslovenia), 27 Junio – 8 Julio 2016 www.prevajalstvo.net/doctoral-summer-school 2. Training in Translation Pedagogy Program School of Translation and Interpretation, University of Ottawa (Canadá), 4-29 Julio 2016. https://arts.uottawa.ca/translation/summer-programs 3. 2016 Nida School of Translation Studies. Translation, Ecology and Entanglement, San Pellegrino University Foundation, Misano Adriatico, Rimini (Italia), 30 Mayo – 10 Junio 2016. http://nsts.fusp.it/Nida-Schools/NSTS-2016 4. TTPP - Intensive Summer Program in Translation Pedagogy University of Ottawa (Canadá), 4-29 Julio 2016. http://arts.uottawa.ca/translation/summer-programs-2016/ttpp 5. CETRA Summer School 2016. 28th Research Summer School University of Leuven, campus Antwerp (Bélgica), 22 Agosto – 2 Sep. 2016. Contacto: cetra@kuleuven.be. http://www.arts.kuleuven.be/cetra 4) LIBROS / BOOKS: 1. Varela Salinas, María-José & Bernd Meyer (eds.) 2016. Translating and Interpreting Healthcare Discourses / Traducir e interpretar en el ámbito sanitario. Berlín : Frank & Timme. www.frank-timme.de/verlag/verlagsprogramm/buch/verlagsprogramm/bd-79-maria-jose-varela-salinasbernd-meyer-eds-translating-and-interpreting-healthcare-disc/backPID/transued-arbeiten-zur-theorie-und-praxis-des-uebersetzens-und-dolmetschens-1.html 2. Ordóñez López, Pilar and José Antonio Sabio Pinilla (ed.) 2015. Historiografía de la traducción en el espacio ibérico. Textos contemporáneos. Madrid: Ediciones de Castilla-La Mancha. www.unebook.es/libro/historiografia-de-latraduccion-en-el-espacio-iberico_50162 3. Bartoll, Eduard. 2015. Introducción a la traducción audiovisual. Barcelona: Editorial UOC. www.editorialuoc.cat/introduccion-a-la-traduccion-audiovisual 4. Rica Peromingo, Juan Pedro & Jorge Braga Riera. 2015. Herramientas y técnicas para la traducción inglés-español. Madrid: Babélica. www.escolarymayo.com/libro.php?libro=7004107&menu=7001002&submenu=7002029 5. Le Disez, Jean-Yves. 2015. F.A.C.T. Une méthode pour traduire de l’anglais au français. París: Ellipses. www.editions-ellipses.fr/product_info.php?cPath=386&products_id=10601 6. Baker, Mona (ed.) 2015. Translating Dissent: Voices from and with the Egyptian Revolution. Londres: Routledge. www.tandf.net/books/details/9781138929876 7. Gallego Hernández, Daniel (ed.) 2015. Current Approaches to Business and Institutional Translation / Enfoques actuales en traducción económica e institucional. Berna: Peter Lang. www.peterlang.com/download/datasheet/86140/datasheet_431656.pdf 8. Vasilakakos, Mary. 2015. A Training Handbook for Health and Medical Interpreters in Australia. www.interpreterrevalidationtraining.com/books-and-resources.html 9. Jankowska, Anna & Agnieszka Szarkowska (eds) 2015. New Points of View on Audiovisual Translation and Media Accessibility. Oxford: Peter Lang. www.peterlang.com/index.cfm?event=cmp.ccc.seitenstruktur.detailseiten&seitentyp=produkt&pk=83114 10. Baer, Brian James (2015). Translation and the Making of Modern Russian Literature, Londres: Bloomsbury. Translation and the Making of Modern Russian Literature is the inaugural book in a new Translation Studies series: Bloomsbury’s “Literatures, Cultures, Translation.” 11. Camps, Assumpta. 2016. La traducción en la creación del canon poético (Recepción de la poesía italiana en el ámbito hispánico en la primera mitad del siglo XX). Berna: Peter Lang. 5) REVISTAS / JOURNALS: 1. JoSTrans, The Journal of Specialised Translation, nº especial sobre Translation & the Profession, Vol. 25, Enero 2016. www.jostrans.org 2. Translation and Interpreting – Nº especial sobre Community Interpreting: Mapping the Present for the Future www.trans-int.org/index.php/transint. 3. inTRAlinea – Nº especial sobre New Insights into Specialised Translation. www.intralinea.org/specials/new_insights 4. Linguistica Antverpiensia NS-Themes in Translation Studies, 2015 issue, Towards a Genetics of Translation. https://lans-tts.uantwerpen.be/index.php/LANS-TTS/issue/view/16 5. Quaderns de Filologia, Nº especial sobre Traducción y Censura: Nuevas Perspectivas, Vol. 20, 2015. https://ojs.uv.es/index.php/qdfed/issue/view/577 6. The Translator – Nº especial sobre Food and Translation, Translation and Food, 2015, 21(3). www.tandfonline.com/eprint/ryqJewJUDKZ6m2YM4IaR/full 7. Current Trends in Translation Teaching and Learning E, 2015, 2 www.cttl.org/cttl-e-2015.html 8. Dragoman Journal of Translation Studies. www.dragoman-journal.org 9. Current Trends in Translation Teaching and Learning E. Edición especial sobre Translation Studies Curricula Across Countries and Cultures. www.cttl.org 10. International Journal of the Sociology of Language, Nº especial sobre Translation Policies and Minority Languages: Theory, Methods and Case Studies http://fouces.webs.uvigo.es/CallForPapersIJSLTranslationPolicies.pdf 11. Nº especial de The Interpreter and Translator Trainer 11(2) – Employability and the Translation Curriculum www.tandfonline.com/doi/full/10.1080/1750399X.2015.1103092 12. InTRAlinea. Nº especial sobre Building Bridges between Film Studies and Translation Studies www.intralinea.org/news/item/cfp_building_bridges_between_film_studies_and_translation_studies 13. Nº especial de TranscUlturAl: Comics, BD & Manga in translation/en traduction https://ejournals.library.ualberta.ca/index.php/TC/announcement/view/290 14. The Journal of Translation Studies 2015, 16(4) Nº especial sobre Translator and Interpreter Training in East Asia Contacto: Won Jun Nam: wjnam@hufs.ac.kr, wonjun_nam@daum.net 15. TRANS Revista de Traductología, 19(2), 2015. www.trans.uma.es/trans_19.2.html 16. Between, 9, 2015 – Censura e auto-censura http://ojs.unica.it/index.php/between/index 17. Translation Studies, Nº especial sobre Translingualism & Transculturality in Russian Contexts of Translation http://explore.tandfonline.com/cfp/ah/rtrs-cfp3 18. Translation & Interpreting, 7:3, 2016 www.trans-int.org/index.php/transint/issue/view/38 19. "The translation profession: Centres and peripheries" The Journal of Specialised Translation (Jostrans), Nº. 25, Enero 2016. The Journal of Translation Studies is a joint publication of the Department of Translation of The Chinese University of Hong Kong and the Chinese University Press. Contact: jts.tra@cuhk.edu.hk, james@arts.cuhk.edu.hk 19. Nuevo artículo: "The Invisibility of the African Interpreter" por Jeanne Garane, Translation: a transdisciplinary journal http://translation.fusp.it/. Contact: siri.nergaard@gmail.com.

During COVID-19, early-childhood school closings led to higher levels of stress in parents when compared to childless adults. In addition, lack of time to prepare, as well as mental-health problems, worry, and stress in parenting, may have hampered parents' ability to support their children's educational needs. The research aims to solve the problem of early childhood parenting during learning from home and improve the quality of early childhood parenting. The research method uses the research and development stage of the Borg & Gall model. Participants are mothers who have children aged 5-6 years. The data collection technique was done through expert validation and effectiveness testing with a quasi-experimental design. The data analysis used paired t-test statistical analysis. The findings show that the validity of the results of the material expert's test is 96%, and the media expert's test is 94% in the very good category. The effectiveness test based on the pre-test and post-test results showed that Sig. (2-tailed) <0,05 (α), which means that the parenting e-book media significantly increases mothers' understanding of parenting well-being practices in early childhood. The implications of this multimedia-based anyflip e-book can be downloaded via gadgets, android, laptop, practical, easy to read and repeated to accompany childcare activities from home. Keywords: Anyflip E-book, Early Childhood, Parenting References Banerjee, A., Hanna, R., Kyle, J., Olken, B. A., & Sumarto, S. (2019). Private Outsourcing and Competition: Subsidized Food Distribution in Indonesia. Journal of Political Economy, 127(1), 101–137. https://doi.org/10.1086/700734 Borg, W. R., & Gall, M. D. (2007). Educational Research an Introduction. Fourth Edition. Bacon Publishing. Bruni, O., Sette, S., Fontanesi, L., Baiocco, R., Laghi, F., & Baumgartner, E. (2015). Technology Use and Sleep Quality in Preadolescence and Adolescence. Journal of Clinical Sleep Medicine, 11(12), 1433–1441. https://doi.org/10.5664/jcsm.5282 de Jong, E., Visscher, T., HiraSing, R., Heymans, M., Seidell, J., & Renders, C. (2013). Association between TV viewing, computer use and overweight, determinants and competing activities of screen time in 4- to 13-year-old children. International Journal of Obesity, 7. Dong, C., Cao, S., & Li, H. (2020). Young children’s online learning during COVID-19 pandemic: Chinese parents’ beliefs and attitudes. Children and Youth Services Review, 118, 105440. https://doi.org/10.1016/j.childyouth.2020.105440 Ebert, S. (2020). Theory of mind, language, and reading: Developmental relations from early childhood to early adolescence. Journal of Experimental Child Psychology, 191, 104739. https://doi.org/10.1016/j.jecp.2019.104739 Evans, M. A., Nowak, S., Burek, B., & Willoughby, D. (2017). The effect of alphabet eBooks and paper books on preschoolers’ behavior: An analysis over repeated readings. Early Childhood Research Quarterly, 40, 1–12. https://doi.org/10.1016/j.ecresq.2017.02.002 Fry, A. (2020). Use patterns for ebooks: The effects of subject, age and availability on rate of use. The Journal of Academic Librarianship, 46(3), 102150. https://doi.org/10.1016/j.acalib.2020.102150 Gerber, L. A., Guggenheim, M., Pang, Y. C., Ross, T., Mayevskaya, Y., Jacobs, S., & Pecora, P. J. (2020). Understanding the effects of an interdisciplinary approach to parental representation in child welfare. Children and Youth Services Review, 116, 105163. https://doi.org/10.1016/j.childyouth.2020.105163 Lau, E. Y. H., & Lee, K. (2020). Parents’ Views on Young Children’s Distance Learning and Screen Time During COVID-19 Class Suspensio. Early Education and Development, 19. https://doi.org/10.1080/10409289.2020.1843925 Lee, S. J., Ward, K. P., Chang, O. D., & Downing, K. M. (2021). Parenting activities and the transition to home-based education during the COVID-19 pandemic. Children and Youth Services Review, 122, 105585. https://doi.org/10.1016/j.childyouth.2020.105585 Morawska, A., Dittman, C. K., & Rusby, J. C. (2019). Promoting Self-Regulation in Young Children: The Role of Parenting Interventions. Clinical Child and Family Psychology Review, 22(1), 43–51. https://doi.org/10.1007/s10567-019-00281-5 Mourlam, D. J., DeCino, D. A., Newland, L. A., & Strouse, G. A. (2020). “It’s fun!” using students’ voices to understand the impact of school digital technology integration on their well-being. Computers & Education, 159, 104003. https://doi.org/10.1016/j.compedu.2020.104003 Nuñez, B., Stuart-Cassel, V., & Temkin, D. (2020). As COVID-19 spreads, most states have laws that address how schools should respond to pandemics. 66. Paredes, E., Hernandez, E., Herrera, A., & Tonyan, H. (2020). Putting the “family” in family childcare: The alignment between familismo (familism) and family childcare providers’ descriptions of their work. Early Childhood Research Quarterly, 52, 74–85. https://doi.org/10.1016/j.ecresq.2018.04.007 Rosen, L. D., Felice, K. T., & Walsh, T. (2020). Whole health learning: The revolutionary child of integrative health and education. EXPLORE, 16(4), 271–273. https://doi.org/10.1016/j.explore.2020.05.003 Thomas, V., De Backer, F., Peeters, J., & Lombaerts, K. (2019). Parental involvement and adolescent school achievement: The mediational role of self-regulated learning. Learning Environments Research, 22(3), 345–363. https://doi.org/10.1007/s10984-019-09278-x Tran, T., Hoang, A.-D., Nguyen, Y.-C., Nguyen, L.-C., Ta, N.-T., Pham, Q.-H., Pham, C.-X., Le, Q.-A., Dinh, V.-H., & Nguyen, T.-T. (2020). Toward Sustainable Learning during School Suspension: Socioeconomic, Occupational Aspirations, and Learning Behavior of Vietnamese Students during COVID-19. Sustainability, 12(10), 4195. https://doi.org/10.3390/su12104195 Troseth, G. L., & Strouse, G. A. (2017). Designing and using digital books for learning: The informative case of young children and video. International Journal of Child-Computer Interaction, 12, 3–7. https://doi.org/10.1016/j.ijcci.2016.12.002 UNESCO, U. (2020). COVID-19 impact on education. United Nations Educational Scientific and Cultural Organization. https://en. unesco.org/covid19/educationresponse Webster, E. K., Martin, C. K., & Staiano, A. E. (2019). Fundamental motor skills, screen-time, and physical activity in preschoolers. Journal of Sport and Health Science, 8(2), 114–121. https://doi.org/10.1016/j.jshs.2018.11.006

Abstract BACKGROUND: Long-term Tirosin Kinase Inhibitor (TKI) treatment is related to notable adverse events, quality-of-life impact and significant costs to health systems. Many patients in optimal response are candidates to TKI discotinuation that has proven to be safe in clinical trials. TFR has become a new goal for CML management. Information about its implementation in clinical practice in LA is limited. The aim of this study is to describe the results, safety and assess the possible economic impact of a cohort of patients that has discontinued TKI in clinical practice in Colombia. MATERIAL AND METHODS : The Colombian Association of Hematology and Oncology (ACHO)'s hematological disease registry (RENEHOC) is a multicenter nationwide registry on hematologic malignancies that captures information from 18 academic and general community centers with Institutional Ethics Committee approval, since 2018. Since 2019, it has been collecting information on CML. This report represents a sub-analysis of CML patients in the registry in whom discontinuation was performed. Treatment was according to investigator preferences. A total of 449 CML adult patients treated in the last 20 years have been registered until now on RENEHOC. 29 patients were considered eligible for TFR; in 27 of them, TKI have been discontinued. The main outcome measured is survival without TKI re-initiation. RESULTS: At diagnosis the median age was 58 yrs. (IQR 51-65), all were in the chronic phase and 86% had intermediate-higk risk Sokal score. First line treatment was Imatinib in 11, Dasatinib 9, and Nilotinib 7. 5 patients required a second line with Nilotinib, only one of them was considered to have failed first line. 17 discontinuations were performed as a planned physician strategy, 6 were carried out by patient's decision, 3 were forced by toxicities and in one case it was carried out to search for a pregnancy. Median time on TKIs before discontinuation was 73 months (IQR 59-135) and median time in RMM before TFR was 46 moths (IQR 35-71). Due to its retrospective nature, many patients did not have exact information on MR4.5 achievement date, since it was not available in Colombia until 2016. At a median follow-up of 12.5 months (IQR 4-20), 22 (81%) patients remain on TFR. As has been previously described most patients lost MMR in the first 6 months (median time to restart TKI 6 months; IQR 2-10). Only 1 patient did not achieve the MMR after TKI reinitiated, no progressions to accelerated or blastic phase were reported. 3 patients reinitiated the same ITK and 2 changed to another. 1 patient that was initially treated with Imatinib was changed to Nilotinib after reinitiation and after 2 years in MMR 4.5 has again discontinued TKI and has not lost response after 3 months. 9 (33%) patients developed withdrawal syndrome in most cases (7) with mild symptoms, only 2 had moderate symptoms. The estimated savings on TKIs for Colombian health care system for this patients are US$1.156.937, it is calculated that the cost of the PCR analysis performed for this patients to monitor TFR safely was US$35019. CONCLUSIONS: TKI has change the landscape for CML patients, that currently have a life expectancy similar to the general population; however, indefinitely treatment is associated with significant toxicities and a very high cost for the systems. TFR has become a real goal for a selected group of patients with CML. This report represents real-world data in Colombia, showing its feasibility and safety under well-controlled settings. Also, the estimated savings for a health care system of a middle-income country as Colombia are very significant, which is an additional support to insist with the decision makers of the system in the importance of the optimal access to TKIs and the necessary tests so that a greater number of patients can reach the necessary goals for a safe TFR. Figure 1 Figure 1. Disclosures Abello: Janssen: Honoraria; Amgen: Honoraria; Dr Reddy's: Research Funding. Sossa: Amgen: Research Funding.

Eating habits develop during the first years of a child's life, children learn what, when, and how much to eat through direct experience with food and by observing the eating habits of others. The aim of this study is to get a clear picture of the Eating program Healthy, starting from the planning, implementation, supervision, and evaluation as a case study of nutrition education; to get information about the advantages, disadvantages and effects of implementing a healthy eating program for children. This research was conducted through a case study with qualitative data analysed using Miles and Huberman techniques. Sample of children in Ananda Islāmic School Kindergarten. The results showed the Healthy Eating program could be implemented well, the diet was quite varied and could be considered a healthy and nutritious food. The visible impact is the emotion of pleasure experienced by children, children become fond of eating vegetables, and make children disciplined and responsible. Inadequate results were found due to the limitations of an adequate kitchen for cooking healthy food, such as cooking activities still carried out by the cook himself at the Foundation's house which is located not far from the school place; use of melamine and plastic cutlery for food; the spoon and fork used already uses aluminium material but still does not match its size; does not involve nutritionists. Keywords: Early Childhood, Eating Healthy Program References: Bandura, A. (1977). Social learning theory. Englewood Cliffs: Prentice-Hall. Bandura, Albert. (2004). Health promotion by social cognitive means. Health Education and Behavior, 31(2), 143–164. https://doi.org/10.1177/1090198104263660 Battjes-Fries, M. C. E., Haveman-Nies, A., Renes, R. J., Meester, H. J., & Van’T Veer, P. (2015). Effect of the Dutch school-based education programme “Taste Lessons” on behavioural determinants of taste acceptance and healthy eating: A quasi-experimental study. Public Health Nutrition, 18(12), 2231–2241. https://doi.org/10.1017/S1368980014003012 Birch, L., Savage, J. S., & Ventura, A. (2007). Influences on the Development of Children’s Eating Behaviours: From Infancy to Adolescence. Canadian Journal of Dietetic Practice and Research : A Publication of Dietitians of Canada = Revue Canadienne de La Pratique et de La Recherche En Dietetique : Une Publication Des Dietetistes Du Canada, 68(1), s1– s56. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19430591%0Ahttp://www.pubmedcentral.nih.gov/a rticlerender.fcgi?artid=PMC2678872 Coulthard, H., Williamson, I., Palfreyman, Z., & Lyttle, S. (2018). Evaluation of a pilot sensory play intervention to increase fruit acceptance in preschool children. Appetite, 120, 609–615. https://doi.org/10.1016/j.appet.2017.10.011 Coulthard, Helen, & Sealy, A. (2017). Play with your food! Sensory play is associated with tasting of fruits and vegetables in preschool children. Appetite, 113, 84–90. https://doi.org/10.1016/j.appet.2017.02.003 Crain, W. C. (2005). Theories of development: Concepts and applications. Upper Saddle River: Pearson Prentice Hall. Dazeley, P., Houston-Price, C., & Hill, C. (2012). Should healthy eating programmes incorporate interaction with foods in different sensory modalities? A review of the evidence. British Journal of Nutrition, 108(5), 769–777. https://doi.org/10.1017/S0007114511007343 Derscheid, L. E., Umoren, J., Kim, S. Y., Henry, B. W., & Zittel, L. L. (2010). Early childhood teachers’ and staff members’ perceptions of nutrition and physical activity practices for preschoolers. Journal of Research in Childhood Education, 24(3), 248–265. https://doi.org/10.1080/02568543.2010.487405 Eliassen, E. K. (2011). The impact of teachers and families on young children’s eating behaviors. YC Young Children, 66(2), 84–89. Elliott, E., Isaacs, M., & Chugani, C. (2010). 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Journal of Human Growth and Development, 29(3), 390–402. https://doi.org/10.7322/jhgd.v29.9538 Froehlich Chow, A., & Humbert, M. L. (2014). Perceptions of early childhood educators: Factors influencing the promotion of physical activity opportunities in Canadian rural care centers. Child Indicators Research, 7(1), 57–73. https://doi.org/10.1007/s12187-013-9202-x Graham, H., Feenstra, G., Evans, A. M., & Zidenberg-Cherr, S. (2002). Healthy Eating Habits in Children. California Agriculture, 58(4), 200–205. Gucciardi, E., Nagel, R., Szwiega, S., Chow, B. Y. Y., Barker, C., Nezon, J., ... Butler, A. (2019). Evaluation of a Sensory-Based Food Education Program on Fruit and V egetable Consumption among Kindergarten Children. Journal of Child Nutrition & Management, 43(1). Holley, C. E., Farrow, C., & Haycraft, E. (2017). A Systematic Review of Methods for Increasing Vegetable Consumption in Early Childhood. 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Abstract INTRODUCTION In sickle cell disease (SCD), abnormal red blood cells (RBCs) sickle upon deoxygenation due to polymerization of hemoglobin S (HbS). Sickle RBCs exhibit poor deformability and increased viscosity, density, and microvascular adhesion. These rheological properties can be measured using existing devices. An oxygen-gradient ektacytometer measures the deformability of sickle RBCs under normoxic (maximum elongation index, or EImax) and hypoxic conditions (minimum elongation index, or EImin), and the pO 2 level at which sickling beings (point of sickling, or PoS). Dense RBCs are measured using a commercially available hematology analyzer. The hematocrit-to-viscosity ratio (HVR), an oxygen delivery index, is calculated based on the viscosity as measured by a cone and plate viscometer. RBC adhesion in the microvasculature can be modeled using a laminin-lined microfluidics device. These rheological biomarkers correlate with clinical complications such as pain events and acute chest syndrome, and are modified by known, clinically effective therapies such as hydroxyurea (HU) and transfusion (TF). HU is the standard of care for most individuals with SCD and positively modifies EImin, EImax, PoS, HVR, adhesion, and %DRBC. Recently, new agents to treat SCD have emerged including voxelotor, crizanlizumab, and pyruvate kinase activators like etavopivat, which have more targeted effects. It is essential to pair the appropriate novel agent to the patient, addressing their most prominent RBC abnormality remaining after HU therapy. We hypothesize that there is significant variability of rheology biomarkers between individuals with SCD on standard of care therapy, and that the most severe aspects of their RBC pathophysiology can be identified and targeted by novel second line therapies for clinical optimization. METHODS We collected peripheral blood in EDTA under an IRB approved protocol from 312 pediatric patients with SCD ranging in age from 2 to 21 years, 70% on HU. Subjects on chronic TF therapy were excluded. We measured whole blood viscosity at 45s -1 shear and calculated the HVR. %DRBC and complete blood counts were obtained using an ADVIA hematology analyzer (Siemens) and EImin, EImax, and PoS obtained using oxygen gradient ektacytometry (Lorrca, RR Mechatronics). RBCs from 17 HbSS subjects were analyzed for adhesion index to a laminin-lined microfluidics device. Values were assembled for each biomarker into histograms to demonstrate distribution, and quartile ranked. Venn diagrams were constructed comparing overlap between top 25% most severe rheology biomarkers to demonstrate effectiveness of a targeted, precision medicine approach to adding second line therapies to individuals with SCD. RESULTS Distribution of biomarkers in a typical pediatric SCD population in a US academic center are shown in Figure 1. High PoS, adhesion index, %DRBC, and low EImin and EImax, low HVR, are associated with disease severity and clinical complications in SCD; biomarker values were stratified from high to low severity association. The most severe quartile subjects from each biomarker were compared, and percentage of overlap noted (Figure 2). CONCLUSION Our rheologic assessment of a large pediatric cohort heavily treated with HU indicates a broad distribution of RBC phenotypes. Even on HU, patients exhibited loss of deformability, sickling, adhesion, or RBC density abnormalities, with little overlap of unrelated biomarkers associated with disease severity in an individual, i.e. the individuals with very high PoS did not have low HVR (16% of highest severity quartile subjects in common), compared to related biomarkers PoS and EImin or EImax (48% of highest severity quartile subjects in common). Only four subjects, all on HU, were in the quartile associated with highest severity for all biomarkers. Given the lack of overlapping pathology between different red cell abnormalities, selection of the appropriate agent should be straightforward. With three new FDA approved therapies for SCD and novel therapies in clinical trials, it is possible to choose the appropriate second agent to be added to HU based on individual patient RBC phenotype according to the principles of precision medicine. Future goals include CLIA certification for novel devices like the oxygen gradient ektacytometer and adhesive microfluidics at major academic SCD centers and use of these biomarkers in routine patient care. Figure 1 Figure 1. Disclosures Rab: Agios Pharmaceuticals: Research Funding; Axcella Health: Research Funding. Lam: Sanguina, Inc.: Current holder of individual stocks in a privately-held company. Wijk: Agios Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Research Funding; Axcella health: Research Funding; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding. Sheehan: Beam Therapeutics: Research Funding; Forma Therapeutics: Research Funding; Novartis: Research Funding.

Background: Although sleep has been identified as an important modifiable risk factor for sports injury, the effect of decreased sleep on sports injuries in adolescents is poorly studied. Purpose: To systematically review published literature to examine if a lack of sleep is associated with sports injuries in adolescents and to delineate the effects of chronic versus acute lack of sleep. Methods: PubMed and EMBASE databases were systematically searched for studies reporting statistics regarding the relationship between sleep and sports injury in adolescents aged <19 years published between 1/1/1997 and 12/21/2017. From included studies, the following information was extracted: bibliographic and demographic information, reported outcomes related to injury and sleep, and definitions of injury and decreased sleep. Additionally, a NOS (Newcastle-Ottawa Scale) assessment and an evaluation of the OCEM (Oxford Center for Evidence-Based Medicine) level of evidence for each study was conducted to assess each study’s individual risk of bias, and the risk of bias across all studies. Results: Of 907 identified articles, 7 met inclusion criteria. Five studies reported that adolescents who chronically slept poorly were at a significantly increased likelihood of experiencing a sports or musculoskeletal injury. Two studies reported on acute sleep behaviors. One reported a significant positive correlation between acutely poor sleep and injury, while the other study reported no significant correlation. In our random effects model, adolescents who chronically slept poorly were more likely to be injured than those who slept well (OR 1.58, 95% CI 1.05 to 2.37, p = 0.03). OCEM criteria assessment showed that all but one study (a case-series) were of 2b level of evidence—which is the highest level of evidence possible for studies which were not randomized control trials or systematic reviews. NOS assessment was conducted for all six cohort studies to investigate each study’s individual risk of bias. Five out of six of these studies received between 4 to 6 stars, categorizing them as having a moderate risk of bias. One study received 7 stars, categorizing it as having a low risk of bias. NOS assessment revealed that the most consistent source of bias was in ascertainment of exposure: all studies relied on self-reported data regarding sleep hours rather than a medical or lab record of sleep hours. Conclusions: Chronic lack of sleep in adolescents is associated with greater risk of sports and musculoskeletal injuries. Current evidence cannot yet definitively determine the effect of acute lack of sleep on injury rates. 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Parents play an important role in the development of their children. This research reflects the role of parents in developing children. Through four stages of identification, screening, eligibility, and acceptable results, this method uses a systematic literature review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) method. The findings from the fourteen articles examined show that parenting skills play an important role in a child's growth and development from birth to death. The determining factor in the development of physical, motoric, moral, language, social-emotional, and life skills aspects is the role of both parents as important teachers for children from birth to adulthood. Parents can also use a variety of parenting strategies and skills, many of which they have learned throughout their lives and passed on to their children, to help their children grow. 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This study examines psycholinguistic structure of autobiographical and traumatic narratives representing positive emotional and stressful traumatic life events. The research applied the cross sectional, between subjects design utilizing the independent variables of external agent they, space and time and dependent variable of word number in traumatic narratives for multiple regression analysis. The approval letter to recruit the participants through SONA system in 2015–2016 academic year was obtained from Institutional Review Board of Oklahoma State University (USA). 64 undergraduates of nonclinical setting, females (n=37), males (n=27), mean age was 19.43 (SD=1.37) were recruited. PTSD-8: A Short PTSD Inventory assesses PTSD, the Linguistic Inquiry and Word Count (LIWC) analyzes traumatic and autobiographical narratives in terms of linguistic units and psychological meaningful categories. The results indicate that there are significant differences between pronoun they as external agent of proposition and psychological categories of negative emotions and anxiety in traumatic and autobiographical narratives. The frequency of these categories is higher in traumatic narratives compared with autobiographical narratives. External agent they, category of time and space taken together significantly contribute to word number in traumatic narrative. There is a negative correlation between focus on the past and word count, and positive correlation between social category and word count in traumatic narrative in nonclinical sample. To sum up, propositional structure of traumatic memory of individuals without PTSD is represented by external agent and context (place and time) taken together. Considering time as a significant negative predictor of creating traumatic narrative, temporal processing without overestimation of time is an important factor of avoiding PTSD. 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Background: There is growing evidence to suggest that continuous monitoring and a proper use of patient-reported outcomes (PROs) in the clinical setting may improve patient care by facilitating doctor-patient communication, promoting individualized supportive care, and increasing patient satisfaction (Velikova, J Clin Oncol. 2004;22(4):714-24; Yang, Support Care Cancer. 2018 Jan;26(1):41-60). This may be of particular importance for patients with MM, a condition characterized by considerable heterogeneity in PROs at different timepoints within a patient's disease journey (TA King et al, Semin Oncol Nurs. 2017;33(3):299-315;R Abonour et al, Ann Hematol. 2018;97(12):2425-36). There is also a growing body of evidence to support that digital platforms in healthcare can have an impact on patients' lives and improve the patient care experience across diverse medical settings. Web-based platforms that provide education and allow patients to track data have demonstrated improvement across a range of PROs measuring empowerment, self-efficacy, and mastery when compared against standard of care in a variety of disease states (MR Fu et al, Internet Interv. 2016;5:56-64; G Bouma et al, Support Care Cancer. 2017;25(7):2075-2083). This may be particularly relevant in light of the current coronavirus disease 2019 (COVID-19) global pandemic. Patient-reported outcome data (e.g., symptoms) that can be readily shared with healthcare professionals (HCPs) can support clinical decision making and impact patient outcomes (E Basch et al, JAMA. 2017 Jul 11;318(2):197-8). Data collected through wearables (such as emoji scales and activity) have been shown to be correlated with traditional, validated PRO measures in patients with cancer (CA Thompson et al, Blood. 2017;130(Suppl 1):2179). Digital medication tracking has led to better medication adherence, increased prescription refills, and better clinical outcomes. Centralized disease management digital platforms have shown potential to reduce patients' risk of complications (S Kumar et al, Abstract for the 77th American Diabetes Association. 2017). Despite this body of evidence supporting the potential impact of the use of digital platforms, there is little evidence specifically in MM. The MyHOPE™ for MM Solution is a validated investigational digital technology platform designed to provide patients with a comprehensive set of tools and resources to support the patient throughout their overall experience with MM and to collect biometrics and self-reported data such as symptom tracking, medication adherence, and health-related quality of life (HRQoL) with the ability to share this data with the patient's care team. MyHOPE™ for MM is the first prospective study evaluating the impact of a digital intervention for patients with hematological malignancies. Study Design and Methods: This is a multi-center, randomized, pilot trial of the MyHOPE™ for MM Solution. Approximately 126 adult patients (≥ 18 years of age) with a diagnosis of MM and who reside in the USA will be recruited from approximately 30 study sites within the USA, reflecting both community and academic centers. Patients will be stratified according to disease status (newly-diagnosed multiple myeloma transplant-eligible or ineligible, newly-diagnosed multiple myeloma in patients undergoing their first autologous stem cell transplant, or relapsed and/or refractory) and will be randomized in a 2:1 manner to either the Patient App + HCP Portal (Cohort 1) or Patient App Alone (Cohort 2). Primary objectives include feasibility of the platform and patient empowerment and self-efficacy. Other objectives include user satisfaction with the platform, health-related quality of life, and clinical outcomes. Enrolled patients will receive MM-treament regimen according to their physician's care plan. The study is in start-up and recruitment is expected through 2021. Disclosures Raje: Celgene: Consultancy. Nadeem:Amgen: Membership on an entity's Board of Directors or advisory committees; Adaptive: Membership on an entity's Board of Directors or advisory committees; Sanofi: Consultancy, Membership on an entity's Board of Directors or advisory committees; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: TRAVEL, ACCOMMODATIONS, EXPENSES; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: TRAVEL, ACCOMMODATIONS, EXPENSES; Janssen: Consultancy, Honoraria, Other: TRAVEL, ACCOMMODATIONS, EXPENSES. Mikhael:Amgen, Celgene, GSK, Janssen, Karyopharm, Sanofi, Takeda: Honoraria. Ludwig:Bristol Myers Squibb: Consultancy. Agarwal:Bristol-Myers Squibb Company: Current Employment, Current equity holder in publicly-traded company. Inumerable:Bristol Myers Squibb: Current Employment. Ong:Bristol Myers Squibb: Current Employment. Jagannath:BMS, Janssen, Karyopharm, Legend Biotech, Sanofi, Takeda: Consultancy.

The pandemic of COVID-19 has afflicted every individual and has initiated a cascade of directly or indirectly involved events in precipitating mental health issues. The human species is a wanderer and hunter-gatherer by nature, and physical social distancing and nationwide lockdown have confined an individual to physical isolation. The present review article was conceived to address psychosocial and other issues and their aetiology related to the current pandemic of COVID-19. The elderly age group has most suffered the wrath of SARS-CoV-2, and social isolation as a preventive measure may further induce mental health issues. Animal model studies have demonstrated an inappropriate interacting endogenous neurotransmitter milieu of dopamine, serotonin, glutamate, and opioids, induced by social isolation that could probably lead to observable phenomena of deviant psychosocial behavior. Conflicting and manipulated information related to COVID-19 on social media has also been recognized as a global threat. Psychological stress during the current pandemic in frontline health care workers, migrant workers, children, and adolescents is also a serious concern. Mental health issues in the current situation could also be induced by being quarantined, uncertainty in business, jobs, economy, hampered academic activities, increased screen time on social media, and domestic violence incidences. The gravity of mental health issues associated with the pandemic of COVID-19 should be identified at the earliest. Mental health organization dedicated to current and future pandemics should be established along with Government policies addressing psychological issues to prevent and treat mental health issues need to be developed. References World Health Organization (WHO) Coronavirus Disease (COVID-19) Dashboard. 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Sharenting is a habit of using social media to share content that disseminates pictures, videos, information, and parenting styles for their children. The purpose of this article is to describe the sharenting phenomenon that occurs among young parents, and the importance of parenting programs, rather than protecting children's privacy. Writing articles use a qualitative approach as a literature review method that utilizes various scientific articles describing the sharenting phenomenon in various countries. The findings show that sharenting behaviour can create the spread of children's identity openly on social media and tends not to protect children's privacy and even seems to exploit children. Apart from that, sharenting can also create pressure on the children themselves and can even have an impact on online crime. 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Early childhood emotional dysregulation is critical in recognizing and preventing psychological well-being disorders, laying the groundwork for developing healthy emotional behaviors early on. This study aims to determine the direct influence of smartphone addiction, executive function, and the mother-child relationship on emotional dysregulation in early childhood in West Sumatra. This research method is a quantitative survey. The data collection technique in this research uses a questionnaire design on 309 parents who were selected using a simple random sampling method. This data processing tool uses the SmartPLS software. The results of the study indicate that smartphone addiction has a significant impact on emotional dysregulation in early childhood, executive function has a positive and significant effect on emotional dysregulation in early childhood, and the mother-child relationship has a positive and significant influence on emotional dysregulation in early childhood. 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Environmental education exists as a solution to improving the intelligence of early childhood naturalists, but its implementation is often forgotten or only as a hidden curriculum. The purpose of this study is to provide information related to the implementation of environmental education for early childhood to improve the intelligence of early childhood naturalists. The research method used in this study is a qualitative method presented in the form of an in-depth literature review. Literature study efforts are carried out by reading, observing, recognizing, and describing to analyze reading material in the form of related literature as a reference source. The result of this study is that the use of instructional strategies for gardening activities and creative game-based environmental learning can be considered to improve the intelligence of early childhood naturalists. In addition, it was also found that the material often used by educators to improve naturalist intelligence is the introduction of animals and plants. The trend of measuring the intelligence of early childhood naturalists uses many observation sheets, but it is also recommended to use research instruments that have been standardized or published in reputable scientific articles to obtain valid and reliable data. Keywords: environmental education, early childhood, naturalist intelligence References: Adawiyah, A. S. R., &; Dewinggih, T. (2021). Environmental Education in Early Childhood through the provision of trash cans and simulation methods. Proceedings UIN Sunan Gunung Djati Bandung, 1(November), 12–23. https://proceedings.uinsgd.ac.id/index.php/Proceedings Adawiyah, R., Rohyana, F., &; Ashari, M. A. (2019). Development of Naturalist Intelligence through Science-based Project Methods at TK Titipan ilahii rencoong Kelayu Jorong. 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Education in Oceania continues to reflect the embedded implicit and explicit colonial practices and processes from the past. This paper conceptualises a cultural approach to education and leadership appropriate and relevant to the Republic of the Marshall Islands. As elementary school leaders, we highlight Kanne Lobal, a traditional Marshallese navigation practice based on indigenous language, values and practices. We conceptualise and develop Kanne Lobal in this paper as a framework for understanding the usefulness of our indigenous knowledge in leadership and educational practices within formal education. Through bwebwenato, a method of talk story, our key learnings and reflexivities were captured. We argue that realising the value of Marshallese indigenous knowledge and practices for school leaders requires purposeful training of the ways in which our knowledge can be made useful in our professional educational responsibilities. Drawing from our Marshallese knowledge is an intentional effort to inspire, empower and express what education and leadership partnership means for Marshallese people, as articulated by Marshallese themselves. Introduction As noted in the call for papers within the Waikato Journal of Education (WJE) for this special issue, bodies of knowledge and histories in Oceania have long sustained generations across geographic boundaries to ensure cultural survival. For Marshallese people, we cannot really know ourselves “until we know how we came to be where we are today” (Walsh, Heine, Bigler & Stege, 2012). Jitdam Kapeel is a popular Marshallese concept and ideal associated with inquiring into relationships within the family and community. In a similar way, the practice of relating is about connecting the present and future to the past. Education and leadership partnerships are linked and we look back to the past, our history, to make sense and feel inspired to transform practices that will benefit our people. In this paper and in light of our next generation, we reconnect with our navigation stories to inspire and empower education and leadership. Kanne lobal is part of our navigation stories, a conceptual framework centred on cultural practices, values, and concepts that embrace collective partnerships. Our link to this talanoa vā with others in the special issue is to attempt to make sense of connections given the global COVID-19 context by providing a Marshallese approach to address the physical and relational “distance” between education and leadership partnerships in Oceania. Like the majority of developing small island nations in Oceania, the Republic of the Marshall Islands (RMI) has had its share of educational challenges through colonial legacies of the past which continues to drive education systems in the region (Heine, 2002). The historical administration and education in the RMI is one of colonisation. Successive administrations by the Spanish, German, Japanese, and now the US, has resulted in education and learning that privileges western knowledge and forms of learning. This paper foregrounds understandings of education and learning as told by the voices of elementary school leaders from the RMI. The move to re-think education and leadership from Marshallese perspectives is an act of shifting the focus of bwebwenato or conversations that centres on Marshallese language and worldviews. The concept of jelalokjen was conceptualised as traditional education framed mainly within the community context. In the past, jelalokjen was practiced and transmitted to the younger generation for cultural continuity. During the arrival of colonial administrations into the RMI, jelalokjen was likened to the western notions of education and schooling (Kupferman, 2004). Today, the primary function of jelalokjen, as traditional and formal education, it is for “survival in a hostile [and challenging] environment” (Kupferman, 2004, p. 43). Because western approaches to learning in the RMI have not always resulted in positive outcomes for those engaged within the education system, as school leaders who value our cultural knowledge and practices, and aspire to maintain our language with the next generation, we turn to Kanne Lobal, a practice embedded in our navigation stories, collective aspirations, and leadership. The significance in the development of Kanne Lobal, as an appropriate framework for education and leadership, resulted in us coming together and working together. Not only were we able to share our leadership concerns, however, the engagement strengthened our connections with each other as school leaders, our communities, and the Public Schooling System (PSS). Prior to that, many of us were in competition for resources. Educational Leadership: IQBE and GCSL Leadership is a valued practice in the RMI. Before the IQBE programme started in 2018, the majority of the school leaders on the main island of Majuro had not engaged in collaborative partnerships with each other before. Our main educational purpose was to achieve accreditation from the Western Association of Schools and Colleges (WASC), an accreditation commission for schools in the United States. The WASC accreditation dictated our work and relationships and many school leaders on Majuro felt the pressure of competition against each other. We, the authors in this paper, share our collective bwebwenato, highlighting our school leadership experiences and how we gained strength from our own ancestral knowledge to empower “us”, to collaborate with each other, our teachers, communities, as well as with PSS; a collaborative partnership we had not realised in the past. The paucity of literature that captures Kajin Majol (Marshallese language) and education in general in the RMI is what we intend to fill by sharing our reflections and experiences. To move our educational practices forward we highlight Kanne Lobal, a cultural approach that focuses on our strengths, collective social responsibilities and wellbeing. For a long time, there was no formal training in place for elementary school leaders. School principals and vice principals were appointed primarily on their academic merit through having an undergraduate qualification. As part of the first cohort of fifteen school leaders, we engaged in the professional training programme, the Graduate Certificate in School Leadership (GCSL), refitted to our context after its initial development in the Solomon Islands. GCSL was coordinated by the Institute of Education (IOE) at the University of the South Pacific (USP). GCSL was seen as a relevant and appropriate training programme for school leaders in the RMI as part of an Asia Development Bank (ADB) funded programme which aimed at “Improving Quality Basic Education” (IQBE) in parts of the northern Pacific. GCSL was managed on Majuro, RMI’s main island, by the director at the time Dr Irene Taafaki, coordinator Yolanda McKay, and administrators at the University of the South Pacific’s (USP) RMI campus. Through the provision of GCSL, as school leaders we were encouraged to re-think and draw-from our own cultural repository and connect to our ancestral knowledge that have always provided strength for us. This kind of thinking and practice was encouraged by our educational leaders (Heine, 2002). We argue that a culturally-affirming and culturally-contextual framework that reflects the lived experiences of Marshallese people is much needed and enables the disruption of inherent colonial processes left behind by Western and Eastern administrations which have influenced our education system in the RMI (Heine, 2002). Kanne Lobal, an approach utilising a traditional navigation has warranted its need to provide solutions for today’s educational challenges for us in the RMI. Education in the Pacific Education in the Pacific cannot be understood without contextualising it in its history and culture. It is the same for us in the RMI (Heine, 2002; Walsh et al., 2012). The RMI is located in the Pacific Ocean and is part of Micronesia. It was named after a British captain, John Marshall in the 1700s. The atolls in the RMI were explored by the Spanish in the 16th century. Germany unsuccessfully attempted to colonize the islands in 1885. Japan took control in 1914, but after several battles during World War II, the US seized the RMI from them. In 1947, the United Nations made the island group, along with the Mariana and Caroline archipelagos, a U.S. trust territory (Walsh et al, 2012). Education in the RMI reflects the colonial administrations of Germany, Japan, and now the US. Before the turn of the century, formal education in the Pacific reflected western values, practices, and standards. Prior to that, education was informal and not binded to formal learning institutions (Thaman, 1997) and oral traditions was used as the medium for transmitting learning about customs and practices living with parents, grandparents, great grandparents. As alluded to by Jiba B. Kabua (2004), any “discussion about education is necessarily a discussion of culture, and any policy on education is also a policy of culture” (p. 181). It is impossible to promote one without the other, and it is not logical to understand one without the other. Re-thinking how education should look like, the pedagogical strategies that are relevant in our classrooms, the ways to engage with our parents and communities - such re-thinking sits within our cultural approaches and frameworks. Our collective attempts to provide a cultural framework that is relevant and appropriate for education in our context, sits within the political endeavour to decolonize. This means that what we are providing will not only be useful, but it can be used as a tool to question and identify whether things in place restrict and prevent our culture or whether they promote and foreground cultural ideas and concepts, a significant discussion of culture linked to education (Kabua, 2004). Donor funded development aid programmes were provided to support the challenges within education systems. Concerned with the persistent low educational outcomes of Pacific students, despite the prevalence of aid programmes in the region, in 2000 Pacific educators and leaders with support from New Zealand Aid (NZ Aid) decided to intervene (Heine, 2002; Taufe’ulungaki, 2014). In April 2001, a group of Pacific educators and leaders across the region were invited to a colloquium funded by the New Zealand Overseas Development Agency held in Suva Fiji at the University of the South Pacific. The main purpose of the colloquium was to enable “Pacific educators to re-think the values, assumptions and beliefs underlying [formal] schooling in Oceania” (Benson, 2002). Leadership, in general, is a valued practice in the RMI (Heine, 2002). Despite education leadership being identified as a significant factor in school improvement (Sanga & Chu, 2009), the limited formal training opportunities of school principals in the region was a persistent concern. As part of an Asia Development Bank (ADB) funded project, the Improve Quality Basic Education (IQBE) intervention was developed and implemented in the RMI in 2017. Mentoring is a process associated with the continuity and sustainability of leadership knowledge and practices (Sanga & Chu, 2009). It is a key aspect of building capacity and capabilities within human resources in education (ibid). Indigenous knowledges and education research According to Hilda Heine, the relationship between education and leadership is about understanding Marshallese history and culture (cited in Walsh et al., 2012). It is about sharing indigenous knowledge and histories that “details for future generations a story of survival and resilience and the pride we possess as a people” (Heine, cited in Walsh et al., 2012, p. v). This paper is fuelled by postcolonial aspirations yet is grounded in Pacific indigenous research. This means that our intentions are driven by postcolonial pursuits and discourses linked to challenging the colonial systems and schooling in the Pacific region that privileges western knowledge and learning and marginalises the education practices and processes of local people (Thiong’o, 1986). A point of difference and orientation from postcolonialism is a desire to foreground indigenous Pacific language, specifically Majin Majol, through Marshallese concepts. Our collective bwebwenato and conversation honours and values kautiej (respect), jouj eo mour eo (reciprocity), and jouj (kindness) (Taafaki & Fowler, 2019). Pacific leaders developed the Rethinking Pacific Education Initiative for and by Pacific People (RPEIPP) in 2002 to take control of the ways in which education research was conducted by donor funded organisations (Taufe’ulungaki, 2014). Our former president, Dr Hilda Heine was part of the group of leaders who sought to counter the ways in which our educational and leadership stories were controlled and told by non-Marshallese (Heine, 2002). As a former minister of education in the RMI, Hilda Heine continues to inspire and encourage the next generation of educators, school leaders, and researchers to re-think and de-construct the way learning and education is conceptualised for Marshallese people. The conceptualisation of Kanne Lobal acknowledges its origin, grounded in Marshallese navigation knowledge and practice. Our decision to unpack and deconstruct Kanne Lobal within the context of formal education and leadership responds to the need to not only draw from indigenous Marshallese ideas and practice but to consider that the next generation will continue to be educated using western processes and initiatives particularly from the US where we get a lot of our funding from. According to indigenous researchers Dawn Bessarab and Bridget Ng’andu (2010), doing research that considers “culturally appropriate processes to engage with indigenous groups and individuals is particularly pertinent in today’s research environment” (p. 37). Pacific indigenous educators and researchers have turned to their own ancestral knowledge and practices for inspiration and empowerment. Within western research contexts, the often stringent ideals and processes are not always encouraging of indigenous methods and practices. However, many were able to ground and articulate their use of indigenous methods as being relevant and appropriate to capturing the realities of their communities (Nabobo-Baba, 2008; Sualii-Sauni & Fulu-Aiolupotea, 2014; Thaman, 1997). At the same time, utilising Pacific indigenous methods and approaches enabled research engagement with their communities that honoured and respected them and their communities. For example, Tongan, Samoan, and Fijian researchers used the talanoa method as a way to capture the stories, lived realities, and worldviews of their communities within education in the diaspora (Fa’avae, Jones, & Manu’atu, 2016; Nabobo-Baba, 2008; Sualii-Sauni & Aiolupotea, 2014; Vaioleti, 2005). Tok stori was used by Solomon Islander educators and school leaders to highlight the unique circles of conversational practice and storytelling that leads to more positive engagement with their community members, capturing rich and meaningful narratives as a result (Sanga & Houma, 2004). The Indigenous Aborigine in Australia utilise yarning as a “relaxed discussion through which both the researcher and participant journey together visiting places and topics of interest relevant” (Bessarab & Ng’andu, 2010, p. 38). Despite the diverse forms of discussions and storytelling by indigenous peoples, of significance are the cultural protocols, ethics, and language for conducting and guiding the engagement (Bessarab & Ng’andu, 2010; Nabobo-Baba, 2008; Sualii-Sauni & Aiolupotea, 2014). Through the ethics, values, protocols, and language, these are what makes indigenous methods or frameworks unique compared to western methods like in-depth interviews or semi-structured interviews. This is why it is important for us as Marshallese educators to frame, ground, and articulate how our own methods and frameworks of learning could be realised in western education (Heine, 2002; Jetnil-Kijiner, 2014). In this paper, we utilise bwebwenato as an appropriate method linked to “talk story”, capturing our collective stories and experiences during GCSL and how we sought to build partnerships and collaboration with each other, our communities, and the PSS. Bwebwenato and drawing from Kajin Majel Legends and stories that reflect Marshallese society and its cultural values have survived through our oral traditions. The practice of weaving also holds knowledge about our “valuable and earliest sources of knowledge” (Taafaki & Fowler, 2019, p. 2). The skilful navigation of Marshallese wayfarers on the walap (large canoes) in the ocean is testament of their leadership and the value they place on ensuring the survival and continuity of Marshallese people (Taafaki & Fowler, 2019; Walsh et al., 2012). During her graduate study in 2014, Kathy Jetnil-Kijiner conceptualised bwebwenato as being the most “well-known form of Marshallese orality” (p. 38). The Marshallese-English dictionary defined bwebwenato as talk, conversation, story, history, article, episode, lore, myth, or tale (cited in Jetnil Kijiner, 2014). Three years later in 2017, bwebwenato was utilised in a doctoral project by Natalie Nimmer as a research method to gather “talk stories” about the experiences of 10 Marshallese experts in knowledge and skills ranging from sewing to linguistics, canoe-making and business. Our collective bwebwenato in this paper centres on Marshallese ideas and language. The philosophy of Marshallese knowledge is rooted in our “Kajin Majel”, or Marshallese language and is shared and transmitted through our oral traditions. For instance, through our historical stories and myths. Marshallese philosophy, that is, the knowledge systems inherent in our beliefs, values, customs, and practices are shared. They are inherently relational, meaning that knowledge systems and philosophies within our world are connected, in mind, body, and spirit (Jetnil-Kijiner, 2014; Nimmer, 2017). Although some Marshallese believe that our knowledge is disappearing as more and more elders pass away, it is therefore important work together, and learn from each other about the knowledges shared not only by the living but through their lamentations and stories of those who are no longer with us (Jetnil-Kijiner, 2014). As a Marshallese practice, weaving has been passed-down from generation to generation. Although the art of weaving is no longer as common as it used to be, the artefacts such as the “jaki-ed” (clothing mats) continue to embody significant Marshallese values and traditions. For our weavers, the jouj (check spelling) is the centre of the mat and it is where the weaving starts. When the jouj is correct and weaved well, the remainder and every other part of the mat will be right. The jouj is symbolic of the “heart” and if the heart is prepared well, trained well, then life or all other parts of the body will be well (Taafaki & Fowler, 2019). In that light, we have applied the same to this paper. Conceptualising and drawing from cultural practices that are close and dear to our hearts embodies a significant ontological attempt to prioritize our own knowledge and language, a sense of endearment to who we are and what we believe education to be like for us and the next generation. The application of the phrase “Majolizing '' was used by the Ministry of Education when Hilda Heine was minister, to weave cultural ideas and language into the way that teachers understand the curriculum, develop lesson plans and execute them in the classroom. Despite this, there were still concerns with the embedded colonized practices where teachers defaulted to eurocentric methods of doing things, like the strategies provided in the textbooks given to us. In some ways, our education was slow to adjust to the “Majolizing '' intention by our former minister. In this paper, we provide Kanne Lobal as a way to contribute to the “Majolizing intention” and perhaps speed up yet still be collectively responsible to all involved in education. Kajin Wa and Kanne Lobal “Wa” is the Marshallese concept for canoe. Kajin wa, as in canoe language, has a lot of symbolic meaning linked to deeply-held Marshallese values and practices. The canoe was the foundational practice that supported the livelihood of harsh atoll island living which reflects the Marshallese social world. The experts of Kajin wa often refer to “wa” as being the vessel of life, a means and source of sustaining life (Kelen, 2009, cited in Miller, 2010). “Jouj” means kindness and is the lower part of the main hull of the canoe. It is often referred to by some canoe builders in the RMI as the heart of the canoe and is linked to love. The jouj is one of the first parts of the canoe that is built and is “used to do all other measurements, and then the rest of the canoe is built on top of it” (Miller, 2010, p. 67). The significance of the jouj is that when the canoe is in the water, the jouj is the part of the hull that is underwater and ensures that all the cargo and passengers are safe. For Marshallese, jouj or kindness is what living is about and is associated with selflessly carrying the responsibility of keeping the family and community safe. The parts of the canoe reflect Marshallese culture, legend, family, lineage, and kinship. They embody social responsibilities that guide, direct, and sustain Marshallese families’ wellbeing, from atoll to atoll. For example, the rojak (boom), rojak maan (upper boom), rojak kōrā (lower boom), and they support the edges of the ujelā/ujele (sail) (see figure 1). The literal meaning of rojak maan is male boom and rojak kōrā means female boom which together strengthens the sail and ensures the canoe propels forward in a strong yet safe way. Figuratively, the rojak maan and rojak kōrā symbolise the mother and father relationship which when strong, through the jouj (kindness and love), it can strengthen families and sustain them into the future. Figure 1. Parts of the canoe Source: https://www.canoesmarshallislands.com/2014/09/names-of-canoe-parts/ From a socio-cultural, communal, and leadership view, the canoe (wa) provides understanding of the relationships required to inspire and sustain Marshallese peoples’ education and learning. We draw from Kajin wa because they provide cultural ideas and practices that enable understanding of education and leadership necessary for sustaining Marshallese people and realities in Oceania. When building a canoe, the women are tasked with the weaving of the ujelā/ujele (sail) and to ensure that it is strong enough to withstand long journeys and the fierce winds and waters of the ocean. The Kanne Lobal relates to the front part of the ujelā/ujele (sail) where the rojak maan and rojak kōrā meet and connect (see the red lines in figure 1). Kanne Lobal is linked to the strategic use of the ujelā/ujele by navigators, when there is no wind north wind to propel them forward, to find ways to capture the winds so that their journey can continue. As a proverbial saying, Kanne Lobal is used to ignite thinking and inspire and transform practice particularly when the journey is rough and tough. In this paper we draw from Kanne Lobal to ignite, inspire, and transform our educational and leadership practices, a move to explore what has always been meaningful to Marshallese people when we are faced with challenges. The Kanne Lobal utilises our language, and cultural practices and values by sourcing from the concepts of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity). A key Marshallese proverb, “Enra bwe jen lale rara”, is the cultural practice where families enact compassion through the sharing of food in all occurrences. The term “enra” is a small basket weaved from the coconut leaves, and often used by Marshallese as a plate to share and distribute food amongst each other. Bwe-jen-lale-rara is about noticing and providing for the needs of others, and “enra” the basket will help support and provide for all that are in need. “Enra-bwe-jen-lale-rara” is symbolic of cultural exchange and reciprocity and the cultural values associated with building and maintaining relationships, and constantly honouring each other. As a Marshallese practice, in this article we share our understanding and knowledge about the challenges as well as possible solutions for education concerns in our nation. In addition, we highlight another proverb, “wa kuk wa jimor”, which relates to having one canoe, and despite its capacity to feed and provide for the individual, but within the canoe all people can benefit from what it can provide. In the same way, we provide in this paper a cultural framework that will enable all educators to benefit from. It is a framework that is far-reaching and relevant to the lived realities of Marshallese people today. Kumit relates to people united to build strength, all co-operating and working together, living in peace, harmony, and good health. Kanne Lobal: conceptual framework for education and leadership An education framework is a conceptual structure that can be used to capture ideas and thinking related to aspects of learning. Kanne Lobal is conceptualised and framed in this paper as an educational framework. Kanne Lobal highlights the significance of education as a collective partnership whereby leadership is an important aspect. Kanne Lobal draws-from indigenous Marshallese concepts like kautiej (respect), jouj eo mour eo (reciprocity), and jouj (kindness, heart). The role of a leader, including an education leader, is to prioritise collective learning and partnerships that benefits Marshallese people and the continuity and survival of the next generation (Heine, 2002; Thaman, 1995). As described by Ejnar Aerōk, an expert canoe builder in the RMI, he stated: “jerbal ippān doon bwe en maron maan wa e” (cited in Miller, 2010, p. 69). His description emphasises the significance of partnerships and working together when navigating and journeying together in order to move the canoe forward. The kubaak, the outrigger of the wa (canoe) is about “partnerships”. For us as elementary school leaders on Majuro, kubaak encourages us to value collaborative partnerships with each other as well as our communities, PSS, and other stakeholders. Partnerships is an important part of the Kanne Lobal education and leadership framework. It requires ongoing bwebwenato – the inspiring as well as confronting and challenging conversations that should be mediated and negotiated if we and our education stakeholders are to journey together to ensure that the educational services we provide benefits our next generation of young people in the RMI. Navigating ahead the partnerships, mediation, and negotiation are the core values of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity). As an organic conceptual framework grounded in indigenous values, inspired through our lived experiences, Kanne Lobal provides ideas and concepts for re-thinking education and leadership practices that are conducive to learning and teaching in the schooling context in the RMI. By no means does it provide the solution to the education ills in our nation. However, we argue that Kanne Lobal is a more relevant approach which is much needed for the negatively stigmatised system as a consequence of the various colonial administrations that have and continue to shape and reframe our ideas about what education should be like for us in the RMI. Moreover, Kannel Lobal is our attempt to decolonize the framing of education and leadership, moving our bwebwenato to re-framing conversations of teaching and learning so that our cultural knowledge and values are foregrounded, appreciated, and realised within our education system. Bwebwenato: sharing our stories In this section, we use bwebwenato as a method of gathering and capturing our stories as data. Below we capture our stories and ongoing conversations about the richness in Marshallese cultural knowledge in the outer islands and on Majuro and the potentialities in Kanne Lobal. Danny Jim When I was in third grade (9-10 years of age), during my grandfather’s speech in Arno, an atoll near Majuro, during a time when a wa (canoe) was being blessed and ready to put the canoe into the ocean. My grandfather told me the canoe was a blessing for the family. “Without a canoe, a family cannot provide for them”, he said. The canoe allows for travelling between places to gather food and other sources to provide for the family. My grandfather’s stories about people’s roles within the canoe reminded me that everyone within the family has a responsibility to each other. Our women, mothers and daughters too have a significant responsibility in the journey, in fact, they hold us, care for us, and given strength to their husbands, brothers, and sons. The wise man or elder sits in the middle of the canoe, directing the young man who help to steer. The young man, he does all the work, directed by the older man. They take advice and seek the wisdom of the elder. In front of the canoe, a young boy is placed there and because of his strong and youthful vision, he is able to help the elder as well as the young man on the canoe. The story can be linked to the roles that school leaders, teachers, and students have in schooling. Without each person knowing intricately their role and responsibility, the sight and vision ahead for the collective aspirations of the school and the community is difficult to comprehend. For me, the canoe is symbolic of our educational journey within our education system. As the school leader, a central, trusted, and respected figure in the school, they provide support for teachers who are at the helm, pedagogically striving to provide for their students. For without strong direction from the school leaders and teachers at the helm, the students, like the young boy, cannot foresee their futures, or envisage how education can benefit them. This is why Kanne Lobal is a significant framework for us in the Marshall Islands because within the practice we are able to take heed and empower each other so that all benefit from the process. Kanne Lobal is linked to our culture, an essential part of who we are. We must rely on our own local approaches, rather than relying on others that are not relevant to what we know and how we live in today’s society. One of the things I can tell is that in Majuro, compared to the outer islands, it’s different. In the outer islands, parents bring children together and tell them legends and stories. The elders tell them about the legends and stories – the bwebwenato. Children from outer islands know a lot more about Marshallese legends compared to children from the Majuro atoll. They usually stay close to their parents, observe how to prepare food and all types of Marshallese skills. Loretta Joseph Case There is little Western influence in the outer islands. They grow up learning their own culture with their parents, not having tv. They are closely knit, making their own food, learning to weave. They use fire for cooking food. They are more connected because there are few of them, doing their own culture. For example, if they’re building a house, the ladies will come together and make food to take to the males that are building the house, encouraging them to keep on working - “jemjem maal” (sharpening tools i.e. axe, like encouraging workers to empower them). It’s when they bring food and entertainment. Rubon Rubon Togetherness, work together, sharing of food, these are important practices as a school leader. Jemjem maal – the whole village works together, men working and the women encourage them with food and entertainment. All the young children are involved in all of the cultural practices, cultural transmission is consistently part of their everyday life. These are stronger in the outer islands. Kanne Lobal has the potential to provide solutions using our own knowledge and practices. Connie Joel When new teachers become a teacher, they learn more about their culture in teaching. Teaching raises the question, who are we? A popular saying amongst our people, “Aelon kein ad ej aelon in manit”, means that “Our islands are cultural islands”. Therefore, when we are teaching, and managing the school, we must do this culturally. When we live and breathe, we must do this culturally. There is more socialising with family and extended family. Respect the elderly. When they’re doing things the ladies all get together, in groups and do it. Cut the breadfruit, and preserve the breadfruit and pandanus. They come together and do it. Same as fishing, building houses, building canoes. They use and speak the language often spoken by the older people. There are words that people in the outer islands use and understand language regularly applied by the elderly. Respect elderly and leaders more i.e., chiefs (iroj), commoners (alap), and the workers on the land (ri-jerbal) (social layer under the commoners). All the kids, they gather with their families, and go and visit the chiefs and alap, and take gifts from their land, first produce/food from the plantation (eojōk). Tommy Almet The people are more connected to the culture in the outer islands because they help one another. They don’t have to always buy things by themselves, everyone contributes to the occasion. For instance, for birthdays, boys go fishing, others contribute and all share with everyone. Kanne Lobal is a practice that can bring people together – leaders, teachers, stakeholders. We want our colleagues to keep strong and work together to fix problems like students and teachers’ absenteeism which is a big problem for us in schools. Demetria Malachi The culture in the outer islands are more accessible and exposed to children. In Majuro, there is a mixedness of cultures and knowledges, influenced by Western thinking and practices. Kanne Lobal is an idea that can enhance quality educational purposes for the RMI. We, the school leaders who did GCSL, we want to merge and use this idea because it will help benefit students’ learning and teachers’ teaching. Kanne Lobal will help students to learn and teachers to teach though traditional skills and knowledge. We want to revitalize our ways of life through teaching because it is slowly fading away. Also, we want to have our own Marshallese learning process because it is in our own language making it easier to use and understand. Essentially, we want to proudly use our own ways of teaching from our ancestors showing the appreciation and blessings given to us. Way Forward To think of ways forward is about reflecting on the past and current learnings. Instead of a traditional discussion within a research publication, we have opted to continue our bwebwenato by sharing what we have learnt through the Graduate Certificate in School Leadership (GCSL) programme. Our bwebwenato does not end in this article and this opportunity to collaborate and partner together in this piece of writing has been a meaningful experience to conceptualise and unpack the Kanne Lobal framework. Our collaborative bwebwenato has enabled us to dig deep into our own wise knowledges for guidance through mediating and negotiating the challenges in education and leadership (Sanga & Houma, 2004). For example, bwe-jen-lale-rara reminds us to inquire, pay attention, and focus on supporting the needs of others. Through enra-bwe-jen-lale-rara, it reminds us to value cultural exchange and reciprocity which will strengthen the development and maintaining of relationships based on ways we continue to honour each other (Nimmer, 2017). We not only continue to support each other, but also help mentor the next generation of school leaders within our education system (Heine, 2002). Education and leadership are all about collaborative partnerships (Sanga & Chu, 2009; Thaman, 1997). Developing partnerships through the GCSL was useful learning for us. It encouraged us to work together, share knowledge, respect each other, and be kind. The values of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity) are meaningful in being and becoming and educational leader in the RMI (Jetnil-Kijiner, 2014; Miller, 2010; Nimmer, 2017). These values are meaningful for us practice particularly given the drive by PSS for schools to become accredited. The workshops and meetings delivered during the GCSL in the RMI from 2018 to 2019 about Kanne Lobal has given us strength to share our stories and experiences from the meeting with the stakeholders. But before we met with the stakeholders, we were encouraged to share and speak in our language within our courses: EDP05 (Professional Development and Learning), EDP06 (School Leadership), EDP07 (School Management), EDP08 (Teaching and Learning), and EDP09 (Community Partnerships). In groups, we shared our presentations with our peers, the 15 school leaders in the GCSL programme. We also invited USP RMI staff. They liked the way we presented Kannel Lobal. They provided us with feedback, for example: how the use of the sail on the canoe, the parts and their functions can be conceptualised in education and how they are related to the way that we teach our own young people. Engaging stakeholders in the conceptualisation and design stages of Kanne Lobal strengthened our understanding of leadership and collaborative partnerships. Based on various meetings with the RMI Pacific Resources for Education and Learning (PREL) team, PSS general assembly, teachers from the outer islands, and the PSS executive committee, we were able to share and receive feedback on the Kanne Lobal framework. The coordinators of the PREL programme in the RMI were excited by the possibilities around using Kanne Lobal, as a way to teach culture in an inspirational way to Marshallese students. Our Marshallese knowledge, particularly through the proverbial meaning of Kanne Lobal provided so much inspiration and insight for the groups during the presentation which gave us hope and confidence to develop the framework. Kanne Lobal is an organic and indigenous approach, grounded in Marshallese ways of doing things (Heine, 2002; Taafaki & Fowler, 2019). Given the persistent presence of colonial processes within the education system and the constant reference to practices and initiatives from the US, Kanne Lobal for us provides a refreshing yet fulfilling experience and makes us feel warm inside because it is something that belongs to all Marshallese people. Conclusion Marshallese indigenous knowledge and practices provide meaningful educational and leadership understanding and learnings. They ignite, inspire, and transform thinking and practice. The Kanne Lobal conceptual framework emphasises key concepts and values necessary for collaborative partnerships within education and leadership practices in the RMI. The bwebwenato or talk stories have been insightful and have highlighted the strengths and benefits that our Marshallese ideas and practices possess when looking for appropriate and relevant ways to understand education and leadership. Acknowledgements We want to acknowledge our GCSL cohort of school leaders who have supported us in the development of Kanne Lobal as a conceptual framework. A huge kommol tata to our friends: Joana, Rosana, Loretta, Jellan, Alvin, Ellice, Rolando, Stephen, and Alan. References Benson, C. (2002). Preface. In F. Pene, A. M. Taufe’ulungaki, & C. Benson (Eds.), Tree of Opportunity: re-thinking Pacific Education (p. iv). Suva, Fiji: University of the South Pacific, Institute of Education. Bessarab, D., Ng’andu, B. (2010). Yarning about yarning as a legitimate method in indigenous research. International Journal of Critical Indigenous Studies, 3(1), 37-50. Fa’avae, D., Jones, A., & Manu’atu, L. (2016). Talanoa’i ‘a e talanoa - talking about talanoa: Some dilemmas of a novice researcher. AlterNative: An Indigenous Journal of Indigenous Peoples,12(2),138-150. Heine, H. C. (2002). A Marshall Islands perspective. In F. Pene, A. M. Taufe’ulungaki, & C. Benson (Eds.), Tree of Opportunity: re-thinking Pacific Education (pp. 84 – 90). Suva, Fiji: University of the South Pacific, Institute of Education. Infoplease Staff (2017, February 28). Marshall Islands, retrieved from https://www.infoplease.com/world/countries/marshall-islands Jetnil-Kijiner, K. (2014). Iep Jaltok: A history of Marshallese literature. (Unpublished masters’ thesis). Honolulu, HW: University of Hawaii. Kabua, J. B. (2004). We are the land, the land is us: The moral responsibility of our education and sustainability. In A.L. Loeak, V.C. Kiluwe and L. Crowl (Eds.), Life in the Republic of the Marshall Islands, pp. 180 – 191. Suva, Fiji: University of the South Pacific. Kupferman, D. (2004). Jelalokjen in flux: Pitfalls and prospects of contextualising teacher training programmes in the Marshall Islands. Directions: Journal of Educational Studies, 26(1), 42 – 54. http://directions.usp.ac.fj/collect/direct/index/assoc/D1175062.dir/doc.pdf Miller, R. L. (2010). Wa kuk wa jimor: Outrigger canoes, social change, and modern life in the Marshall Islands (Unpublished masters’ thesis). Honolulu, HW: University of Hawaii. Nabobo-Baba, U. (2008). Decolonising framings in Pacific research: Indigenous Fijian vanua research framework as an organic response. AlterNative: An Indigenous Journal of Indigenous Peoples, 4(2), 141-154. Nimmer, N. E. (2017). Documenting a Marshallese indigenous learning framework (Unpublished doctoral thesis). Honolulu, HW: University of Hawaii. Sanga, K., & Houma, S. (2004). Solomon Islands principalship: Roles perceived, performed, preferred, and expected. Directions: Journal of Educational Studies, 26(1), 55-69. Sanga, K., & Chu, C. (2009). Introduction. In K. Sanga & C. Chu (Eds.), Living and Leaving a Legacy of Hope: Stories by New Generation Pacific Leaders (pp. 10-12). NZ: He Parekereke & Victoria University of Wellington. Suaalii-Sauni, T., & Fulu-Aiolupotea, S. M. (2014). Decolonising Pacific research, building Pacific research communities, and developing Pacific research tools: The case of the talanoa and the faafaletui in Samoa. Asia Pacific Viewpoint, 55(3), 331-344. Taafaki, I., & Fowler, M. K. (2019). Clothing mats of the Marshall Islands: The history, the culture, and the weavers. US: Kindle Direct. Taufe’ulungaki, A. M. (2014). Look back to look forward: A reflective Pacific journey. In M. ‘Otunuku, U. Nabobo-Baba, S. Johansson Fua (Eds.), Of Waves, Winds, and Wonderful Things: A Decade of Rethinking Pacific Education (pp. 1-15). Fiji: USP Press. Thaman, K. H. (1995). Concepts of learning, knowledge and wisdom in Tonga, and their relevance to modern education. Prospects, 25(4), 723-733. Thaman, K. H. (1997). Reclaiming a place: Towards a Pacific concept of education for cultural development. The Journal of the Polynesian Society, 106(2), 119-130. Thiong’o, N. W. (1986). Decolonising the mind: The politics of language in African literature. Kenya: East African Educational Publishers. Vaioleti, T. (2006). Talanoa research methodology: A developing position on Pacific research. Waikato Journal of Education, 12, 21-34. Walsh, J. M., Heine, H. C., Bigler, C. M., & Stege, M. (2012). Etto nan raan kein: A Marshall Islands history (First Edition). China: Bess Press.

Background:Ultrasonographic (U/S) evaluation of the fetus, placenta, and amniotic fluid is an integral part of antenatal care (ANC). U/S results confirm fetal viability and gestational age, and multiple gestations. U/S can also provide evidence to rule out fetal abnormalities related to anatomy or blood flow. However, a woman’s knowledge about prenatal U/S is not clear. Therefore, the aim of this study was to assess pregnant women’s knowledge of this prenatal U/S assessment technique.Methods:An institutional-based cross-sectional study was conducted on 303 pregnant women attending ANC in Jimma Town, Ethiopia, from July to August 2021. Women were interviewed in Jimma town public health care facilities.The sample size was calculated using the single population proportion formula, and samples were taken after proportional allocation was performed for the hospital and health centers using the proportion allocation formula.Data were entered into Epi-data version 3.1.1 and exported into the Statistical Packages for Social Sciences version 21.0 for cleaning and further analysis. Logistic regression analysis was performed to determine the association between the explanatory and response variables.The strength of the association of the dependent and independent variables was presented as crude and adjusted odds ratios at a 95% confidence interval. For the multivariable logistic regression, the level of significance was ap-value of less than 0.05.Results:In this study, 190 (62.7%) of the respondents had a good knowledge of obstetric ultrasound. Residency, primary school (grades 1–8), an education greater than secondary school, and a history of at least one abortion were significantly associated with participants’ knowledge about prenatal ultrasound.Conclusions:Approximately two-thirds of pregnant women had a good knowledge related to prenatal U/S. However, the proportion with good knowledge in the current study was lower than the World Health Organization recommendation.

Objective To compare universal severe acute respiratory syndrome coronvirus-2 (SARS-CoV-2) testing to symptomatic testing at two large academic centers. Study Design We performed a retrospective cohort study comparing the approach to testing at two academic centers in Northeast Ohio. The study period started with the inception of symptomatic testing for SARS-CoV-2 at both institutions in March 2020. Women younger than 18 years were excluded. The primary outcome was the SARS-CoV-2 positivity rate in symptomatic pregnant patients at both institutions. Our coprimary outcome was the additional positivity rate obtained from universal testing at the University Hospitals. The secondary outcome of interest was the percentage of SARS-CoV-2 screen positive mothers with screen positive neonates. Data were analyzed using Mann–Whitney U test for continuous variables with chi-square and Fisher's exact tests for proportions. Results During the study period, 144 pregnant women with symptoms of coronavirus disease 2019 (COVID-19) were tested at MetroHealth of which 27 resulted as positive for SARS-CoV-2 (18.7% positivity rate). University Hospitals tested 392 pregnant women with symptoms of COVID-19 of which 67 resulted as positive for SARS-CoV-2 (positivity rate 17.0%). In the universal testing program at University Hospitals, an additional 2,870 tests were performed on asymptomatic pregnant women of which 30 were positive for SARS-CoV-2 (1.0% positivity rate).There were no SARS-CoV-2 positive infants in our cohort, and all cases of maternal critical illness occurred in symptomatic patients. Conclusion Universal and symptomatic testing approaches demonstrated similar clinical performance within a single geographic region in obstetric patients. Key Points

Photo by 193001056 © Yee Xin Tan on Dreamstime.com ABSTRACT Suicide and overdose, associated with perinatal mental health conditions, are the leading causes of maternal mortality in the United States. Experts in the field of perinatal mental health are using perinatal mood and anxiety disorders (PMAD) as an umbrella term that includes many mental health conditions and bring to light the lack of screening and treatment for perinatal mental health in the United States. There is a growing need to equip Obstetricians and Gynecologist (OB-GYN) providers with better tools to screen, triage, and refer to mental health services that are equitable and immediately accessible to their patients. Integrating a tech-enabled perinatal collaborative care model with peer-to-peer coaching as the driver of behavior change is a novel approach to addressing the maternal mental health crisis by improving outcomes, reducing disparities, and lowering costs. INTRODUCTION Over the past two decades, maternal mortality and other maternal health outcomes have worsened in the United States disproportionately to those in other developed countries.[1] In 2021, 1,205 pregnant women died in the US, representing a 40 percent increase in maternal death from 2020 and the highest rise in rates since the 1960s.[2] Suicide and overdose associated with perinatal mental health conditions are the leading causes of maternal mortality.[3] Mental health-related deaths are most likely to occur after six weeks postpartum.[4] Despite the postpartum period representing a higher risk for mental health conditions, historically, only a single postpartum visit is performed between 4 and 6 weeks after delivery. 40 percent of women do not attend a postpartum visit.[5] Recent data from Maternal Mortality Review Committees reveal that 80 percent of maternal deaths are preventable. The maternal mental health crisis represents a unique ethical dilemma. For perinatal women, the current healthcare system is unjust. There is a growing need to equip obstetricians and gynecologists (OB-GYNs) with the tools to screen, triage, and refer patients to mental health services that are equitable and immediately accessible to their patients. This paper will analyze the current state of perinatal mental healthcare in America. It will introduce the Psychiatric Collaborative Care Model and demonstrate its effectiveness. I highlight research performed using the Psychiatric Collaborative Care Model in obstetrics as well as barriers to real-world implementation. Lastly, this paper will argue that the integration of a tech-enabled perinatal collaborative care model with peer-to-peer coaching as the driver of behavior change would improve outcomes, reduce disparities, and lower costs. I. Scope of the Problem Prior to the COVID-19 pandemic, the prevalence of postpartum depression ranged from 13.2 percent, to as high as 23.5 percent, of births in the US.[6] The COVID-19 pandemic has exacerbated this issue, with studies revealing up to 1 in 3 postpartum women experiencing postpartum depression.[7] Although postpartum depression has been the focus of perinatal mental health conditions, it is just the tip of the iceberg. Experts in the field of perinatal mental health are now using perinatal mood and anxiety disorders as an umbrella term that includes perinatal depression, anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, bipolar disorder, and psychosis from the prenatal period through the first year postpartum. Socio-economically disadvantaged women are at increased risk of experiencing perinatal mood and anxiety disorders and face greater barriers to high-quality mental health care.[8] The American College of Obstetricians and Gynecologists (ACOG) recommends that physicians perform postpartum depression screenings during pregnancy. The Health Resources and Services Administration provides Healthy Start Initiative Grants to communities with high rates of adverse perinatal outcomes. Yet, the Healthcare Effectiveness Data and Information Set (HEDIS) reveals that screening in both pregnancy and the postpartum period occurs in fewer than 20 percent of patients.[9] Furthermore, in the US, if screening does occur, only 22 percent of women who are deemed positive in their screening receive mental health care.[10] The United States is currently experiencing a shortage of mental health providers that is expected to worsen in the upcoming years.[11] Nearly half of all Americans currently live in a mental health professional desert.[12] Waitlists for therapists and psychiatrists average 48 days, and individuals report not seeking mental health care due to cost or lack of insurance coverage.[13] Given the significant mental health provider shortage, obstetric providers have a unique opportunity to care for the “whole patient” during and after pregnancy by addressing not only their physical health but also their mental health. Approximately one-third of women consider their OB-GYN their primary care provider during and after pregnancy, and over 50 percent of OB-GYNs perceive themselves as primary care providers for women, supporting primary, specialty, and preventive care.[14] Medicaid covers 42 percent of all births in the US, and more than half of all births in some states, thus OB-GYNs provide a disproportionate amount of care for poor and minority women as compared to other specialties.[15] Yet, OB-GYN providers commonly feel hesitant to screen for depression due to the shortage of therapists and psychiatrists to address the mental health needs of their patients, particularly in the Medicaid population.[16] As a result, fewer than 10 percent of pregnant women with mental health conditions receive adequate treatment.[17] A recent study of 288 obstetrics fellows revealed that 84 percent prescribed SSRIs to their patients; obstetricians are filling the mental health provider gap and taking ownership over their patients’ mental health.[18] Despite ACOG’s recommendations that obstetrics providers screen for and treat mental health conditions in the perinatal period, OB-GYNs do not receive formal mental health training during residency or fellowship and do not typically use validated tools such as the Diagnostic and Statistical Manual of Mental Disorders-Forth Edition (DSM-IV) for diagnosis of depression or prior to prescribing antidepressants. Their lack of a standard reference can lead to misdiagnoses.[19] In fact, 22 percent of women screened and found to have postpartum depression are later diagnosed with bipolar disorder.[20] Screening and treatment for perinatal mood and anxiety disorders are further impacted by patients’ lack of trust in healthcare providers. Distrust between patients, particularly those receiving Medicaid, and their OB-GYNs in the US is high and strongly associated with worse self-reported health outcomes.[21] Notably, women with Medicaid coverage reported being treated unfairly and with disrespect by providers because of their race and insurance status. They reported a loss of decision-making autonomy during labor and delivery and less postpartum emotional and practical support at home.[22] Many women do not feel comfortable discussing mental disorders with a healthcare provider.[23] Connecting perinatal women to a person with shared lived experiences, known as peer-to-peer engagement or coaching, may be a simple solution. II. Collaborative Care Model The Psychiatric Collaborative Care Model (collaborative care), developed by the University of Washington in 2002, is an integrated behavioral health approach designed to treat common mental health conditions such as depression and anxiety that require measurement-based follow-up due to their chronic nature.[24] Centers for Medicare and Medicaid Services issued billing codes for the Psychiatric Collaborative Care Model in 2016. Medicare adopted them in 2017, and they were widely operationalized in the primary care field.[25] As of 2022, the collaborative care billing codes have been adopted by 19 state Medicaid plans.[26] The collaborative care model facilitates the integration of a behavioral health care manager, typically a licensed therapist or care worker, in the primary care setting. The behavioral health care manager can provide in-person or virtual care and facilitate mental health screenings, symptom monitoring, psychiatric consultations, and care coordination.[27] A psychiatric consultant, typically a board-certified psychiatrist or psychiatric nurse practitioner, is an integrated behavioral health provider on the collaborative care team. Psychiatric consultants do not see patients one on one. Rather, they review complex or treatment-resistant cases and provide psychiatric management recommendations to the primary provider. Thus, the primary care team is expanded by two members who provide behavioral health expertise to the primary care provider, who is ultimately the prescribing provider if any psychoactive medications are indicated.[28] This model has been tested in over 90 randomized clinical trials evaluating efficacy for the treatment of depression and anxiety across multiple medical specialties.[29] Data from the primary care setting indicate that this integrated behavioral health approach is both successful and more cost-effective than usual care for patients with behavioral health conditions.[30] Studies show that the collaborative care model improves clinical outcomes and lowers costs, returning $6.50 for every dollar spent on treatment of depression. Furthermore, the model is effective across diverse patient populations.[31] III. Evidence for Collaborative Care in Obstetrics The success of the collaborative care model for identifying anxiety and depression in the primary care setting and its potential for cost savings suggest that implementation of perinatal collaborative care for perinatal mood and anxiety disorders is a feasible approach.[32] Randomized clinical trials showed significant improvement in quality care, depression severity, and remission rates from before birth to 18 months postbaseline for socioeconomically disadvantaged women.[33] In addition, collaborative care is associated with mitigating racial disparities in antenatal depression care; it may be an equity-promoting intervention for maternal health.[34] The trials faced limitations, including the inability to establish causality, and the researchers recommended further research. Although further research is warranted, the collaborative care model in obstetrics programs has indicated improved depression outcomes. IV. Barriers to Adoption of a Collaborative Care Model in Obstetrics Despite promising results, implementation is limited, and collaborative care is billable under Medicaid in only 19 states.[35] Large health systems have difficulty operationalizing a collaborative care model in obstetrics due to implementation costs, mental health provider shortages, and administrative burdens. More evidence of financial benefits to obstetrics clinics, hospitals, and health systems is needed. Additionally, obstetric practices must adapt to updated care plans, and obstetricians must be motivated to become involved in behavioral health issues and potentially broaden their scope of practice.[36] As this is a major ask from practices and providers, robust evidence is lacking to show that a perinatal collaborative care model can be applied without the resources and infrastructure of a randomized trial. V. Peer-to-Peer Engagement Peer support in healthcare is growing. Peer support is defined as help and support that people with lived experiences can give one another.[37] Effective examples of peer support or engagement are found in addiction, mental health services, and the workforce. Regarding addiction recovery support, a systematic review concluded that peer support interventions have a beneficial effect on participants and positively contribute to substance use outcomes.[38] Peer support is highly used in medicine and other professions when attending physicians or skilled professionals train new colleagues. The nursing profession uses peer support to help deliver quality care and reduce symptoms of burnout.[39] Peer support has been well described in literature, and programs differ in their methodology and delivery. The feasibility and maintenance of peer support programs are possible through collaboration with all healthcare stakeholders.[40] Understanding that shared experiences establish a foundation of trust may help obstetricians see peers as a way to bridge the gap. A peer coach may be valuable in the collaborative care model. VI. Integrating Peer-to-Peer into the Collaborative Care Model for Obstetrics Currently, a start-up based in Boston and Philadelphia, FamilyWell, has piloted tech-enabled peer-to-peer engagement into a collaborative care model for obstetric patients. The company strives to solve the perinatal mental health crisis and close the health equity gap in the US by applying a text messaging platform to connect expecting and newly postpartum mothers with peer coaches. Peer coaches are trained to support perinatal mothers, defined as third-trimester pregnancy through 12 months postpartum, by providing quality support based on the latest research. Coaches have their own unique birth and postpartum stories, making them relatable and equipped to support mothers through the ups and downs of parenthood.[41] Increased education, screening, and treatment for perinatal mood and anxiety disorders co-occur as connections are being made through texting and virtual visits with coaches. On demand texting with coaches ensures no mother feels alone and that mothers have a safe space to ask questions and process emotions. If needed, enrolled moms can request longer virtual coaching sessions of 50 minutes with certified perinatal mental health coaches, who focus on current issues and how to move forward and feel better, accomplished through cognitive behavioral coaching techniques.[42] The platform schedules automated text messages containing educational content. Individual care plans are developed in collaboration with an individual’s OB and include monthly mental health screenings during and post-pregnancy. Notably, at three-week postpartum, participants are sent the Edinburg postnatal depression scale 3 (EPDS-3) questions via text messages.[43] This screening is three weeks prior to the national six-weeks postpartum screening recommendation and focuses on antepartum anxiety, which represents a risk factor for depression.[44] If an individual needs more mental health support compared to coaching, virtual therapy sessions are available through the platform, giving access to licensed therapist, specializing in perinatal mental health without extensive waitlist. Therapists can diagnosis and provide medication management if needed. FamilyWell CEO and founder, Jessica Gaulton, revealed that preliminary data collected during the first two months of the company’s launch, limited to the Philadelphia, PA region and three clinics, indicated that 24 postpartum mothers consented to the program. A total of 3,000 texts were exchanged, and 44.2 percent of those texts came from participants to peer coaches.[45] The platform expediates appropriate referrals, creates individualized maternal wellness treatment plans, and serves as a resource for navigating the medical system. VII. Providing Justice in the Maternal Healthcare System The well-being of mothers is a bellwether for the well-being of society; every injustice in our society shows up in maternal health.[46] Earlier, broader, and more frequent screening combined with direct mental health access is essential to address perinatal mood and anxiety disorders and ultimately the maternal mortality rate. Integrating collaborative care with peer-to-peer coaching provides new mothers with direct support and follow-up care. This simple yet novel integration begins to close the gap by providing equitable care. The tech-based platform’s research and success highlight that a broader focus on screening is critical. Limiting mental illness to depression fails to serve women adequately. Expanding criteria to screen for indicators of future depression, such as anxiety, is a simple, proactive step. A relatable peer may be a critical factor in helping perinatal women feel comfortable openly discussing problems they are facing and beginning conversations not otherwise occurring in a perinatal or postpartum visit. Companies like FamilyWell can contribute to making collaborative care feasible in the OB-GYN setting. Having an outside organization with peer-coaches building a foundation of trust and championing the collaborative care model reduces the burden for overworked obstetricians. Furthermore, the tech-based platform can organize and facilitate interprofessional communications, which rarely take place in the current system.[47] The texting and telehealth approach brings compassion, care, and more frequent contact directly to the patient, which is critical for socioeconomically disadvantaged women as they are the demographic not properly accessing care now. As the coaches and behavior care coordinator make the referrals for mental health services that align with a mother’s insurance coverage, they reduce stress for new mothers who might not know where to begin when navigating the mental health care system. Additionally, obstetricians may feel more comfortable performing mental health screenings knowing their patients can access mental health care. CONCLUSION The perinatal mental health crisis is significant. Women are currently experiencing injustice in the healthcare system due to a lack of trust, screening, and effective, accessible care. The psychiatric collaborative care model has been proven effective in the primary care setting, and randomized clinical trials conclude it is also effective in obstetrics, but barriers exist. Integrating peer-to-peer coaching through a tech-enabled platform into obstetrics collaborative care may eliminate barriers and build trust between patients and the healthcare system. More research is needed to show the efficacy of a tech-enabled model, and more research is critical to demonstrate that this model can be financially sustainable and revenue-generating for hospitals and obstetrics departments. However, this simple novel step may begin to generate equitable care for women and potentially save lives. - [1] Collier, A. R. Y., & Molina, R. L. (2019). Maternal mortality in the United States: updates on trends, causes, and solutions. Neoreviews, 20(10), e561-e574. [2] Hoyert, D. L. (2023). Maternal Mortality Rates in the United States, 2021.Health E-Stats. National Center for Health Statistics. Centers for Disease Control. https://dx.doi.org/10.15620/cdc:124678 [3] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275. [4] Trost, S. L., Beauregard, J. L., Smoots, A. N., Ko, J. Y., Haight, S. C., Moore Simas, T. A., ... & Goodman, D. (2021). Preventing Pregnancy-Related Mental Health Deaths: Insights From 14 US Maternal Mortality Review Committees, 2008–17: Study examines maternal mortality and mental health. Health Affairs, 40(10), 1551-1559. [5] Blenning, C. E., & Paladine, H. L. (2005). An approach to the postpartum office visit. American Family Physician, 72(12), 2491-2496; ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstetrics and gynecology, 132(3), 784–785. https://doi.org/10.1097/AOG.0000000000002849 [6]Bauman, B. L., Ko, J. Y., Cox, S., D'Angelo Mph, D. V., Warner, L., Folger, S., Tevendale, H. D., Coy, K. C., Harrison, L., & Barfield, W. D. (2020). Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression - United States, 2018. MMWR. Morbidity and mortality weekly report, 69(19), 575–581. https://doi.org/10.15585/mmwr.mm6919a2 [7] Shuman, C.J., Peahl, A.F., Pareddy, N. (2022) Postpartum depression and associated risk factors during the COVID-19 pandemic. BMC Res Notes 15, 102. https://doi.org/10.1186/s13104-022-05991-8 [8] Grote, N. K., Katon, W. J., Russo, J. E., Lohr, M. J., Curran, M., Galvin, E., & Carson, K. (2015). Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized trial. Depression and Anxiety, 32(11), 821-834. [9] HESI Annual Report. HESI. (2022, November). Retrieved April 30, 2023, from Special-Report-Nov-2022-Results-for-Measures-Leveraging-Electronic-Clinical-Data-for-HEDIS.pdf (ncqa.org) [10] Byatt, N., Levin, L. L., Ziedonis, D., Moore Simas, T. A., & Allison, J. (2015). Enhancing Participation in Depression Care in Outpatient Perinatal Care Settings: A Systematic Review. Obstetrics and Gynecology, 126(5), 1048–1058. https://doi.org/10.1097/AOG.0000000000001067 [11] Satiani, A., Niedermier, J., Satiani, B., & Svendsen, D. P. (2018). Projected Workforce of Psychiatrists in the United States: A Population Analysis. Psychiatric Services (Washington, D.C.), 69(6), 710–713. https://doi.org/10.1176/appi.ps.201700344 [12] Bureau of Health Workforce Health Resources and Services Administration (HRSA) U.S. Department of Health & Human Services. (April 27, 2023) Designated Health Professional Shortage Areas Statistics, Second Quarter of Fiscal Year 2023 Designated HPSA Quarterly Summary. https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport [13] Coward, K. (2021). New data shows CCBHCs improve behavioral health access, reduce wait times. Behavioral Health Business. https://bhbusiness.com/2021/05/25/new-data-shows-ccbhcs-improve-behavioral-health-access-reduce-wait-times; The United States Government. (2022, June 17). Reducing the economic burden of unmet mental health needs - CEA. The White House. Retrieved April 30, 2023, from https://www.whitehouse.gov/cea/written-materials/2022/05/31/reducing-the-economic-burden-of-unmet-mental-health-needs/ [14] LaRocco-Cockburn, A., Reed, S. D., Melville, J., Croicu, C., Russo, J. E., Inspektor, M., ... & Katon, W. (2013). Improving depression treatment for women: integrating a collaborative care depression intervention into OB-GYN care. Contemporary clinical trials, 36(2), 362-370. [15] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [16] Hansen, M. E. D., Tobón, A. L., Haider, U. K., Simas, T. A. M., Newsome, M., Finelli, J., ... & Byatt, N. (2023). The role of perinatal psychiatry access programs in advancing mental health equity. General Hospital Psychiatry. [17] Cox, E. Q., Sowa, N. A., Meltzer-Brody, S. E., & Gaynes, B. N. (2016). The perinatal depression treatment cascade: baby steps toward improving outcomes. The Journal of clinical psychiatry, 77(9), 20901. [18] Taouk, L. H., Matteson, K. A., Stark, L. M., & Schulkin, J. (2018). Prenatal depression screening and antidepressant prescription: obstetrician-gynecologists' practices, opinions, and interpretation of evidence. Archives of women's mental health, 21(1), 85–91. https://doi.org/10.1007/s00737-017-0760-7 [19] Garbarino, A. H., Kohn, J. R., Coverdale, J. H., & Kilpatrick, C. C. (2019). Current Trends in Psychiatric Education Among Obstetrics and Gynecology Residency Programs. Academic psychiatry: the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 43(3), 294–299. https://doi.org/10.1007/s40596-019-01018-w ; [20] Wisner, K. L., Sit, D. K., McShea, M. C., Rizzo, D. M., Zoretich, R. A., Hughes, C. L.,& Hanusa, B. H. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA psychiatry, 70(5), 490-498 [21] Armstrong, K., Rose, A., Peters, N., Long, J. A., McMurphy, S., & Shea, J. A. (2006). Distrust of the health care system and self-reported health in the United States. Journal of general internal medicine, 21(4), 292–297. https://doi.org/10.1111/j.1525-1497.2006.00396.x [22] Declercq, E., & Zephyrin, L. (2020). Maternal mortality in the United States: A Primer. Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer [23] Scholle, S. H., & Kelleher, K. (2003). Preferences for depression advice among low-income women. Maternal and child health journal, 7(2), 95–102. https://doi.org/10.1023/a:1023864810207https://doi.org/10.1023/a:1023864810207 [24] AIMS Center. (n.d.). Collaborative care. https://aims.uw.edu/collaborative-care [25] Press, M. J., Howe, R., Schoenbaum, M., Cavanaugh, S., Marshall, A., Baldwin, L., & Conway, P. H. (2017). Medicare payment for behavioral health integration. n Engl j Med, 376(5), 405-407. [26] Chang, D., Morrison, D. J., Bowen, D. J., Harris, H. M., Dusic, E. J., Velasquez, M. B., & Ratzliff, A. D. H. (2023). Making It to Sustainability: Evaluating Billing Strategies for Collaborative Care. Psychiatric services (Washington, D.C.), appips20220596. Advance online publication. https://doi.org/10.1176/appi.ps.20220596 [27] Miller, E. S., Jensen, R., Hoffman, M. C., Osborne, L. M., McEvoy, K., Grote, N., & Moses-Kolko, E. L. (2020). Implementation of perinatal collaborative care: a health services approach to perinatal depression care. Primary health care research & development, 21, e30. [28] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [29] Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr, Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., Langston, C., & IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment (2002). Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA, 288(22), 2836–2845. https://doi.org/10.1001/jama.288.22.2836 [30] Raney, L. (2020). [31] Unützer, J., Harbin, H., Schoenbaum, M., & Druss, B. (2013). The collaborative care model: An approach for integrating physical and mental health care in Medicaid health homes. Health Home Information Resource Center, 1-13. [32] Raney, L. (2020). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care. Oakland, California Health Care Foundation. [33] Grote, N. K., Katon, W. J., Russo, J. E., Lohr, M. J., Curran, M., Galvin, E., & Carson, K. (2015). Collaborative care for perinatal depression in socioeconomically disadvantaged women: a randomized trial. Depression and anxiety, 32(11), 821-834 [34] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275; Snowber, K., Ciolino, J. D., Clark, C. T., Grobman, W. A., & Miller, E. S. (2022). Associations Between Implementation of the Collaborative Care Model and Disparities in Perinatal Depression Care. Obstetrics & Gynecology, 140(2), 204-211. [35] Percent of People Covered By Medicaid/CHIP, 2022. (2022). Medicaid State Fact Sheets. KFF. Retrieved May 1, 2023, from https://www.kff.org/interactive/medicaid-state-fact-sheets/ [36] Miller, E. S., Grobman, W. A., Ciolino, J. D., Zumpf, K., Sakowicz, A., Gollan, J., & Wisner, K. L. (2021). Increased depression screening and treatment recommendations after implementation of a perinatal collaborative care program. Psychiatric Services, 72(11), 1268-1275. [37] Shalaby, R. A. H., & Agyapong, V. I. (2020). Peer support in mental health: literature review. JMIR mental health, 7(6), e15572. [38] Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M., & Laudet, A. (2016). Peer-delivered recovery support services for addictions in the United States: A systematic review. Journal of substance abuse treatment, 63, 1-9. [39] Eastburg, M. C., Williamson, M., Gorsuch, R., & Ridley, C. (1994). Social support, personality, and burnout in nurses. Journal of Applied Social Psychology, 24(14), 1233-1250. [41] FamilyWell. (2023.). https://familywellhealth.com/ [42] Patients, Family Well (2023). https://familywellhealth.com/patients [43] Providers, Family Well (2023). https://familywellhealth.com/providers [44] Patients, Family Well (2023). https://familywellhealth.com/patients [45] Author interview with Jessica Gaulton, FamilyWell. (2023) [46] Maven (2022). “If moms are unwell, society is unwell.” Recapping our Q&A with Dr. Neel Shah. Maven. https://www.mavenclinic.com/post/if-moms-are-unwell-society-is-unwell-recapping-our-q-a-with-dr-neel-shah#! [47] Klatter, C. K., van Ravesteyn, L. M., & Stekelenburg, J. (2022). Is collaborative care a key component for treating pregnant women with psychiatric symptoms (and additional psychosocial problems)? A systematic review. Archives of Women's Mental Health, 25(6), 1029-1039.

Introduction This article assesses (1) access to splenic embolization (SE), (2) indications for SE, and (3) post-embolization management in high-grade splenic trauma in children. Materials and Methods An online questionnaire was sent in 2021 to all members of European Pediatric Surgeons' Association. Results There were a total of 157 responses (50 countries, 83% academic hospitals). Among them, 68% have access to SE (SE) and 32% do not (nSE). For a hemodynamic stable patient with high-grade isolated splenic trauma without contrast extravasation (CE) on computed tomography (CT) scan, 99% SE and 95% nSE respondents use nonoperative management (NOM). In cases with CE, NOM decreases to 50% (p = 0.01) and 51% (p = 0.007) in SE and nSE centers, respectively. SE respondents report a significant reduction of NOM in stable patients with an associated spine injury requiring urgent surgery in prone position, both without and with CE (90 and 28%, respectively). For these respondents, in stable patients the association of a femur fracture only tends to decrease the NOM, both without and with CE (93 and 39%, respectively). There was no significant difference in NOM in group nSE with associated injuries with or without CE. After proximal SE with preserved spleen vascularization on ultrasound Doppler, 44% respondents prescribe antibiotics and/or immunizations. Conclusion Two-thirds of respondents have access to SE. For SE respondents, SE is used even in stable patients when CE showed on initial CT scan and its use increased with the concomitant need for spinal surgery. There is currently a variation in the use of SE and antibiotics/immunizations following SE.

Abstract Background Hand, foot and mouth disease (HFMD) caused by a variety of enteroviruses remains a major public health problem in China. Previous studies have found that social factors may contribute to the inconsistency of the relationship patterns between meteorological factors and HFMD, but the conclusions are inconsistent. The influence of social factors on the association between meteorology and HFMD is still less well understood. We aimed to analyze whether social factors affected the effect of meteorological factors on HFMD in Sichuan Province. Method We collected daily data on HFMD, meteorological factors and social factors in Sichuan Province from 2011 to 2017. First, we used a Bayesian spatiotemporal model combined with a distributed lag nonlinear model to evaluate the exposure-lag-response association between meteorological factors and HFMD. Second, by constructing the interaction of meteorological factors and social factors in the above model, the changes in the relative risk (RR) under different levels of social factors were evaluated. Results The cumulative exposure curves for average temperature, relative humidity, and HFMD were shaped like an inverted “V” and a “U” shape. As the average temperature increased, the RR increased and peaked at 19 °C (RR 1.020 [95% confidence interval CI 1.004–1.050]). The urbanization rate, per capita gross domestic product (GDP), population density, birth rate, number of beds in health care centers and number of kindergartens interacted with relative humidity. With the increase in social factors, the correlation curve between relative humidity and HFMD changed from an “S” shape to a “U” shape. Conclusions Relative humidity and average temperature increased the risk of HFMD within a certain range, and social factors enhanced the impact of high relative humidity. These results could provide insights into the combined role of environmental factors in HFMD and useful information for regional interventions.

Annually, one in five childbearing persons in the United States experiences a mental health or substance use disorder before, during or after pregnancy, the American Psychiatric Association (APA) stated in an Aug. 1 news release. To ensure that psychiatrists and mental health clinicians are best positioned to respond to this need, the APA, with support from the CDC [Centers for Disease Control and Prevention] Foundation, has released a series of educational materials for addressing perinatal mental health in its Psychiatric Toolkit. The toolkit includes eight fact sheets for clinicians and patients, a white paper, and a four‐part webinar series covering this understudied and underserved area of mental health. These materials can be accessed at APA's Perinatal Mental Health website (https://www.psychiatry.org/psychiatrists/practice/professional‐interests/women‐s‐mental‐health/maternal‐mental‐health‐toolkit). The white paper calls for revisions to academic and continuing education curricula to improve competency and confidence within the behavioral care workforce for treating this population. It examines the care of vulnerable populations, raising such issues as cultural competency and lack of access. This “Mental Health Needs Assessment in the Management of Perinatal Psychiatric Disorders” is supported by the CDC and the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $447,209 funded by the CDC/HHS.

Objective Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to investigate the rates of conversion to CD for planned twin VDs and identify predictors and outcomes of conversion. Study Design A retrospective cohort study of all women who underwent a planned twin VD at two large academic medical centers over 4 years. Demographic and outcome data were chart abstracted. Various statistical tests were used to evaluate the influence of perinatal variables on mode of delivery and identify possible predictors of conversion. Results Eight hundred and eighty-five twin deliveries were identified, of which 725 (81.9%) were possible candidates for VD. Of those, 237 (32.7%) underwent successful VD of twin A. Ninety-five (40.1%) had a nonvertex second twin at time of delivery. Conversion to CD occurred in 10 planned VDs (4.2%). Conversions were higher with spontaneous labor (relative risk [RR]: 2.1; 95% confidence interval [CI] 1.6–2.7; p = 0.003), and having an intertwin delivery interval greater than 60 minutes (RR: 5.1; 95% CI: 2.5–10.8; p < 0.001). Nonvertex presentation of twin B, type of delivery provider, or years out in practice of delivery provider were not significantly different between groups. There were no significant differences in neonatal outcomes between VD and conversion groups. There was a significant association between use of forceps for twin B and successful VD (p = 0.02), with 84.6% in the setting of a nonvertex twin B. Conclusion Successful VD was achieved in planned VD of twins in 95.8% of cases, and there were no significant differences in maternal and fetal outcomes between successful VD and conversion to CD for twin B. With the optimal clinical scenario and shared decision-making, performing vaginal twin deliveries in labor and delivery rooms should be discussed. Key Points

Objective Breast cancer is one of the most frequently diagnosed cancers in pregnancy and is commonly treated with chemotherapy. To date, studies examining effects of chemotherapy during pregnancy on fetal growth have yielded conflicting results, and most are limited by small sample sizes or are nonspecific with respect to cytotoxic regimen or type of cancer treated. We sought to evaluate the effect of chemotherapy for breast cancer in pregnancy on birthweight and small for gestational age infants. Study Design This is a retrospective cohort study of 74 women diagnosed with pathologically confirmed breast cancer during pregnancy between 1997 and 2018 at one of three academic medical centers, who had a singleton birth with known birthweight. Forty-nine received chemotherapy and 25 did not receive chemotherapy. Linear regression modeling was used to compare birthweight (by gestational age and sex-specific z-score) by chemotherapy exposure. Subanalyses of specific chemotherapy regimen and duration of chemotherapy exposure were also performed. Placental, neonatal, and maternal outcomes were also analyzed by chemotherapy exposure. Results In the adjusted model, chemotherapy exposure was associated with lower birthweight (∆ z-score = − 0.49, p = 0.03), but similar rates of small for gestational age (defined as birthweight <10th percentile for gestational age) infants (8.2 vs. 8.0%, p = 1.0; Fisher’s exact test). Each additional week of chemotherapy (∆ z-score = − 0.05, p = 0.03) was associated with decreased birthweight, although no association was found with specific chemotherapy regimen. Chemotherapy exposure was associated with lower median placental weight percentile by gestational age (9th vs. 75th, p < 0.05). Secondary maternal outcomes were similar between the group that did and did not receive chemotherapy. Conclusion Chemotherapy for breast cancer in pregnancy in this cohort is associated with lower birthweight but no difference in the rate of small for gestational age infants. Key Points

Abstract Background and Objectives Delirium is a common disorder among older adults following hospitalization or major surgery. Whereas many studies examine the risk of proximate exposures and comorbidities, little is known about pathways linking childhood exposures to later life delirium. In this study, we explored the association between paternal occupation and delirium risk. Research Design and Methods A prospective observational cohort study of 528 older adults undergoing elective surgery at two academic medical centers. Paternal occupation group (white collar vs. blue-collar) served as our independent variable. Delirium incidence was assessed using the Confusion Assessment Method (CAM) supplemented by medical chart review. Delirium severity was measured using the peak CAM Severity score (CAM-S Peak), the highest value of CAM-S observed throughout the hospital stay. Results Blue-collar paternal occupation was significantly associated with a higher rate of incident delirium (91/234, 39%) compared with white-collar paternal occupation (84/294, 29%), adjusted odds ratio OR [95% confidence interval, CI] = 1.6 [1.1, 2.3]. All analyses were adjusted for participant age, race, gender, and Charlson Comorbidity Index (CCI). Blue-collar paternal occupation was also associated with greater delirium severity, with a mean score (SD) of 4.4 (3.3), compared to white-collar paternal occupation with a mean score (SD) of 3.5 (2.8). Among participants reporting blue-collar paternal occupation, we observed an adjusted mean difference of 0.86 [95% CI, 0.4, 1.4] additional severity units. Discussion and Implications Blue-collar paternal occupation is associated with greater delirium incidence and severity, after adjustment for covariates. These findings support the application of a life course framework to evaluate the risk of later life delirium and delirium severity. Our results also demonstrate the importance of considering childhood exposures, which may be consequential even decades later.

Introduction & Objective: CGM is associated with better clinical and psychosocial outcomes. While expanding, CGM is limited in primary care (PC), where most diabetes care occurs and where NPs are often crucial. We identified NP and practice factors associated with CGM-related behaviors, attitudes, and needs to understand how to support CGM use by NPs in PC. Methods: Cross-sectional survey; multivariable linear and logistic regression. N=200 NPs in PC, recruited through the American Association of Nurse Practitioners. Outcome: CGM use. Independent variables: NP characteristics (eg, years since training, full- or part-time status) and practice setting (eg, organization type, payer mix). Results: Most participants practiced family (67%) or internal medicine (28%). Practices included private (34%), hospital-owned (29%), and FQHC (20%). 44% had prescribed CGM. Primary outcome: Compared to private practice, hospital-owned practice NPs were more likely to have prescribed CGM (OR 2.32, 95% CI: 1.09-4.90, p&lt;.01); academic medical center NPs were less likely to have prescribed (OR .098, 95% CI: .012-.799, p&lt;.01). Secondary outcomes: Predictors of favorability toward future CGM prescribing were past CGM prescribing (coef = .73, p&lt;.0001) and time since training (1-5 years: coef = -.48, 6-15 years: coef = -.41; p&lt;.01). Predictors of confidence using CGM in diabetes care were prior CGM prescribing (T1D coef = 3.57, T2D coef = 3.49; p&lt;.0001) and having &gt;50% Medicare patients (T1D coef = 1.77; T2D coef = 2.04, p&lt;.01). NPs identified a one-time endocrine consult (62%), CGM education website (61%), and asynchronous endocrine e-consult (59%) as resources that would make them moderately/very likely to prescribe CGM. Conclusion: Targeting academic medical centers, private practice, and NPs who serve mostly non-Medicare patients, as well as consults and education resources, could help PC NPs bring CGM to more people with diabetes. Disclosure T. Hall: None. L. Dickinson: None. M.K. Warman: None. T. Oser: Research Support; Abbott. Advisory Panel; Medscape. Consultant; Dexcom, Inc. Research Support; Insulet Corporation. S. Oser: Other Relationship; American Diabetes Association, Association of Diabetes Care & Education Specialists. Research Support; Abbott. Advisory Panel; Dexcom, Inc., Jaeb Center for Health Research.

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino Population From Obscurity to the Forefront of Health Care, Public Health Intervention, and Societal Presence. JAMA, 326(7), 597–598. https://doi.org/10.1001/jama.2021.11997 [3] Association of American Medical Colleges. (2023). Who is eligible to participate in the fee assistance program? https://students-residents.aamc.org/fee-assistance-program/who-eligble-participate-fee-assistance-mprogram [4] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [5] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm; Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf; Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [6] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm [7] Center for Disease Control and Prevention. (2021, October). Estimated HIV incidence and prevalence in the United States 2015–2019. https://www.cdc.gov/hiv/pdf/group/racialethnic/hispanic-latino/cdc-hiv-group-hispanic-latino-factsheet.pdf [8] Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [9] CDC. (2020). [10] CDC. (2020). [11] Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf [12] Office of the Assistant Secretary for Planning and Evaluation. (2021, October). Issue Brief No. HP-2021-2. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-latinos [13] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [14] Alsan, M., Garrick, O., & Graziani, G. (2019). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 [15] Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11). https://doi.org/10.1001/jamanetworkopen.2020.24583 [16] Alsan, et. al. (2019). [17] Marrast, L., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians’ role in the care of underserved patients. JAMA Internal Medicine, 174(2), 289. https://doi.org/10.1001/jamainternmed.2013.12756 (“Nonwhite physicians cared for 53.5% of minority and 70.4% of non-English speaking patients.” Increasing the number of Latino doctors could lead to more nonwhite physicians to care for the underserved populations as they serve those populations at disproportionate rates. This may lead to better care for the patients.) [18] Cersosimo, E., & Musi, N. (2011). Improving Treatment in Hispanic/Latino Patients. The American Journal of Medicine, 124(10), S16–S21. https://doi.org/10.1016/j.amjmed.2011.07.019 [19] Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/s0022-3476(00)90043-x [20] Cersosimo & Musi. (2011). [21] Flores. (2000). [22] Torres, D. (2019). Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study. The Permanente Journal. https://doi.org/10.7812/tpp/18-258 [23] The Princeton Review. (n.d.). Score 513+ on the MCAT, Guaranteed! | The Princeton Review. [24] 2021 FACTS: Applicants and Matriculants Data. (2022). AAMC. https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data [25] The Princeton Review. (n.d.). How Many Med Schools Should You Apply To? https://www.princetonreview.com/med-school-advice/how-many-med-schools-should-you-apply-to [26] Association of American Medical Colleges. (n.d.). Fee Assistance Program (FAP). AAMC. https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program-fap [27] Nguyen, M., Desai, M. M., Fancher, T. L., Chaudhry, S. I., Mason, H. R. C., & Boatright, D. (2023). Temporal trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income, 2014-2019. JAMA. https://doi.org/10.1001/jama.2023.5654 [28] Ramirez, et al. (2021). [29] Ko, M. J., Henderson, M. C., Fancher, T. L., London, M., Simon, M., & Hardeman, R. R. (2023). US medical school admissions leaders’ experiences with barriers to and advancements in diversity, equity, and inclusion. JAMA Network Open, 6(2), e2254928. https://doi.org/10.1001/jamanetworkopen.2022.54928 [30] Johns Hopkins University School of Medicine. (n.d.). JHU CSM SIP. Johns Hopkins Initiative for Careers in Science and Medicine - the Summer Internship Program. https://csmsip.cellbio.jhmi.edu/ [31] Figure 18. Percentage of all active physicians by race/ethnicity, 2018 | AAMC. (2018). AAMC. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018 [32] Ramirez, et al. (2021). [33] Passel, et al. (2022). [34] Census Reporter. (n.d.). Census profile: Manhattan borough, New York County, NY. https://censusreporter.org/profiles/06000US3606144919-manhattan-borough-new-york-county-ny/ [35] MD Student Diversity Recruitment. (2022). NYU Langone Health. https://med.nyu.edu/our-community/why-nyu-grossman-school-medicine/diversity-inclusion/recruiting-diversity/md-student-diversity-recruitment [36] NYU. (n.d.). STEP Pre-College Program. New York University. https://www.nyu.edu/admissions/undergraduate-admissions/how-to-apply/all-freshmen-applicants/opportunity-programs/pre-college-programs.html [37] Association of American Medical Colleges. (2022). NYU Grossman School of Medicine. Medical School Admission Requirements (MSAR). https://mec.aamc.org/msar-ui/#/medSchoolDetails/152 [38] Association of American Medical Colleges. (2022). [39] U.S. Census Bureau. (2021). U.S. Census Bureau QuickFacts: Philadelphia County, Pennsylvania. Census Bureau QuickFacts. https://www.census.gov/quickfacts/philadelphiacountypennsylvania [40] Association of American Medical Colleges. (2022). Drexel University College of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/833 [41] Association of American Medical Colleges. (2022). [42] Drexel University College of Medicine. (n.d.). Diversity, Equity & Inclusion For Students. https://drexel.edu/medicine/about/diversity/diversity-for-students/ [43] Drexel University College of Medicine. (n.d.-b). Drexel Pathway to Medical School. https://drexel.edu/medicine/academics/graduate-school/drexel-pathway-to-medical-school/ [44] Drexel University College of Medicine. Drexel Pathway to Medical School. [45] Association of American Medical Colleges. (2022). University of California, San Francisco, School of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/108 [46] The Regents of the University of California. (n.d.). Differences Matter. UCSF School of Medicine. https://medschool.ucsf.edu/differences-matter [47] The Regents of the University of California. (n.d.-b). Post Baccalaureate Program | UCSF Medical Education. UCSF Medical Education. https://meded.ucsf.edu/post-baccalaureate-program [48] United States Census Bureau. (2021). U.S. Census Bureau QuickFacts: San Francisco County, California. Census Bureau QuickFacts. https://www.census.gov/quickfacts/sanfranciscocountycalifornia [49] Memorial Sloan Kettering Cancer Center. (n.d.). Student Programs. https://www.mskcc.org/about/leadership/office-faculty-development/student-programs [50] Alsan, et al. (2021). [51] National Health Service Corps. (2021, November 2). Mission, Work, and Impact | NHSC. https://nhsc.hrsa.gov/about-us [52] Elam, C. L., & Wagoner, N. E. (2012). Legacy Admissions in Medical School. AMA Journal of Ethics, 14(12), 946–949. https://doi.org/10.1001/virtualmentor.2012.14.12.ecas3-1212

Abstract Background Gut microbiome composition is shaped by a combination of host genetic make-up and dietary habits. In addition, large ethnic differences exist in microbiome composition. Several studies in humans and animals have shown that differences in gut microbiota and its metabolites, including short chain fatty acids (SCFA), are associated with blood pressure (BP). We hypothesized that gut microbiome composition and its metabolites may be differently associated with BP across ethnic groups. Purpose To investigate associations of gut microbiome composition and fecal SCFA levels with BP across different ethnic groups. Methods We assessed the association between gut microbiome composition and office BP among 4672 subjects (mean age 49.8±11.7 years, 52%F) of 6 different ethnic groups participating in the HELIUS study. Gut microbiome composition was determined using 16S rRNA sequencing. Associations between microbiome composition and blood pressure were assessed using machine learning prediction models. The resulting best predictors were correlated with BP using Spearman's rank correlations. Fecal SCFA levels were measured with high-performance liquid chromatography in an age- and body mass index (BMI)-matched subgroup of 200 participants with either extreme low or high systolic BP. Differences in abundances of best predictors and fecal SCFA levels between high and low BP groups were assessed with Mann-Whitney U tests. Results Gut microbiome composition explained 4.4% of systolic BP variance. Best predictors for systolic BP included Roseburia spp. (ρ −0.15, p&lt;0.001), Clostridium spp. (ρ −0.14, p&lt;0.001), Romboutsia spp. (ρ −0.10, p&lt;0.001), and Ruminococceae spp. (ρ −0.15, p&lt;0.001) (Figure 1). Explained variance of the microbiome composition was highest in Dutch subjects (4.8%), but very low in African Surinamese, Ghanaian, and Turkish ethnic groups (ranging from 0–0.77%) Hence, we selected only participants with Dutch ethnicity for the matched subgroup. Participants with high BP had lower abundance of Roseburia hominis (p&lt;0.01) and Roseburia spp. (p&lt;0.05) compared to participants with low BP. However, fecal acetate (p&lt;0.05) and propionate (p&lt;0.01) levels were higher in participants with high BP. Conclusions In this cross-sectional study, gut microbiome composition was moderately associated with BP. Associations were strongly divergent between ethnic groups, with strongest associations in Dutch participants. Intriguingly, while Dutch participants with high BP had lower abundances of several SCFA-producing microbes, they had higher fecal SCFA levels. Intervention studies with SCFAs could provide more insight in the effects of these metabolites on BP. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): The Academic Medical Center (AMC) of Amsterdam and the Public Health Service of Amsterdam (GGD Amsterdam) provided core financial support for HELIUS. The HELIUS study is also funded by research grants of the Dutch Heart Foundation (Hartstichting; grant no. 2010T084), the Netherlands Organization for Health Research and Development (ZonMw; grant no. 200500003), the European Integration Fund (EIF; grant no. 2013EIF013) and the European Union (Seventh Framework Programme, FP-7; grant no. 278901).

ObjectiveTo assess the accuracy of a surveillance-based definition for hepatitis B treatment eligibility among New York City residents with chronic hepatitis B infection.IntroductionApproximately 100,000 New York City (NYC) residents are currently diagnosed with chronic hepatitis B virus (HBV) infection.1 Routine monitoring and treatment, where indicated, are necessary to reduce HBV disease progression. Using the 2017 European Association for the Study of the Liver (EASL) 2 guidelines on HBV infection management, we developed a surveillance-based definition for treatment eligibility. Validation of this definition will support the creation of a population-level HBV care continuum, which will allow us to monitor gaps from HBV diagnosis to viral suppression and to develop public health interventions to address these gaps.MethodsLaboratories everywhere are required to electronically report the following HBV tests to the NYC Department of Health and Mental Hygiene (DOHMH) for all NYC residents: positive and negative (as of April 2018) DNA, positive surface antigen, positive e antigen, positive core IgM, and Alanine aminotransferase (ALT) (when ordered at the same time as another reportable HBV test). Using reportable HBV tests, treatment eligibility was defined as ever having an HBV DNA result >2000 IU/mL and ALT>40 U/L. We assessed the accuracy of the surveillance-based definition by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) by applying the definition to the test data of people participating in two DOHMH programs that included clinical information on treatment eligibility: the Enhanced Surveillance Project (provider interviews conducted for 300 randomly selected patients with chronic HBV) and the Check Hep B Patient Navigation Program (program providing HBV-related patient navigation at community organizations, health centers, and hospitals). Everyone meeting inclusion criteria in the Enhanced Surveillance Project who were also identified as being in care and being monitored (two or more HBV DNA results reported at any time) were included in our analysis. For Check Hep B, we included everyone enrolled prior December 31, 2017 who also met our criteria of being in care and being monitored. To determine treatment eligibility using surveillance data, we used all HBV DNA and ALT results reported prior to January 31st, 2016 for the Enhanced Surveillance project and prior to December 31st, 2017 for Check Hep B.ResultsTreatment eligibility was 62.0% (145/234) among people from the Enhanced Surveillance Project (Table 1A) and 40.0% (161/402) among people enrolled in Check Hep B (Table 1B). Sensitivity of the surveillance-based definition was low using both data sources (Enhanced Surveillance Project: 26.2%; Check Hep B: 24.2%) and specificity high (Enhanced Surveillance Project: 92.1%; Check Hep B: 94.2%). PPV was 84.4% and 73.6% for the Enhanced Surveillance project and Check Hep B, respectively, while NPV was 43.4% and 65.0% for the Enhanced Surveillance project and Check Hep B respectively.ConclusionsOur surveillance-based definition had high specificity, indicating that the great majority of patients who were truly not treatment-eligible were correctly classified. However, sensitivity was low, indicating that the surveillance-based definition was unable to accurately identify those considered treatment-eligible from either data source. Low sensitivity suggests that clinicians are likely using other clinical factors not included in laboratory-based reporting to assess a patient’s eligibility for treatment, such as fibrosis and cirrhosis, and that clinicians might be using guidelines other than EASL (e.g., American Association for the Study of Liver Diseases (AASLD)3) to determine treatment eligibility. We will conduct chart reviews to better understand the variability in criteria being used. These chart reviews will allow us to further refine our surveillance-based definition (e.g., by incorporating different HBV tests or for clinical criteria that are not laboratory-based, including information from external sources such as Regional Health Information Organizations (RHIOs)), eventually supporting the creation of an HBV care continuum for NYC.References1. France AM, Bornschlegel K, Lazaroff J, Kennedy J, Balter S. Estimating the prevalence of chronic hepatitis B virus infection--New York City, 2008. Journal of urban health: bulletin of the New York Academy of Medicine 2012; 89(2): 373-83.2. European Association for the Study of the Liver. Electronic address eee, European Association for the Study of the L. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. J Hepatol 2017; 67(2): 370-98.3. Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH; American Association for the Study of Liver Diseases. AASLD guidelines for treatment of chronic hepatitis B. Hepatology. 2016;63(1):261–83. https://doi.org/10.1002/hep.28156.

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Photo by Sharon McCutcheon on Unsplash ABSTRACT COVID-19 highlighted a disproportionate impact upon marginalized communities that needs to be addressed. Specifically, a focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can provide this great benefit but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. INTRODUCTION COVID-19 disproportionately impacted communities of color and lower socioeconomic status, sparking political discussion about existing inequities in the US.[1] Some states amended their guidelines for allocating resources, including vaccines, to provide care for marginalized communities experiencing these inequities, but there has been no clear consensus on which guidelines states should amend or how they should be ethically grounded. In part, this is because traditional justice theories do not acknowledge the deep-seated institutional and interpersonal discrimination embedded in our medical system. Therefore, a revamped distributive justice approach that accounts for these shortcomings is needed to guide healthcare decision-making now and into the post-COVID era. BACKGROUND Three terms – health disparity, health inequities, and health equity – help frame the issue. A health disparity is defined as any difference between populations in terms of disease incidence or adverse health events, such as morbidity or mortality. In contrast, health inequities are health disparities due to avoidable systematic structures rooted in racial, social, and economic injustice.[2] For example, current data demonstrate that Black, Latino, Indigenous Americans, and those living in poverty suffer higher morbidity and mortality rates from COVID-19.[3] Finally, health equity is the opportunity for anyone to attain his or her full health potential without interference from systematic structures and factors that generate health inequities, including race, socioeconomic status, gender, ethnicity, religion, sexual orientation, or geography.[4] ANALYSIS Health inequities for people of color with COVID-19 have led to critiques of states that do not account for race in their resource allocation guidelines.[5] For example, the Massachusetts Department of Public Health revised its COVID-19 guidelines regarding resource allocation to patients with the best chance of short-term survival.[6] Critics have argued that this change addresses neither preexisting structural inequities nor provider bias that may have led to comorbidities and increased vulnerability to COVID-19. By failing to address race specifically, they argue the policy will perpetuate poorer outcomes in already marginalized groups. As the inequities in COVID-19 outcomes continue to be uncovered and the data continue to prove that marginalized communities suffered disproportionately, we, as healthcare providers, must reconsider our role in addressing the injustices. Our actions must be ethically grounded in the concept of justice. l. Primary Theories of Justice The principle of justice in medical ethics relates to how we ought to treat people and allocate resources. Multiple theories have emerged to explain how justice should be implemented, with three of the most prominent being egalitarianism, utilitarianism, and distributive. This paper argues that distributive justice is the best framework for remedying past actions and enacting systemic changes that may persistently prevent injustices. An egalitarian approach to justice states all individuals are equal and, therefore, should have identical access to resources. In the allocation of resources, an egalitarian approach would support a strict distribution of equal value regardless of one’s attributes or characteristics. Putting this theory into practice would place a premium on guidelines based upon first-come, first-served basis or random selection.[7] However, the egalitarian approach taken in the UK continues to worsen health inequities due to institutional and structural discrimination.[8] A utilitarian approach to justice emphasizes maximizing overall benefits and achieving the greatest good for the greatest number of people. When resources are limited, the utilitarian principle historically guides decision-making. In contrast to the egalitarian focus on equal distribution, utilitarianism focuses on managing distributions to maximize numerical outcomes. During the COVID-19 pandemic, guidelines for allocating resources had utilitarian goals like saving the most lives, which may prioritize the youthful and those deemed productive in society, followed by the elderly and the very ill. It is important to reconsider using utilitarian approaches as the default in the post-COVID healthcare community. These approaches fail to address past inequity, sacrificing the marginalized in their emphasis on the greatest amount of good rather than the type of good. Finally, a distributive approach to justice mandates resources should be allocated in a manner that does not infringe individual liberties to those with the greatest need. Proposed by John Rawls in a Theory of Justice, this approach requires accounting for societal inequality, a factor absent from egalitarianism and utilitarianism.[9] Naomi Zack elaborates how distributive justice can be applied to healthcare, outlining why racism is a social determinant of health that must be acknowledged and addressed.[10] Until there are parallel health opportunities and better alignment of outcomes among different social and racial groups, the underlying systemic social and economic variables that are driving the disparities must be fixed. As a society and as healthcare providers, we should be striving to address the factors that perpetuate health inequities. While genetics and other variables influence health, the data show proportionately more exposure, more cases, and more deaths in the Black American and Hispanic populations. Preexisting conditions and general health disparities are signs of health inequity that increased vulnerability. Distributive justice as a theoretical and applied framework can be applied to preventable conditions that increase vulnerability and can justify systemic changes to prevent further bias in the medical community. During a pandemic, egalitarian and utilitarian approaches to justice are prioritized by policymakers and health systems. Yet, as COVID-19 has demonstrated, they further perpetuate the death and morbidity of populations that face discrimination. These outcomes are due to policies and guidelines that overall benefit white communities over communities of color. Historically, US policy that looks to distribute resources equally (focusing on equal access instead of outcomes), in a color-blind manner, has further perpetuated poor outcomes for marginalized communities.[11] ll. Historical and Ongoing Disparities Across socio-demographic groups, the medical system exacerbates historical and current inequities. Members of marginalized races,[12] women,[13] LGBTQ people,[14] and poor people[15] experience trauma caused by discrimination, marginalization, and failure to access high-quality public and private goods. Through the unequal treatment of marginalized communities, these historic traumas continue. In the US, people of color do not receive equal and fair medical treatment. A meta-analysis found that Hispanics and Black Americans were significantly undertreated for pain compared to their white counterparts over the last 20 years.[16] This is partly due to provider bias. Through interviewing medical trainees, a study by the National Academy of Science found that half of medical students and residents harbored racist beliefs such as “Black people’s nerve endings are less sensitive than white people’s” or “Black people’s skin is thicker than white people’s skin.”[17] More than 3,000 Indigenous American women were coerced, threatened, and deliberately misinformed to ensure cooperation in forced sterilization.[18] Hispanic people have less support in seeking medical care, in receiving culturally appropriate care, and they suffer from the medical community’s lack of resources to address language barriers.[19] In the US, patients of different sexes do not receive the same quality of healthcare. Despite having greater health needs, middle-aged and older women are more likely to have fewer hospital stays and fewer physician visits compared to men of similar demographics and health risk profiles.[20] In the field of critical care, women are less likely to be admitted to the ICU, less likely to receive interventions such as mechanical ventilation, and more likely to die compared to their male ICU counterparts.[21] In the US, patients of different socioeconomic statuses do not receive the same quality of healthcare. Low-income patients are more likely to have higher rates of infant mortality, chronic disease, and a shorter life span.[22] This is partly due to the insurance-based discrimination in the medical community.[23] One in three deaths of those experiencing homelessness could have been prevented by timely and effective medical care. An individual experiencing homelessness has a life expectancy that is decades shorter than that of the average American.[24] lll. Action Needed: Policy Reform While steps need to be taken to provide equitable care in the current pandemic, including the allocation of vaccines, they may not address the historical failures of health policy, hospital policy, and clinical care to eliminate bias and ensure equal treatment of patients. According to an applied distributive justice framework, inequities must be corrected. Rather than focusing primarily on fair resource allocation, medicine must be actively anti-racist, anti-sexist, anti-transphobic, and anti-discriminatory. Evidence has shown that the health inequities caused by COVID-19 are smaller in regions that have addressed racial wealth gaps through forms of reparations.[25] Distributive justice calls for making up for the past using tools of allocation as well as tools to remedy persistent problems. For example, Brigham and Women’s Hospital in Boston, MA, began “Healing ARC,” a pilot initiative that involves acknowledgement, redress, and closure on an institutional level.[26] Acknowledgement entails informing patients about disparities at the hospital, claiming responsibility, and incorporating community ideas for redress. Redress involves a preferential admission option for Black and Hispanic patients to specialty services, especially cardiovascular services, rather than general medicine. Closure requires that community and patient stakeholders work together to ensure that a new system is in place that will continue to prioritize equity. Of note, redress could take the form of cash transfers, discounted or free care, taxes on nonprofit hospitals that exclude patients of color,[27] or race-explicit protocol changes (such as those being instituted by Brigham and Women’s Hospital that admit patients historically denied access to certain forms of medical care). In New York, for instance, the New York State Bar Association drafted the COVID-19 resolutions to ensure that emergency regulations and guidelines do not discriminate against communities of color, and even mandate that diverse patient populations be included in clinical trials.[28] Also, physicians must listen to individuals from marginalized communities to identify needs and ensure that community members take part in decision-making. The solution is not to simply build new health centers in communities of color, as this may lead to tiers of care. Rather, local communities should have a chance to impact existing hospital policy and should also use their political participation to further their healthcare interests. Distributive justice does not seek to disenfranchise groups that hold power in the system. It aims to transform the system so that those in power do not continue to obtain unfair benefits at the expense of others. The framework accounts for unjust historical oppression and current injustices in our system to provide equitable outcomes to all who access the system. In this vein, we can begin to address the flagrant disparities between communities that have always – and continue to – exist in healthcare today.[29] CONCLUSION As equality focuses on access, it currently fails to do justice. Instead of outcomes, it is time to focus on equity. A focus on equity rather than equality would better address and prevent the disparities seen in COVID-19. A distributive justice framework can gain traction in clinical decision-making guidelines and system-level reallocation of resources but will succeed only if the medical community engages in outreach, anti-racism measures, and listens to communities in need. There should be an emphasis on implementing a distributive justice framework that treats all patients equitably, accounts for historical harm, and focuses on transparency in allocation and public health decision-making. [1] APM Research Lab Staff. 2020. “The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S.” APM Research Lab. https://www.apmresearchlab.org/covid/deaths-by-race. [2] Bharmal, N., K. P. Derose, M. Felician, and M. M. Weden. 2015. “Understanding the Upstream Social Determinants of Health.” California: RAND Corporation 1-18. https://www.rand.org/pubs/working_papers/WR1096.html. [3] Yancy, C. W. 2020. “COVID-19 and African Americans.” JAMA. 323 (19): 1891-2. https://doi.org/10.1001/jama.2020.6548; Centers for Disease Control and Prevention. 2020. “COVID-19 in Racial and Ethnic Health Disparities.” Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/index.html. [4] Braveman, P., E. Arkin, T. Orleans, D. Proctor, and A. Plough. 2017. “What is Health Equity?” Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html. [5] Bedinger, M. 2020 Apr 22. “After Uproar, Mass. Revises Guidelines on Who Gets an ICU Bed or Ventilator Amid COVID-19 Surge.” Wbur. https://www.wbur.org/commonhealth/2020/04/20/mass-guidelines-ventilator-covid-coronavirus; Wigglesworth, A. 2020 May 11. “Institutional Racism, Inequity Fuel High Minority Death Toll from Coronavirus, L.A. Officials Say.” Los Angeles Times. https://www.latimes.com/california/story/2020-05-11/institutional-racism-inequity-high-minority-death-toll-coronavirus. [6] Executive Office of Health and Human Services Department of Public Health. 2020 Oct 20. “Crises Standards of Care Planning and Guidance for the COVID-19 Pandemic.” Commonwealth of Massachusetts. https://www.mass.gov/doc/crisis-standards-of-care-planning-guidance-for-the-covid-19-pandemic. [7] Emanuel, E. J., G. Persad, R. Upshur, et al. 2020. “Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine 382: 2049-55. https://doi.org/10.1056/NEJMsb2005114. [8] Salway, S., G. Mir, D. Turner, G. T. Ellison, L. Carter, and K. Gerrish. 2016. “Obstacles to "Race Equality" in the English National Health Service: Insights from the Healthcare Commissioning Arena.” Social Science and Medicine 152: 102-110. https://doi.org/10.1016/j.socscimed.2016.01.031. [9] Rawls, J. A Theory of Justice (Revised Edition) (Cambridge, MA: Belknap Press of Harvard University Press, 1999). [10] Zack, N. Applicative Justice: A Pragmatic Empirical Approach to Racial Injustice (New York: The Rowman & Littlefield Publishing Group, 2016). [11] Charatz-Litt, C. 1992. “A Chronicle of Racism: The Effects of the White Medical Community on Black Health.” Journal of the National Medical Association 84 (8): 717-25. http://hdl.handle.net/10822/857182. [12] Washington, H. A. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (New York: Doubleday, 2006). [13] d'Oliveira, A. F., S. G. Diniz, and L. B. Schraiber. 2002. “Violence Against Women in Health-care Institutions: An Emerging Problem.” Lancet. 359 (9318): 1681-5. https://doi.org/10.1016/S0140-6736(02)08592-6. [14] Hafeez, H., M. Zeshan, M. A. Tahir, N. Jahan, and S. Naveed. 2017. “Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus 9 (4): e1184. https://doi.org/10.7759/cureus.1184; Drescher, J., A. Schwartz, F. Casoy, et al. 2016. “The Growing Regulation of Conversion Therapy.” Journal of Medical Regulation 102 (2): 7-12. https://doi.org/10.30770/2572-1852-102.2.7; Stroumsa, D. 2014. “The State of Transgender Health Care: Policy, Law, and Medical Frameworks.” American Journal of Public Health. 104 (3): e31-8. https://doi.org/10.2105/AJPH.2013.301789. [15] Stepanikova, I., and G. R. Oates. 2017. “Perceived Discrimination and Privilege in Health Care: The Role of Socioeconomic Status and Race.” American Journal of Preventative Medicine. 52 (1s1): S86-s94. https://doi.org/10.1016/j.amepre.2016.09.024; Swartz, K. “Health Care for the Poor: For Whom, What Care, and Whose Responsibility?” In Cancian, M., and S. Danziger (Eds.). Changing Poverty, Changing Policies (New York: Russell Sage Foundation Press, 2009), 69-74. [16] Meghani, S. H., E. Byun, and R. M. Gallagher. 2012. “Time to Take Stock: A Meta-analysis and Systematic Review of Analgesic Treatment Disparities for Pain in the United States.” Pain Medicine 13 (2): 150-74. https://doi.org/10.1111/j.1526-4637.2011.01310.x; Williams, D. R., and T. D. Rucker. 2000. “Understanding and Addressing Racial Disparities in Health Care.” Health Care Financing Review 21 (4): 75-90. https://scholar.harvard.edu/davidrwilliams/dwilliam/publications/understanding-and-addressing-racial-disparities-health. [17] Hoffman, K. M., S. Trawalter, J. R. Axt, and M. N. Oliver. 2016. “Racial Bias in Pain assessment and treatment recommendations, and false beliefs about biological Differences Between Blacks and Whites.” PNAS 113 (16): 4296-4301. https://doi.org/10.1073/pnas.1516047113. [18] Pacheco, C. M., S. M. Daley, T. Brown, M. Filipp, K. A. Greiner, and C. M. Daley. 2013. “Moving Forward: Breaking the Cycle of Mistrust Between American Indians and Researchers.” American Journal of Public Health. 103 (12): 2152-9. https://doi.org/10.2105/AJPH.2013.301480. [19] Velasco-Mondragon, E., A. Jimenez, A. G. Palladino-Davis, D. Davis, and J. A. Escamilla-Cejudo. 2016. “Hispanic Health in the USA: A Scoping Review of the Literature.” Public Health Reviews 37:31. https://doi.org/10.1186/s40985-016-0043-2. [20] Cameron, K. A., J. Song, L. M. Manheim, and D. D. Dunlop. 2010. “Gender Disparities in Health and Healthcare Use Among Older Adults.” Journal of Women’s Health (Larchmt) 19 (9): 1643-50. https://doi.org/10.1089/jwh.2009.1701. [21] Bierman, A. S. 2007. “Sex Matters: Gender Disparities in Quality and Outcomes of Care. Canadian Medical Association Journal 177 (12): 1520-1. https://doi.org/10.1503/cmaj.071541; Fowler, R. A., S. Sabur, P. Li, et al. 2007. “Sex-and Age-based Differences in the Delivery and Outcomes of Critical Care. Canadian Medical Association Journal 177 (12): 1513-9. https://doi.org/10.1503/cmaj.071112. [22] McLaughlin, D. K., and C. S. Stokes. 2002. “Income Inequality and Mortality in US Counties: Does Minority Racial Concentration Matter?” American Journal of Public Health 92 (1): 99-104. https://doi.org/.10.2105/ajph.92.1.99; Shea, S., J. Lima, A. Diez-Roux, N. W. Jorgensen, and R. L. McClelland. 2016. “Socioeconomic Status and Poor Health Outcome at 10 years of Follow-up in the Multi-ethnic Study of Atherosclerosis.” PLoS One 11 (11): e0165651. https://doi.org/10.1371/journal.pone.0165651. [23] Han, X., K. T. Call, J. K. Pintor, G. Alarcon-Espinoza, and A. B. Simon. 2015. “Reports of Insurance-based Discrimination in Health care and its Association with Access to Care.” American Journal of Public Health 105 Suppl 3 (Suppl 3): S517-25. https://doi.org/10.2105/AJPH.2015.302668. [24] Aldridge, R. W., D. Menezes, D. Lewer, et al. 2019. “Causes of Death Among Homeless People: A Population-based Cross-sectional Study of Linked Hospitalization and Mortality Data in England.” Wellcome Open Research 4:49. https://doi.org/10.12688/wellcomeopenres.15151.1. [25] Richardson, E. T., M. M. Malik, W. A. Darity Jr., et al. 2021. “Reparations for Black American Descendants of Persons Enslaved in the U.S. and their Potential Impact on SARS-CoV-2 Transmission.” Social Science and Medicine 276: 113741. https://doi.org/10.1016/j.socscimed.2021.113741. [26] Wispelwey, B., and M. Morse. 2021. “An Antiracist Agenda for Medicine.” Boston Review. http://bostonreview.net/science-nature-race/bram-wispelwey-michelle-morse-antiracist-agenda-medicine. [27] Johnson, S. F., A. Ojo, and H. J. Warraich. 2021. “Academic Health Centers’ Antiracism Strategies Must Extend to their Business Practices.” Annals of Internal Medicine 174 (2): 254-5. https://doi.org/10.7326/M20-6203; Golub, M., N. Calman, C. Ruddock, et al. 2011. “A Community Mobilizes to End Medical Apartheid.” Progress in Community Health Partnerships: Research, Education, and Action 5 (3): 317-25. https://doi.org/10.1353/cpr.2011.0041. [28] New York State Bar Association. 2020. “New York State Bar Association House of Delegates: Revised COVID-19 Resolutions.” https://nysba.org/app/uploads/2020/10/Final-Health-Law-Section-COVID-19-Resolutions_10-8-20-1-1.pdf. [29] Egede, L. E. 2006. “Race, Ethnicity, Culture, and Disparities in Health Care.” Journal of General Internal Medicine 21 (6): 667-669. https://doi.org/10.1111%2Fj.1525-1497.2006.0512.x

Yaşadığımız çağda meydana gelen teknolojik gelişmeler avantajlarının yanısıra bazı dezavantajları da beraberinde getirmiştir. Otomasyon sistemlerinin yaygınlaşması bu sistemleri kullanan tüm kesimleri etkilemiştir. Bu etkilerden birisi de stresin alt boyutu olarak tanımlanan ve son yıllarda iş yaşamında ciddi problemlere yol açan ‘teknostres’tir. Teknostres, çok sayıda bilgisayar sistemiyle çalışmanın ve bu sistemler ile kişisel yaşamın, kuruluşun ve kullanıcıların taleplerini gerçekleştirirken oluşan kaygı veya zihinsel baskı hissi olarak adlandırılmaktadır. Teknostresin olumsuz etkileri; hem kütüphane personeli hem de kullanıcılar için teknoloji tabanlı eğitim ve öğretim, teknolojiye karşı olumlu bir tutum geliştirmek, yeterli ekipman ve teknik destek sağlamak, daha ergonomik çalışma ortamı sağlamak, teknolojiyi kullanırken düzenli molalar vermek, çoklu görevden kaçınmak, stres yönetimi eğitimi, etkili zaman yönetimi ve düzenli fiziksel egzersiz ve meditasyon yapmak vb. çözüm yolları ile azaltılabilir. Bu çalışmanın amacı teknostres ile verimlilik arasındaki ilişkiyi ele almak, teknostresin nedenlerini ve kütüphaneciler üzerindeki etkilerini örgütsel verimlilik açısından incelemek ve teknostres yönetimine ilişkin önerilerde bulunarak alan yazına kavramsal açıdan katkı sağlamaya çalışmaktır. Betimleme yöntemi kullanılan çalışma kuramsal niteliktedir. Kaynakça Aghwotu, P. T. ve Owajeme, O. J. (2010). Technostress: Causes, symptoms and coping strategies among librarians in university libraries. Educational Research, 1(12), 713-720. doi:http://www.interesjournals.org/ER Ahmad, U. N. ve Amin, S. M. (2012). The dimensions of technostress among academic librarians. Procedia – Social and Behavioral Sciences. 65, 266-271. doi: 10.1016/j.sbspro.2012.11.121 Akınoğlu, H. F. (1993). Teknostres. Türk Kütüphaneciliği, 7(3), 159-173. Erişim adresi: http://www.tk.org.tr/index.php/tk/article/view/1388 Al-Qallaf, C. L. (2006). Librarians and technology in aca­demic and research libraries in Kuwait: Perceptions and effects. Libri, 56(3), 168-179. Erişim adresi: https://doi.org/10.1515/ libr.2006.168 Arnetz, B. B. ve Wiholm, C. (1997). Technological stress: Psychophysiological symptoms in modern offices. Journal of Psychosomatic Research, 43(1), 35-42. Erişim adresi: https://doi.org/10.1016/S0022-3999(97)00083-4. Ayyagari, R. (2007). What and why of technostress: Technology antecedents and implications (Doktora tezi). Amerika Birleşik Devletleri: Clemson Universitesi. Erişim adresi: https://tigerprints.clemson.edu/cgi/viewcontent.cgi?article=1133&context=all_dissert Ayyagari, R., Grover, V. ve Purvis, R . (2011). Technostress: Technological antecedents and implications. MIS Quarterly, 35(4), 831-858. Erişim adresi: https://www.jstor.org/stable/41409963 Bondanini, G., Giorgi, G. , Ariza-Montes, A. ve Vega-Munoz, A. ve Andreucci-Annunziata, P. (2020). Technostress dark side of technology in the workplace: A scientometric analysis. International Journal of Environmental Research and Public Health, 17(21), 1-25. doi:10.3390/ijerph17218013 Brod, C. (1984). Technostress: The Human Cost of the Computer Revolution. Addison-Wesley Publishing Company, Reading. Champion, S. (1998, Nov). Technostress: Technology’s Toll. School Library Journal, 44(1), 48-51. Chauhan, K. (2018). The influence of technostress on productivity among OPJGU library professionals. Indian Journal of Library and Information Science, 12(2), 83-88. Erişim adresi: http://dx.doi.org/10.21088/ijlis.0973.9548.12218.2 Clark, K. ve Kalin, S. (1996). Technostressed out? How to cope in the digital age. Library Journal, 30-32. Clute, R. (1998). Technostress: A content analysis [Yayımlanmamış Yüksek Lisans Tezi]. Ohio, USA: Kent State University. Erişim adresi: https://files.eric.ed.gov/fulltext/ED423911.pdf Çınar, K. (2017). Potansiyel stres kaynaklarının üniversite kütüphanecilerinin çalışma yaşamı kalitesi üzerindeki etkisi. İstanbul örneği (Yayımlanmamış Yüksek Lisans Tezi). İstanbul: İstanbul Üniversitesi Sosyal Bilimler Enstitüsü. Çoklar, A. N. ve Şahin, Y. L. (2011). Technostress levels of social network users based on ICTs in Turkey. European Journal of Social Sciences,, 23(2), 171-172. Erişim adresi: https://www.tecnostress.it/wp-content/uploads/2011/09/Technostress-in-Social-Turkey.pdf Das, S. (2019). The status and impact of technostress on library professionals: essionals: A study among the professionals of the selected Private College Libraries in North Bengal. Library Philosophy and Practice (e-journal)(3642). Erişim adresi: https://digitalcommons.unl.edu/libphilprac/3642 Davis-Millis, N. (1998). Technostress and the Organization: A Manager's Guide to Survival in the Information Age. 67th Annual Meeting of the Music Library Association, 14 February 1998. Boston, Massachusetts. Erişim adresi: https://web.mit.edu/ninadm/www/mla.html

Background “The sense of taste,” write Nelson and colleagues in a 2002 issue of Nature, “provides animals with valuable information about the nature and quality of food. Mammals can recognize and respond to a diverse repertoire of chemical entities, including sugars, salts, acids and a wide range of toxic substances” (199). The authors go on to argue that several amino acids—the building blocks of proteins—taste delicious to humans and that “having a taste pathway dedicated to their detection probably had significant evolutionary implications”. They imply, but do not specify, that the evolutionary implications are positive. This may be the case with some amino acids, but contemporary tastes, and changes in them, are far from universally beneficial. Indeed, this article argues that modern food production shapes and distorts human taste with significant implications for health and wellbeing. Take the western taste for fried chipped potatoes, for example. According to Schlosser in Fast Food Nation, “In 1960, the typical American ate eighty-one pounds of fresh potatoes and about four pounds of frozen french fries. Today [2002] the typical American eats about forty-nine pounds of fresh potatoes every year—and more than thirty pounds of frozen french fries” (115). Nine-tenths of these chips are consumed in fast food restaurants which use mass-manufactured potato-based frozen products to provide this major “foodservice item” more quickly and cheaply than the equivalent dish prepared from raw ingredients. These choices, informed by human taste buds, have negative evolutionary implications, as does the apparently long-lasting consumer preference for fried goods cooked in trans-fats. “Numerous foods acquire their elastic properties (i.e., snap, mouth-feel, and hardness) from the colloidal fat crystal network comprised primarily of trans- and saturated fats. These hardstock fats contribute, along with numerous other factors, to the global epidemics related to metabolic syndrome and cardiovascular disease,” argues Michael A. Rogers (747). Policy makers and public health organisations continue to compare notes internationally about the best ways in which to persuade manufacturers and fast food purveyors to reduce the use of these trans-fats in their products (L’Abbé et al.), however, most manufacturers resist. Hank Cardello, a former fast food executive, argues that “many products are designed for ‘high hedonic value’, with carefully balanced combinations of salt, sugar and fat that, experience has shown, induce people to eat more” (quoted, Trivedi 41). Fortunately for the manufactured food industry, salt and sugar also help to preserve food, effectively prolonging the shelf life of pre-prepared and packaged goods. Physiological Factors As Glanz et al. discovered when surveying 2,967 adult Americans, “taste is the most important influence on their food choices, followed by cost” (1118). A person’s taste is to some extent an individual response to food stimuli, but the tongue’s taste buds respond to five basic categories of food: salty, sweet, sour, bitter, and umami. ‘Umami’ is a Japanese word indicating “delicious savoury taste” (Coughlan 11) and it is triggered by the amino acid glutamate. Japanese professor Kikunae Ikeda identified glutamate while investigating the taste of a particular seaweed which he believed was neither sweet, sour, bitter, or salty. When Ikeda combined the glutamate taste essence with sodium he formed the food additive sodium glutamate, which was patented in 1908 and subsequently went into commercial production (Japan Patent Office). Although individual, a person’s taste preferences are by no means fixed. There is ample evidence that people’s tastes are being distorted by modern food marketing practices that process foods to make them increasingly appealing to the average palate. In particular, this industrialisation of food promotes the growth of a snack market driven by salty and sugary foods, popularly constructed as posing a threat to health and wellbeing. “[E]xpanding waistlines [are] fuelled by a boom in fast food and a decline in physical activity” writes Stark, who reports upon the 2008 launch of a study into Australia’s future ‘fat bomb’. As Deborah Lupton notes, such reports were a particular feature of the mid 2000s when: intense concern about the ‘obesity epidemic’ intensified and peaked. Time magazine named 2004 ‘The Year of Obesity’. That year the World Health Organization’s Global Strategy on Diet, Physical Activity and Health was released and the [US] Centers for Disease Control predicted that a poor diet and lack of exercise would soon claim more lives than tobacco-related disease in the United States. (4) The American Heart Association recommends eating no more than 1500mg of salt per day (Hamzelou 11) but salt consumption in the USA averages more than twice this quantity, at 3500mg per day (Bernstein and Willett 1178). In the UK, a sustained campaign and public health-driven engagement with food manufacturers by CASH—Consensus Action on Salt and Health—resulted in a reduction of between 30 and 40 percent of added salt in processed foods between 2001 and 2011, with a knock-on 15 percent decline in the UK population’s salt intake overall. This is the largest reduction achieved by any developed nation (Brinsden et al.). “According to the [UK’s] National Institute for Health and Care Excellence (NICE), this will have reduced [UK] stroke and heart attack deaths by a minimum of 9,000 per year, with a saving in health care costs of at least £1.5bn a year” (MacGregor and Pombo). Whereas there has been some success over the past decade in reducing the amount of salt consumed, in the Western world the consumption of sugar continues to rise, as a graph cited in the New Scientist indicates (O’Callaghan). Regular warnings that sugar is associated with a range of health threats and delivers empty calories devoid of nutrition have failed to halt the increase in sugar consumption. Further, although some sugar is a natural product, processed foods tend to use a form invented in 1957: high-fructose corn syrup (HFCS). “HFCS is a gloopy solution of glucose and fructose” writes O’Callaghan, adding that it is “as sweet as table sugar but has typically been about 30% cheaper”. She cites Serge Ahmed, a French neuroscientist, as arguing that in a world of food sufficiency people do not need to consume more, so they need to be enticed to overeat by making food more pleasurable. Ahmed was part of a team that ran an experiment with cocaine-addicted rats, offering them a mutually exclusive choice between highly-sweetened water and cocaine: Our findings clearly indicate that intense sweetness can surpass cocaine reward, even in drug-sensitized and -addicted individuals. We speculate that the addictive potential of intense sweetness results from an inborn hypersensitivity to sweet tastants. In most mammals, including rats and humans, sweet receptors evolved in ancestral environments poor in sugars and are thus not adapted to high concentrations of sweet tastants. The supranormal stimulation of these receptors by sugar-rich diets, such as those now widely available in modern societies, would generate a supranormal reward signal in the brain, with the potential to override self-control mechanisms and thus lead to addiction. (Lenoir et al.) The Tongue and the Brain One of the implications of this research about the mammalian desire for sugar is that our taste for food is about more than how these foods actually taste in the mouth on our tongues. It is also about the neural response to the food we eat. The taste of French fries thus also includes that “snap, mouth-feel, and hardness” and the “colloidal fat crystal network” (Rogers, “Novel Structuring” 747). While there is no taste receptor for fats, these nutrients have important effects upon the brain. Wang et al. offered rats a highly fatty, but palatable, diet and allowed them to eat freely. 33 percent of the calories in the food were delivered via fat, compared with 21 percent in a normal diet. The animals almost doubled their usual calorific intake, both because the food had a 37 percent increased calorific content and also because the rats ate 47 percent more than was standard (2786). The research team discovered that in as little as three days the rats “had already lost almost all of their ability to respond to leptin” (Martindale 27). Leptin is a hormone that acts on the brain to communicate feelings of fullness, and is thus important in assisting animals to maintain a healthy body weight. The rats had also become insulin resistant. “Severe resistance to the metabolic effects of both leptin and insulin ensued after just 3 days of overfeeding” (Wang et al. 2786). Fast food restaurants typically offer highly palatable, high fat, high sugar, high salt, calorific foods which can deliver 130 percent of a day’s recommended fat intake, and almost a day’s worth of an adult man’s calories, in one meal. The impacts of maintaining such a diet over a comparatively short time-frame have been recorded in documentaries such as Super Size Me (Spurlock). The after effects of what we widely call “junk food” are also evident in rat studies. Neuroscientist Paul Kenny, who like Ahmed was investigating possible similarities between food- and cocaine-addicted rats, allowed his animals unlimited access to both rat ‘junk food’ and healthy food for rats. He then changed their diets. “The rats with unlimited access to junk food essentially went on a hunger strike. ‘It was as if they had become averse to healthy food’, says Kenny. It took two weeks before the animals began eating as much [healthy food] as those in the control group” (quoted, Trivedi 40). Developing a taste for certain food is consequently about much more than how they taste in the mouth; it constitutes an individual’s response to a mixture of taste, hormonal reactions and physiological changes. Choosing Health Glanz et al. conclude their study by commenting that “campaigns attempting to change people’s perception of the importance of nutrition will be interpreted in terms of existing values and beliefs. A more promising strategy might be to stress the good taste of healthful foods” (1126). Interestingly, this is the strategy already adopted by some health-focused cookbooks. I have 66 cookery books in my kitchen. None of ten books sampled from the five spaces in which these books are kept had ‘taste’ as an index entry, but three books had ‘taste’ in their titles: The Higher Taste, Taste of Life, and The Taste of Health. All three books seek to promote healthy eating, and they all date from the mid-1980s. It might be that taste is not mentioned in cookbook indexes because it is a sine qua non: a focus upon taste is so necessary and fundamental to a cookbook that it goes without saying. Yet, as the physiological evidence makes clear, what we find palatable is highly mutable, varying between people, and capable of changing significantly in comparatively short periods of time. The good news from the research studies is that the changes wrought by high salt, high sugar, high fat diets need not be permanent. Luciano Rossetti, one of the authors on Wang et al’s paper, told Martindale that the physiological changes are reversible, but added a note of caution: “the fatter a person becomes the more resistant they will be to the effects of leptin and the harder it is to reverse those effects” (27). Morgan Spurlock’s experience also indicates this. In his case it took the actor/director 14 months to lose the 11.1 kg (13 percent of his body mass) that he gained in the 30 days of his fast-food-only experiment. Trivedi was more fortunate, stating that, “After two weeks of going cold turkey, I can report I have successfully kicked my ice cream habit” (41). A reader’s letter in response to Trivedi’s article echoes this observation. She writes that “the best way to stop the craving was to switch to a diet of vegetables, seeds, nuts and fruits with a small amount of fish”, adding that “cravings stopped in just a week or two, and the diet was so effective that I no longer crave junk food even when it is in front of me” (Mackeown). Popular culture indicates a range of alternative ways to resist food manufacturers. In the West, there is a growing emphasis on organic farming methods and produce (Guthman), on sl called Urban Agriculture in the inner cities (Mason and Knowd), on farmers’ markets, where consumers can meet the producers of the food they eat (Guthrie et al.), and on the work of advocates of ‘real’ food, such as Jamie Oliver (Warrin). Food and wine festivals promote gourmet tourism along with an emphasis upon the quality of the food consumed, and consumption as a peak experience (Hall and Sharples), while environmental perspectives prompt awareness of ‘food miles’ (Weber and Matthews), fair trade (Getz and Shreck) and of land degradation, animal suffering, and the inequitable use of resources in the creation of the everyday Western diet (Dare, Costello and Green). The burgeoning of these different approaches has helped to stimulate a commensurate growth in relevant disciplinary fields such as Food Studies (Wessell and Brien). One thing that all these new ways of looking at food and taste have in common is that they are options for people who feel they have the right to choose what and when to eat; and to consume the tastes they prefer. This is not true of all groups of people in all countries. Hiding behind the public health campaigns that encourage people to exercise and eat fresh fruit and vegetables are the hidden “social determinants of health: The conditions in which people are born, grow, live, work and age, including the health system” (WHO 45). As the definitions explain, it is the “social determinants of health [that] are mostly responsible for health iniquities” with evidence from all countries around the world demonstrating that “in general, the lower an individual’s socioeconomic position, the worse his or her health” (WHO 45). For the comparatively disadvantaged, it may not be the taste of fast food that attracts them but the combination of price and convenience. If there is no ready access to cooking facilities, or safe food storage, or if a caregiver is simply too time-poor to plan and prepare meals for a family, junk food becomes a sensible choice and its palatability an added bonus. For those with the education, desire, and opportunity to break free of the taste for salty and sugary fats, however, there are a range of strategies to achieve this. There is a persuasive array of evidence that embracing a plant-based diet confers a multitude of health benefits for the individual, for the planet and for the animals whose lives and welfare would otherwise be sacrificed to feed us (Green, Costello and Dare). Such a choice does involve losing the taste for foods which make up the lion’s share of the Western diet, but any sense of deprivation only lasts for a short time. The fact is that our sense of taste responds to the stimuli offered. It may be that, notwithstanding the desires of Jamie Oliver and the like, a particular child never will never get to like broccoli, but it is also the case that broccoli tastes differently to me, seven years after becoming a vegan, than it ever did in the years in which I was omnivorous. When people tell me that they would love to adopt a plant-based diet but could not possibly give up cheese, it is difficult to reassure them that the pleasure they get now from that specific cocktail of salty fats will be more than compensated for by the sheer exhilaration of eating crisp, fresh fruits and vegetables in the future. Conclusion For decades, the mass market food industry has tweaked their products to make them hyper-palatable and difficult to resist. They do this through marketing experiments and consumer behaviour research, schooling taste buds and brains to anticipate and relish specific cocktails of sweet fats (cakes, biscuits, chocolate, ice cream) and salty fats (chips, hamburgers, cheese, salted nuts). They add ingredients to make these products stimulate taste buds more effectively, while also producing cheaper items with longer life on the shelves, reducing spoilage and the complexity of storage for retailers. Consumers are trained to like the tastes of these foods. Bitter, sour, and umami receptors are comparatively under-stimulated, with sweet, salty, and fat-based tastes favoured in their place. Western societies pay the price for this learned preference in high blood pressure, high cholesterol, diabetes, and obesity. 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Pentingnya membangun OCB tidak lepas dari komitmen karyawan dalam organisasi. Komitmen karyawan akan mendorong terciptanya OCB dan tanpa adanya kontrol yang baik dalam pemberian kompensasi yang sesuai dengan hasil kerja tentunya memperlambat kerja pegawai. Penelitian ini bertujuan untuk menguji dan menganalisis pengaruh kompensasi dan komitmen organisasi terhadap kepuasan kerja dan OCB. Jumlah responden dalam penelitian ini berjumlah 86 orang. Pengumpulan data diperoleh dengan kuesioner menggunakan skala likert. Metode analisis data menggunakan Path Analysis. Hasil penelitian diperoleh bahwa kompensasi berpengaruh positif dan signifikan terhadap kepuasan kerja dan Kepuasan kerja berpengaruh positif dan signifikan terhadap OCB. Kata Kunci : Komitmen Organisasi, Kompensasi, Kepuasan kerja dan OCBDAFTAR PUSTAKA Bangun, Wilson. (2012). Manajemen Sumber Daya Manusia. Erlangga. Jakarta. Bernardin, H. John, & Joyce E.A Russel. (2003). 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Introduction The academic area known as food studies—incorporating elements from disciplines including anthropology, folklore, history, sociology, gastronomy, and cultural studies as well as a range of multi-disciplinary approaches—asserts that cooking and eating practices are less a matter of nutrition (maintaining life by absorbing nutrients from food) and more a personal or group expression of various social and/or cultural actions, values or positions. The French philosopher, Michel de Certeau agrees, arguing, moreover, that there is an urgency to name and unpick (what he identifies as) the “minor” practices, the “multifarious and silent reserve of procedures” of everyday life. Such practices are of crucial importance to all of us, as although seemingly ordinary, and even banal, they have the ability to “organise” our lives (48). Within such a context, the following aims to consider the influence and significance of an important (although largely unstudied) professional figure in rural and regional economic life: the country food preparer variously known as the local chef or cook. Such an approach is obviously framed by the concept of “cultural economy”. This term recognises the convergence, and interdependence, of the spheres of the cultural and the economic (see Scott 335, for an influential discussion on how “the cultural geography of space and the economic geography of production are intertwined”). Utilising this concept in relation to chefs and cooks seeks to highlight how the ways these figures organise (to use de Certeau’s term) the social and cultural lives of those in their communities are embedded in economic practices and also how, in turn, their economic contributions are dependent upon social and cultural practices. This initial mapping of the influence and significance of the rural and regional chef in one rural and regional area, therefore, although necessarily different in approach and content, continues the application of such converged conceptualisations of the cultural and economic as Teema Tairu’s discussion of the social, recreational and spiritual importance of food preparation and consumption by the unemployed in Finland, Guy Redden’s exploration of how supermarket products reflect shared values, and a series of analyses of the cultural significance of individual food products, such as Richard White’s study of vegemite. While Australians, both urban and rural, currently enjoy access to an internationally renowned food culture, it is remarkable to consider that it has only been during the years following the Second World War that these sophisticated and now much emulated ways of eating and cooking have developed. It is, indeed, only during the last half century that Australian eating habits have shifted from largely Anglo-Saxon influenced foods and meals that were prepared and eaten in the home, to the consumption of a wider range of more international and sophisticated foods and meals that are, increasingly, prepared by others and eaten outside the consumer’s residence. While a range of commonly cited influences has prompted this relatively recent revolution in culinary practice—including post-war migration, increasing levels of prosperity, widespread international travel, and the forces of globalisation—some of this change owes a debt to a series of influential individual figures. These tastemakers have included food writers and celebrity chefs; with early exponents including Margaret Fulton, Graham Kerr and Charmaine Solomon (see Brien). The findings of this study suggests that many restaurant chefs, and other cooks, have similarly played, and continue to take, a key role in the lives of not only the, necessarily, limited numbers of individuals who dine in a particular eatery or the other chefs and/or cooks trained in that establishment (Ruhlman, Reach), but also the communities in which they work on a much broader scale. Considering Chefs In his groundbreaking study, A History of Cooks and Cooking, Australian food historian Michael Symons proposes that those who prepare food are worthy of serious consideration because “if ‘we are what we eat’, cooks have not just made our meals, but have also made us. They have shaped our social networks, our technologies, arts and religions” (xi). Writing that cooks “deserve to have their stories told often and well,” and that, moreover, there is a “need to invent ways to think about them, and to revise our views about ourselves in their light” (xi), Symons’s is a clarion call to investigate the role and influence of cooks. Charles-Allen Baker-Clark has explicitly begun to address this lacunae in his Profiles from the Kitchen: What Great Cooks Have Taught Us About Ourselves and Our Food (2006), positing not only how these figures have shaped our relationships with food and eating, but also how these relationships impact on identities, culture and a range of social issues including those of social justice, spirituality and environmental sustainability. With the growing public interest in celebrities, it is perhaps not surprising that, while such research on chefs and/or cooks is still in its infancy, most of the existing detailed studies on individuals focus on famed international figures such as Marie-Antoine Carême (Bernier; Kelly), Escoffier (James; Rachleff; Sanger), and Alexis Soyer (Brandon; Morris; Ray). Despite an increasing number of tabloid “tell-all” surveys of contemporary celebrity chefs, which are largely based on mass media sources and which display little concern for historical or biographical accuracy (Bowyer; Hildred and Ewbank; Simpson; Smith), there have been to date only a handful of “serious” researched biographies of contemporary international chefs such as Julia Child, Alice Waters (Reardon; Riley), and Bernard Loiseux (Chelminski)—the last perhaps precipitated by an increased interest in this chef following his suicide after his restaurant lost one of its Michelin stars. Despite a handful of collective biographical studies of Australian chefs from the later-1980s on (Jenkins; O’Donnell and Knox; Brien), there are even fewer sustained biographical studies of Australian chefs or cooks (Clifford-Smith’s 2004 study of “the supermarket chef,” Bernard King, is a notable exception). Throughout such investigations, as well as in other popular food writing in magazines and cookbooks, there is some recognition that influential chefs and cooks have worked, and continue to work, outside such renowned urban culinary centres as Paris, London, New York, and Sydney. The Michelin starred restaurants of rural France, the so-called “gastropubs” of rural Britain and the advent of the “star-chef”-led country bed and breakfast establishment in Australia and New Zealand, together with the proliferation of farmer’s markets and a public desire to consume locally sourced, and ecologically sustainable, produce (Nabhan), has focused fresh attention on what could be called “the rural/regional chef”. However, despite the above, little attention has focused on the Australian non-urban chef/cook outside of the pages of a small number of key food writing magazines such as Australian Gourmet Traveller and Vogue Entertaining + Travel. Setting the Scene with an Australian Country Example: Armidale and Guyra In 2004, the Armidale-Dumaresq Council (of the New England region, New South Wales, Australia) adopted the slogan “Foodies thrive in Armidale” to market its main city for the next three years. With a population of some 20,000, Armidale’s main industry (in economic terms) is actually education and related services, but the latest Tourist Information Centre’s Dining Out in Armidale (c. 2006) brochure lists some 25 restaurants, 9 bistros and brasseries, 19 cafés and 5 fast food outlets featuring Australian, French, Italian, Mediterranean, Chinese, Thai, Indian and “international” cuisines. The local Yellow Pages telephone listings swell the estimation of the total number of food-providing businesses in the city to 60. Alongside the range of cuisines cited above, a large number of these eateries foreground the use of fresh, local foods with such phrases as “local and regional produce,” “fresh locally grown produce,” “the finest New England ingredients” and locally sourced “New England steaks, lamb and fresh seafood” repeatedly utilised in advertising and other promotional material. Some thirty kilometres to the north along the New England highway, the country town of Guyra, proclaimed a town in 1885, is the administrative and retail centre for a shire of some 2,200 people. Situated at 1,325 metres above sea level, the town is one of the highest in Australia with its main industries those of fine wool and lamb, beef cattle, potatoes and tomatoes. Until 1996, Guyra had been home to a large regional abattoir that employed some 400 staff at the height of its productivity, but rationalisation of the meat processing industry closed the facility, together with its associated pet food processor, causing a downturn in employment, local retail business, and real estate values. Since 2004, Guyra’s economy has, however, begun to recover after the town was identified by the Costa Group as the perfect site for glasshouse grown tomatoes. Perfect, due to its rare combination of cool summers (with an average of less than two days per year with temperatures over 30 degrees celsius), high winter light levels and proximity to transport routes. The result: 3.3 million kilograms of truss, vine harvested, hydroponic “Top of the Range” tomatoes currently produced per annum, all year round, in Guyra’s 5-hectare glasshouse: Australia’s largest, opened in December 2005. What residents (of whom I am one) call the “tomato-led recovery” has generated some 60 new local jobs directly related to the business, and significant flow on effects in terms of the demand for local services and retail business. This has led to substantial rates of renovation and building of new residential and retail properties, and a noticeably higher level of trade flowing into the town. Guyra’s main street retail sector is currently burgeoning and stories of its renewal have appeared in the national press. Unlike many similar sized inland towns, there are only a handful of empty shops (and most of these are in the process of being renovated), and new commercial premises have recently been constructed and opened for business. Although a small town, even in Australian country town terms, Guyra now has 10 restaurants, hotel bistros and cafés. A number of these feature local foods, with one pub’s bistro regularly featuring the trout that is farmed just kilometres away. Assessing the Contribution of Local Chefs and Cooks In mid-2007, a pilot survey to begin to explore the contribution of the regional chef in these two close, but quite distinct, rural and regional areas was sent to the chefs/cooks of the 70 food-serving businesses in Armidale and Guyra that I could identify. Taking into account the 6 returns that revealed a business had closed, moved or changed its name, the 42 replies received represented a response rate of 65.5per cent (or two thirds), representatively spread across the two towns. Answers indicated that the businesses comprised 18 restaurants, 13 cafés, 6 bistro/brasseries, 1 roadhouse, 1 takeaway/fast food and 3 bed and breakfast establishments. These businesses employed 394 staff, of whom 102 were chefs and/cooks, or 25.9 per cent of the total number of staff then employed by these establishments. In answer to a series of questions designed to ascertain the roles played by these chefs/cooks in their local communities, as well as more widely, I found a wide range of inputs. These chefs had, for instance, made a considerable contribution to their local economies in the area of fostering local jobs and a work culture: 40 (95 per cent) had worked with/for another local business including but not exclusively food businesses; 30 (71.4 per cent) had provided work experience opportunities for those aspiring to work in the culinary field; and 22 (more than half) had provided at least one apprenticeship position. A large number had brought outside expertise and knowledge with them to these local areas, with 29 (69 per cent) having worked in another food business outside Armidale or Guyra. In terms of community building and sustainability, 10 (or almost a quarter) had assisted or advised the local Council; 20 (or almost half) had worked with local school children in a food-related way; 28 (two thirds) had helped at least one charity or other local fundraising group. An extra 7 (bringing the cumulative total to 83.3 per cent) specifically mentioned that they had worked with/for the local gallery, museum and/or local history group. 23 (more than half) had been involved with and/or contributed to a local festival. The question of whether they had “contributed anything else important, helpful or interesting to the community” elicited the following responses: writing a food or wine column for the local paper (3 respondents), delivering TAFE teacher workshops (2 respondents), holding food demonstrations for Rotary and Lions Clubs and school fetes (5 respondents), informing the public about healthy food (3 respondents), educating the public about environmental issues (2 respondents) and working regularly with Meals on Wheels or a similar organisation (6 respondents, or 14.3 per cent). One respondent added his/her work as a volunteer driver for the local ambulance transport service, the only non-food related response to this question. Interestingly, in line with the activity of well-known celebrity chefs, in addition to the 3 chefs/cooks who had written a food or wine column for the local newspaper, 11 respondents (more than a quarter of the sample) had written or contributed to a cookbook or recipe collection. One of these chefs/cooks, moreover, reported that he/she produced a weblog that was “widely read”, and also contributed to international food-related weblogs and websites. In turn, the responses indicated that the (local) communities—including their governing bodies—also offer some support of these chefs and cooks. Many respondents reported they had been featured in, or interviewed and/or photographed for, a range of media. This media comprised the following: the local newspapers (22 respondents, 52.4 per cent), local radio stations (19 respondents, 45.2 per cent), regional television stations (11 respondents, 26.2 per cent) and local websites (8 respondents, 19 per cent). A number had also attracted other media exposure. This was in the local, regional area, especially through local Council publications (31 respondents, 75 per cent), as well as state-wide (2 respondents, 4.8 per cent) and nationally (6 respondents, 14.3 per cent). Two of these local chefs/cooks (or 4.8 per cent) had attracted international media coverage of their activities. It is clear from the above that, in the small area surveyed, rural and regional chefs/cooks make a considerable contribution to their local communities, with all the chefs/cooks who replied making some, and a number a major, contribution to those communities, well beyond the requirements of their paid positions in the field of food preparation and service. The responses tendered indicate that these chefs and cooks contributed regularly to local public events, institutions and charities (with a high rate of contribution to local festivals, school programs and local charitable activities), and were also making an input into public education programs, local cultural institutions, political and social debates of local importance, as well as the profitability of other local businesses. They were also actively supporting not only the future of the food industry as a whole, but also the viability of their local communities, by providing work experience opportunities and taking on local apprentices for training and mentorship. Much more than merely food providers, as a group, these chefs and cooks were, it appears, also operating as food historians, public intellectuals, teachers, activists and environmentalists. They were, moreover, operating as content producers for local media while, at the same time, acting as media producers and publishers. Conclusion The terms “chef” and “cook” can be diversely defined. All definitions, however, commonly involve a sense of professionalism in food preparation reflecting some specialist knowledge and skill in the culinary arts, as well as various levels of creativity, experience and responsibility. In terms of the specific duties that chefs and professional cooks undertake every day, almost all publications on the subject deal specifically with workplace related activities such as food and other supply ordering, staff management, menu planning and food preparation and serving. This is constant across culinary textbooks (see, for instance, Culinary Institute of America 2002) and more discursive narratives about the professional chef such as the bestselling autobiographical musings of Anthony Bourdain, and Michael Ruhlman’s journalistic/biographical investigations of US chefs (Soul; Reach). An alternative preliminary examination, and categorisation, of the roles these professionals play outside their kitchens reveals, however, a much wider range of community based activities and inputs than such texts suggest. It is without doubt that the chefs and cooks who responded to the survey discussed above have made, and are making, a considerable contribution to their local New England communities. It is also without doubt that these contributions are of considerable value, and valued by, those country communities. Further research will have to consider to what extent these contributions, and the significance and influence of these chefs and cooks in those communities are mirrored, or not, by other country (as well as urban) chefs and cooks, and their communities. Acknowledgements An earlier version of this paper was presented at the Engaging Histories: Australian Historical Association Regional Conference, at the University of New England, September 2007. I would like to thank the session’s participants for their insightful comments on that presentation. A sincere thank you, too, to the reviewers of this article, whose suggestions assisted my thinking on this piece. Research to complete this article was carried out whilst a Visiting Fellow with the Research School of Humanities, the Australian National University. References Armidale Tourist Information Centre. Dining Out in Armidale [brochure]. Armidale: Armidale-Dumaresq Council, c. 2006. Baker-Clark, C. A. 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Introduction: Technology EnthusiasmEnthusiasts are people who have a passion, keenness, dedication or zeal for a particular activity or hobby. Today, there are enthusiasts for almost everything, from genealogy, costume dramas, and country houses, to metal detectors, coin collecting, and archaeology. But to be described as an enthusiast is not necessarily a compliment. Historically, the term “enthusiasm” was first used in England in the early seventeenth century to describe “religious or prophetic frenzy among the ancient Greeks” (Hanks, n.p.). This frenzy was ascribed to being possessed by spirits sent not only by God but also the devil. During this period, those who disobeyed the powers that be or claimed to have a message from God were considered to be enthusiasts (McLoughlin).Enthusiasm retained its religious connotations throughout the eighteenth century and was also used at this time to describe “the tendency within the population to be swept by crazes” (Mee 31). However, as part of the “rehabilitation of enthusiasm,” the emerging middle-classes adopted the word to characterise the intensity of Romantic poetry. The language of enthusiasm was then used to describe the “literary ideas of affect” and “a private feeling of religious warmth” (Mee 2 and 34). While the notion of enthusiasm was embraced here in a more optimistic sense, attempts to disassociate enthusiasm from crowd-inciting fanaticism were largely unsuccessful. As such enthusiasm has never quite managed to shake off its pejorative connotations.The 'enthusiasm' discussed in this paper is essentially a personal passion for technology. It forms part of a longer tradition of historical preservation in the United Kingdom and elsewhere in the world. From preserved railways to Victorian pumping stations, people have long been fascinated by the history of technology and engineering; manifesting their enthusiasm through their nostalgic longings and emotional attachment to its enduring material culture. Moreover, enthusiasts have been central to the collection, conservation, and preservation of this particular material record. Technology enthusiasm in this instance is about having a passion for the history and material record of technological development, specifically here industrial archaeology. Despite being a pastime much participated in, technology enthusiasm is relatively under-explored within the academic literature. For the most part, scholarship has tended to focus on the intended users, formal spaces, and official narratives of science and technology (Adas, Latour, Mellström, Oldenziel). In recent years attempts have been made to remedy this imbalance, with researchers from across the social sciences examining the position of hobbyists, tinkerers and amateurs in scientific and technical culture (Ellis and Waterton, Haring, Saarikoski, Takahashi). Work from historians of technology has focussed on the computer enthusiast; for example, Saarikoski’s work on the Finnish personal computer hobby:The definition of the computer enthusiast varies historically. Personal interest, pleasure and entertainment are the most significant factors defining computing as a hobby. Despite this, the hobby may also lead to acquiring useful knowledge, skills or experience of information technology. Most often the activity takes place outside working hours but can still have links to the development of professional expertise or the pursuit of studies. In many cases it takes place in the home environment. On the other hand, it is characteristically social, and the importance of friends, clubs and other communities is greatly emphasised.In common with a number of other studies relating to technical hobbies, for example Takahashi who argues tinkerers were behind the advent of the radio and television receiver, Saarikoski’s work focuses on the role these users played in shaping the technology in question. The enthusiasts encountered in this paper are important here not for their role in shaping the technology, but keeping technological heritage alive. As historian of technology Haring reminds us, “there exist alternative ways of using and relating to technology” (18). Furthermore, the sociological literature on audiences (Abercrombie and Longhurst, Ang), fans (Hills, Jenkins, Lewis, Sandvoss) and subcultures (Hall, Hebdige, Schouten and McAlexander) has also been extended in order to account for the enthusiast. In Abercrombie and Longhurst’s Audiences, the authors locate ‘the enthusiast’ and ‘the fan’ at opposing ends of a continuum of consumption defined by questions of specialisation of interest, social organisation of interest and material productivity. Fans are described as:skilled or competent in different modes of production and consumption; active in their interactions with texts and in their production of new texts; and communal in that they construct different communities based on their links to the programmes they like. (127 emphasis in original) Based on this definition, Abercrombie and Longhurst argue that fans and enthusiasts differ in three ways: (1) enthusiasts’ activities are not based around media images and stars in the way that fans’ activities are; (2) enthusiasts can be hypothesized to be relatively light media users, particularly perhaps broadcast media, though they may be heavy users of the specialist publications which are directed towards the enthusiasm itself; (3) the enthusiasm would appear to be rather more organised than the fan activity. (132) What is striking about this attempt to differentiate between the fan and the enthusiast is that it is based on supposition rather than the actual experience and observation of enthusiasm. It is here that the ethnographic account of enthusiasm presented in this paper and elsewhere, for example works by Dannefer on vintage car culture, Moorhouse on American hot-rodding and Fuller on modified-car culture in Australia, can shed light on the subject. My own ethnographic study of groups with a passion for telecommunications heritage, early British computers and industrial archaeology takes the discussion of “technology enthusiasm” further still. Through in-depth interviews, observation and textual analysis, I have examined in detail the formation of enthusiast societies and their membership, the importance of the material record to enthusiasts (particularly at home) and the enthusiastic practices of collecting and hoarding, as well as the figure of the technology enthusiast in the public space of the museum, namely the Science Museum in London (Geoghegan). In this paper, I explore the culture of enthusiasm for the industrial past through the example of the Greater London Industrial Archaeology Society (GLIAS). Focusing on industrial sites around London, GLIAS meet five or six times a year for field visits, walks and a treasure hunt. The committee maintain a website and produce a quarterly newsletter. The title of my paper, “If you can walk down the street and recognise the difference between cast iron and wrought iron, the world is altogether a better place,” comes from an interview I conducted with the co-founder and present chairman of GLIAS. He was telling me about his fascination with the materials of industrialisation. In fact, he said even concrete is sexy. Some call it a hobby; others call it a disease. But enthusiasm for industrial archaeology is, as several respondents have themselves identified, “as insidious in its side effects as any debilitating germ. It dictates your lifestyle, organises your activity and decides who your friends are” (Frow and Frow 177, Gillespie et al.). Through the figure of the industrial archaeology enthusiast, I discuss in this paper what it means to be enthusiastic. I begin by reflecting on the development of this specialist subject area. I go on to detail the formation of the Society in the late 1960s, before exploring the Society’s fieldwork methods and some of the other activities they now engage in. I raise questions of enthusiast and professional knowledge and practice, as well as consider the future of this particular enthusiasm.Defining Industrial ArchaeologyThe practice of 'industrial archaeology' is much contested. For a long time, enthusiasts and professional archaeologists have debated the meaning and use of the term (Palmer). On the one hand, there are those interested in the history, preservation, and recording of industrial sites. For example the grandfather figures of the subject, namely Kenneth Hudson and Angus Buchanan, who both published widely in the 1960s and 1970s in order to encourage publics to get involved in recording. Many members of GLIAS refer to the books of Hudson Industrial Archaeology: an Introduction and Buchanan Industrial Archaeology in Britain with their fine descriptions and photographs as integral to their early interest in the subject. On the other hand, there are those within the academic discipline of archaeology who consider the study of remains produced by the Industrial Revolution as too modern. Moreover, they find the activities of those calling themselves industrial archaeologists as lacking sufficient attention to the understanding of past human activity to justify the name. As a result, the definition of 'industrial archaeology' is problematic for both enthusiasts and professionals. Even the early advocates of professional industrial archaeology felt uneasy about the subject’s methods and practices. In 1973, Philip Riden (described by one GLIAS member as the angry young man of industrial archaeology), the then president of the Oxford University Archaeology Society, wrote a damning article in Antiquity, calling for the subject to “shed the amateur train drivers and others who are not part of archaeology” (215-216). He decried the “appallingly low standard of some of the work done under the name of ‘industrial archaeology’” (211). He felt that if enthusiasts did not attempt to maintain high technical standards, publish their work in journals or back up their fieldwork with documentary investigation or join their county archaeological societies then there was no value in the efforts of these amateurs. During this period, enthusiasts, academics, and professionals were divided. What was wrong with doing something for the pleasure it provides the participant?Although relations today between the so-called amateur (enthusiast) and professional archaeologies are less potent, some prejudice remains. Describing them as “barrow boys”, some enthusiasts suggest that what was once their much-loved pastime has been “hijacked” by professional archaeologists who, according to one respondent,are desperate to find subjects to get degrees in. So the whole thing has been hijacked by academia as it were. Traditional professional archaeologists in London at least are running head on into things that we have been doing for decades and they still don’t appreciate that this is what we do. A lot of assessments are handed out to professional archaeology teams who don’t necessarily have any knowledge of industrial archaeology. (James, GLIAS committee member)James went on to reveal that GLIAS receives numerous enquiries from professional archaeologists, developers and town planners asking what they know about particular sites across the city. Although the Society has compiled a detailed database covering some areas of London, it is by no means comprehensive. In addition, many active members often record and monitor sites in London for their own personal enjoyment. This leaves many questioning the need to publish their results for the gain of third parties. Canadian sociologist Stebbins discusses this situation in his research on “serious leisure”. He has worked extensively with amateur archaeologists in order to understand their approach to their leisure activity. He argues that amateurs are “neither dabblers who approach the activity with little commitment or seriousness, nor professionals who make a living from that activity” (55). Rather they pursue their chosen leisure activity to professional standards. A point echoed by Fine in his study of the cultures of mushrooming. But this is to get ahead of myself. How did GLIAS begin?GLIAS: The GroupThe 1960s have been described by respondents as a frantic period of “running around like headless chickens.” Enthusiasts of London’s industrial archaeology were witnessing incredible changes to the city’s industrial landscape. Individuals and groups like the Thames Basin Archaeology Observers Group were recording what they could. Dashing around London taking photos to capture London’s industrial legacy before it was lost forever. However the final straw for many, in London at least, was the proposed and subsequent demolition of the “Euston Arch”. The Doric portico at Euston Station was completed in 1838 and stood as a symbol to the glory of railway travel. Despite strong protests from amenity societies, this Victorian symbol of progress was finally pulled down by British Railways in 1962 in order to make way for what enthusiasts have called a “monstrous concrete box”.In response to these changes, GLIAS was founded in 1968 by two engineers and a locomotive driver over afternoon tea in a suburban living room in Woodford, North-East London. They held their first meeting one Sunday afternoon in December at the Science Museum in London and attracted over 130 people. Firing the imagination of potential members with an exhibition of photographs of the industrial landscape taken by Eric de Maré, GLIAS’s first meeting was a success. Bringing together like-minded people who are motivated and enthusiastic about the subject, GLIAS currently has over 600 members in the London area and beyond. This makes it the largest industrial archaeology society in the UK and perhaps Europe. Drawing some of its membership from a series of evening classes hosted by various members of the Society’s committee, GLIAS initially had a quasi-academic approach. Although some preferred the hands-on practical element and were more, as has been described by one respondent, “your free-range enthusiast”. The society has an active committee, produces a newsletter and journal, as well as runs regular events for members. However the Society is not simply about the study of London’s industrial heritage, over time the interest in industrial archaeology has developed for some members into long-term friendships. Sociability is central to organised leisure activities. It underpins and supports the performance of enthusiasm in groups and societies. For Fine, sociability does not always equal friendship, but it is the state from which people might become friends. Some GLIAS members have taken this one step further: there have even been a couple of marriages. Although not the subject of my paper, technical culture is heavily gendered. Industrial archaeology is a rare exception attracting a mixture of male and female participants, usually retired husband and wife teams.Doing Industrial Archaeology: GLIAS’s Method and PracticeIn what has been described as GLIAS’s heyday, namely the 1970s to early 1980s, fieldwork was fundamental to the Society’s activities. The Society’s approach to fieldwork during this period was much the same as the one described by champion of industrial archaeology Arthur Raistrick in 1973:photographing, measuring, describing, and so far as possible documenting buildings, engines, machinery, lines of communication, still or recently in use, providing a satisfactory record for the future before the object may become obsolete or be demolished. (13)In the early years of GLIAS and thanks to the committed efforts of two active Society members, recording parties were organised for extended lunch hours and weekends. The majority of this early fieldwork took place at the St Katherine Docks. The Docks were constructed in the 1820s by Thomas Telford. They became home to the world’s greatest concentration of portable wealth. Here GLIAS members learnt and employed practical (also professional) skills, such as measuring, triangulations and use of a “dumpy level”. For many members this was an incredibly exciting time. It was a chance to gain hands-on experience of industrial archaeology. Having been left derelict for many years, the Docks have since been redeveloped as part of the Docklands regeneration project.At this time the Society was also compiling data for what has become known to members as “The GLIAS Book”. The book was to have separate chapters on the various industrial histories of London with contributions from Society members about specific sites. Sadly the book’s editor died and the project lost impetus. Several years ago, the committee managed to digitise the data collected for the book and began to compile a database. However, the GLIAS database has been beset by problems. Firstly, there are often questions of consistency and coherence. There is a standard datasheet for recording industrial buildings – the Index Record for Industrial Sites. However, the quality of each record is different because of the experience level of the different authors. Some authors are automatically identified as good or expert record keepers. Secondly, getting access to the database in order to upload the information has proved difficult. As one of the respondents put it: “like all computer babies [the creator of the database], is finding it hard to give birth” (Sally, GLIAS member). As we have learnt enthusiasm is integral to movements such as industrial archaeology – public historian Raphael Samuel described them as the “invisible hands” of historical enquiry. Yet, it is this very enthusiasm that has the potential to jeopardise projects such as the GLIAS book. Although active in their recording practices, the GLIAS book saga reflects one of the challenges encountered by enthusiast groups and societies. In common with other researchers studying amenity societies, such as Ellis and Waterton’s work with amateur naturalists, unlike the world of work where people are paid to complete a task and are therefore meant to have a singular sense of purpose, the activities of an enthusiast group like GLIAS rely on the goodwill of their members to volunteer their time, energy and expertise. When this is lost for whatever reason, there is no requirement for any other member to take up that position. As such, levels of commitment vary between enthusiasts and can lead to the aforementioned difficulties, such as disputes between group members, the occasional miscommunication of ideas and an over-enthusiasm for some parts of the task in hand. On top of this, GLIAS and societies like it are confronted with changing health and safety policies and tightened security surrounding industrial sites. This has made the practical side of industrial archaeology increasingly difficult. As GLIAS member Bob explains:For me to go on site now I have to wear site boots and borrow a hard hat and a high visibility jacket. Now we used to do incredibly dangerous things in the seventies and nobody batted an eyelid. You know we were exploring derelict buildings, which you are virtually not allowed in now because the floor might give way. Again the world has changed a lot there. GLIAS: TodayGLIAS members continue to record sites across London. Some members are currently surveying the site chosen as the location of the Olympic Games in London in 2012 – the Lower Lea Valley. They describe their activities at this site as “rescue archaeology”. GLIAS members are working against the clock and some important structures have already been demolished. They only have time to complete a quick flash survey. Armed with the information they collated in previous years, GLIAS is currently in discussions with the developer to orchestrate a detailed recording of the site. It is important to note here that GLIAS members are less interested in campaigning for the preservation of a site or building, they appreciate that sites must change. Instead they want to ensure that large swathes of industrial London are not lost without a trace. Some members regard this as their public duty.Restricted by health and safety mandates and access disputes, GLIAS has had to adapt. The majority of practical recording sessions have given way to guided walks in the summer and public lectures in the winter. Some respondents have identified a difference between those members who call themselves “industrial archaeologists” and those who are just “ordinary members” of GLIAS. The walks are for those with a general interest, not serious members, and the talks are public lectures. Some audience researchers have used Bourdieu’s metaphor of “capital” to describe the experience, knowledge and skill required to be a fan, clubber or enthusiast. For Hills, fan status is built up through the demonstration of cultural capital: “where fans share a common interest while also competing over fan knowledge, access to the object of fandom, and status” (46). A clear membership hierarchy can be seen within GLIAS based on levels of experience, knowledge and practical skill.With a membership of over 600 and rising annually, the Society’s future is secure at present. However some of the more serious members, although retaining their membership, are pursuing their enthusiasm elsewhere: through break-away recording groups in London; active membership of other groups and societies, for example the national Association for Industrial Archaeology; as well as heading off to North Wales in the summer for practical, hands-on industrial archaeology in Snowdonia’s slate quarries – described in the Ffestiniog Railway Journal as the “annual convention of slate nutters.” ConclusionsGLIAS has changed since its foundation in the late 1960s. Its operation has been complicated by questions of health and safety, site access, an ageing membership, and the constant changes to London’s industrial archaeology. Previously rejected by professional industrial archaeology as “limited in skill and resources” (Riden), enthusiasts are now approached by professional archaeologists, developers, planners and even museums that are interested in engaging in knowledge exchange programmes. As a recent report from the British think-tank Demos has argued, enthusiasts or pro-ams – “amateurs who work to professional standards” (Leadbeater and Miller 12) – are integral to future innovation and creativity; for example computer pro-ams developed an operating system to rival Microsoft Windows. As such the specialist knowledge, skill and practice of these communities is of increasing interest to policymakers, practitioners, and business. So, the subject once described as “the ugly offspring of two parents that shouldn’t have been allowed to breed” (Hudson), the so-called “amateur” industrial archaeology offers enthusiasts and professionals alike alternative ways of knowing, seeing and being in the recent and contemporary past.Through the case study of GLIAS, I have described what it means to be enthusiastic about industrial archaeology. I have introduced a culture of collective and individual participation and friendship based on a mutual interest in and emotional attachment to industrial sites. As we have learnt in this paper, enthusiasm is about fun, pleasure and joy. The enthusiastic culture presented here advances themes such as passion in relation to less obvious communities of knowing, skilled practices, material artefacts and spaces of knowledge. Moreover, this paper has been about the affective narratives that are sometimes missing from academic accounts; overlooked for fear of sniggers at the back of a conference hall. Laughter and humour are a large part of what enthusiasm is. Enthusiastic cultures then are about the pleasure and joy experienced in doing things. Enthusiasm is clearly a potent force for active participation. I will leave the last word to GLIAS member John:One meaning of enthusiasm is as a form of possession, madness. Obsession perhaps rather than possession, which I think is entirely true. It is a pejorative term probably. The railway enthusiast. But an awful lot of energy goes into what they do and achieve. Enthusiasm to my mind is an essential ingredient. If you are not a person who can muster enthusiasm, it is very difficult, I think, to get anything out of it. On the basis of the more you put in the more you get out. In terms of what has happened with industrial archaeology in this country, I think, enthusiasm is a very important aspect of it. The movement needs people who can transmit that enthusiasm. ReferencesAbercrombie, N., and B. Longhurst. Audiences: A Sociological Theory of Performance and Imagination. London: Sage Publications, 1998.Adas, M. Machines as the Measure of Men: Science, Technology and Ideologies of Western Dominance. Ithaca: Cornell UP, 1989.Ang, I. Desperately Seeking the Audience. London: Routledge, 1991.Bourdieu, P. Distinction: A Social Critique of the Judgement of Taste. London: Routledge, 1984.Buchanan, R.A. Industrial Archaeology in Britain. 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Making Technology Masculine: Men, Women and Modern Machines in America 1870-1945. Amsterdam: Amsterdam UP, 1999.Palmer, M. “‘We Have Not Factory Bell’: Domestic Textile Workers in the Nineteenth Century.” The Local Historian 34 (2004): 198–213.Raistrick, A. Industrial Archaeology. London: Granada, 1973.Riden, P. “Post-Post-Medieval Archaeology.” Antiquity XLVII (1973): 210-216.Rix, M. “Industrial Archaeology: Progress Report 1962.” The Amateur Historian 5 (1962): 56–60.Rix, M. Industrial Archaeology. London: The Historical Association, 1967.Saarikoski, P. The Lure of the Machine: The Personal Computer Interest in Finland from the 1970s to the Mid-1990s. Unpublished PhD Thesis, 2004. ‹http://users.utu.fi/petsaari/lure.pdf›.Samuel, R. Theatres of Memory London: Verso, 1994.Sandvoss, C. Fans: The Mirror of Consumption Cambridge: Polity, 2005.Schouten, J.W., and J. 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In this essay we challenge whether current conceptions of optimism, hope, and resilience are complete enough to account for the complexity and nuance of developing and maintaining these in practice. For example, a quick perusal of popular outlets (e.g., Forbes, Harvard Business Review) reveals advice to managers urging them to “be optimistic,” or “be happy” so that these types of emotions or feelings can spread to the workplace. One even finds simple advice and steps to follow on how to foster these types of things in the workplace (McKee; Tjan). We argue that this common perspective focuses narrowly on individuals and does not account for the complexity of resilience. Consequently, it denies the role of context, culture, and interactions as ways people develop shared meaning and reality. To fill this gap in our understanding, we take a social constructionist perspective to understand resilience. In other words, we foreground communication as the primary building block to sharing meaning and creating our worlds. In so doing, we veer away from the traditional focus on the individual and instead emphasise the social and cultural elements that shape how meaning is shared by peoples in various contexts (Fairhurst, Considering Context). Drawing on a communication, discourse-centered perspective we explore hope and optimism as concepts commonly associated with resilience in a work context. At work, leaders play a vital role in communicating ways that foster resilience in the face of organisational issues and events (e.g., environmental crises, downsizing). Following this lead, discursive leadership offers a framework that positions leadership as co-created and as the management of meaning through framing (Fairhurst, Power of Framing). Thus, we propose that a discursive leadership orientation can contribute to the communicative construction of resilience that moves away from individual perspectives to an emphasis on the social. From a discursive perspective, leadership is defined as a process of meaning management; attribution given by followers or observers; process-focused rather than leader-focused; and as shifting and distributed among several organizational members (Fairhurst Power of Framing). By switching from the individual focus and concentrating on social and cultural systems, discursive leadership is able to study concepts related to subjectivity, cultures, and identities as it relates to meaning. Our aim is to offer leaders an alternative perspective on resilience at the individual and group level by explaining how a discursive orientation to leadership can contribute to the communicative construction of resilience. We argue that a social constructionist approach provides a perspective that can unravel the multiple layers that make up hope, optimism, and resilience. We begin with a peek into the social scientific perspective that is so commonplace in media and popular portrayals of these constructs. Then, we explain the social constructionist perspective that grounds our framework, drawing on discursive leadership. Next, we present an alternative model of resilience, one that takes resilience as communicatively constructed and socially created. We believe this more robust perspective can help individuals, groups, and cultures be more resilient in the face of challenges. Social Scientific Perspectives Hope, optimism, and resilience have widely been spoken in the same breath; thus, in what follows we review how each is treated in common portrayals. In addition, we discuss each to point to further implications of our model proposed in this essay. Traditionally taken as cognitive states, each construct is based in an individual or an entity (Youssef and Luthans) and thus minimises the social and cultural. Hope Snyder, Irving, and Anderson define the construct of hope as “a positive motivational state that is based on an interactively derived sense of successful (1) agency (goal-directed energy) and (2) pathways (planning to meet goals)” (287). This cognitive set therefore is composed of the belief in the ability to create strategies toward a goal and the belief that those plans can be realised. Exploring hope can provide insight into how individuals deal with stress and more importantly how they use past experiences to produce effective routes toward goals (Brown Kirschman et al.). Mills-Scofield writing in Harvard Business Review mirrors this two-part hope structure and describes how to integrate hope into business strategy. Above all she emphasises that hope is based in fact, not fiction; the need to learn and apply from failures; and the need to focus on what is working instead of what is broken. These three points contribute to hope by reinforcing the strategies (pathways) and ability (agency) to accomplish a particular goal. This model of hope is widely held across social scientific and popular portrayals. This position, however, does not allow for exploring how forces of social interaction shape either how these pathways are created or how agency is developed in the first place. By contrast, a communication-centered approach like the one we propose foregrounds interaction and the various social forces necessary for hope to be fostered in the workplace. Optimism Optimism centers on how an individual processes the causality of an event (e.g., an organisational crisis). From this perspective, an employee facing significant conflict with his immediate supervisor, for example, may explain this threat as an opportunity to learn the importance of supervisor-subordinate relationships. This definition therefore explores how the individual interprets his/her world (Brown Kirschman et al.). According to Seligman et al. the ways in which one interprets events has its origins in several places: (1) genetics; (2) the environment in the form of modeling optimistic behaviours; (3) environment in forms of criticism; and (4) life experiences that teach personal mastery or helplessness (cited in Brown Kirschman et al.). Environmental sources function as a dialectical tension. On one hand the environment provides productive modeling for optimism behaviours, and on the other the environment, through criticism, produces the opposite. Both extremes illustrate the significance of cultural and societal factors as they contribute to optimism. Additionally, life experiences play a role in either mastery or helplessness. Again, interaction and social influences play a significant part in the development of optimism. Much like hope, due to the attention given to social and interactive forces, the concept of optimism requires a framework rooted in the social and cultural rather than the individual and cognitive. A significant drawback related to optimism (Brown Kirschman et al.) is the danger of unrelenting optimism and the possibility this has on producing unrealistic scenarios. Individuals, rather, should strive to acknowledge the facts (good or bad) of certain circumstances in order to learn how to properly manage automatic negative thoughts (Brown Kirschman et al.). Tony Schwartz writing in Harvard Business Review argues that “realistic optimism” is more than putting on a happy face but instead is more about telling what is the most hopeful and empowering of a given situation (1). Thus, a more interaction-based approach much like the model that we are proposing could help overcome some of optimism’s shortcomings. If the power of optimism is in the telling, then we need a model where the telling is front and center. Later, we propose such a model and method for helping leaders’ foster optimism in the workplace and in their communities. Resilience Resilience research offers several definitions and approaches in attempt to examine the phenomenon. Masten defines resilience as a “class of phenomena characterized by good outcomes in spite of serious threats to adaptation or development” (228). Luthar, Cicchetti, and Becker argue that resilience is “a dynamic process encompassing positive adaptation within the context of significant adversity” (543). Interestingly, resilience and developmental researchers alike have positioned resilience as an individual consistently meeting the expectations of a given society or culture within a particular historical context. Broadly speaking, two central conditions apply toward resilience: (1) the presence of significant threat or adversity; and (2) the achievement of positive adaptation (Luthar, Cicchetti, and Becker. Masten goes on to argue that resilience is however ordinary and naturally occurring. That is, the adaptive systems required during significant threat are already present in individuals and is not solely retained by a select few. Masten et al., argues that resilience does not come “from rare and special qualities, but from the operations of ordinary human systems in the biology and psychology of children, from the relationships in the family and community, and from schools, religions, cultures, and other aspects of societies” (129). Based on this, the emphasis of resilience should be within adaptive processes, such that are found in supportive relationships, emotion regulation, and environment engagement (Masten et al.), rather than on individuals. Of these varied interpretations of resilience, two research designs drive the academic literature— outcome- and process-based perspectives (Kolar). Those following an outcome-focused approach tend to concentrate on functionality and functional behaviour as key indicators of resilience (Kolar). Following this model, cognitive states such as composure, assurance, and confidence are examples of resilience. By contrast, a process-focused approach concentrates on the interplay of protective and risk factors as they influence the adaptive capacity of an individual (Kolar). This approach acknowledges that resilience is contextual and interactive, and is “a shared responsibility between individuals, their families, and the formal social system rather than as an individual burden (Kolar 425). This process-based approach toward resilience allows for greater inclusion of factors across individual, group, and societal levels (Kolar). The rigidity of outcome-based models and related constructs does not allow for such flexibility and therefore prevents exploring full accounts of resilience. A process-based approach allows for the inclusion of context throughout measures of resilience and acknowledges that interplay of risk and protective factors across the individual, social, and community level (Kolar). Bearing this in mind, what is needed are more complex models of resilience that account for a multiplicity of factors. An Alternate Framework: Social Construction of Reality Language is the tool storytellers use to generate interest and convey ideas. From a social constructionist standpoint, language is the primary mechanism in the construction of reality. Berger and Luckmann present language as a system that allows us to categorise subjective ideas, which over time accumulates into our “social stock of knowledge” (41). As our language creates the symbols that we use to make sense of the world around us, we add to our social knowledge thereby creating a shared vision of our own social reality. Because we accumulate varying levels and amounts of social knowledge, what we know of the world constantly changes. For example, in organisations, our discourse and on-going interactions with each other serve to shape what we consider to be real in our day-to-day lives. In this view, subjective experiences of individuals are central to our understanding of various events (e.g., organizational change, crises, conflict) and the ways in which we cope with such occurrences (e.g., through hope, optimism, resilience). Alternative Models of Resilience We take Buzzanell’s framework as inspiration for an alternative model of resilience. Her communication-centric model is based in messages, d/Discourse, and narrative where communication is an emergent process involving the interplay of messages and interaction (Buzzanell). Furthermore, the communicative construction of resilience involves “a collaborative exchange that invites participation of family, workplace, community, and interorganizational network members” (Buzzanell 9). This alternative perspective of resilience explores human communication resilience processes as the focal point rather than examining the person or entity. This is essentially a design change, where the focus shifts from the individual or singular toward the communication processes that enable resilience. Essentially, according to Poole, “in process, we can see resilience as dynamic, integrated, unfolding over time and through events, evolving into patterns, and dependent on contingencies” (qtd. in Buzzanell 2). Buzzanell describes five processes included in the communicative construction of resilience: (1) crafting normalcy; (2) affirming identity anchors; (3) maintaining and using communication networks; (4) legitimising negative feelings while foregrounding productive action; and (5) putting alternative logics to work. Here, we highlight two that most directly relate to the alternative model we propose. First, legitimising negative feelings while foregrounding productive action may sound like repression, but in fact it emphasises that negative feelings (nonproductive emotions) are real and that focusing on positive action enables success while facing significant threat. Furthermore, as a communicative construction, this process includes reframing of a situation both linguistically and metaphorically. This communicative process address a major drawback related to the optimism construct presented by Brown Kirschman and colleagues regarding the potential danger of unrelenting optimism. Similarly, putting alternative logics to work, in its practical application, creates resilient systems through (re)framing. Through (re)framing, individuals, groups, and communities can create their own logics that enable them to reintegrate when facing adverse experiences. That is, (re)framing provides an opportunity to endure unfavorable situations while creating communicatively creating conditions that enable adaptation. This idea can also be seen in popular press such as in the Harvard Business Review blog “Craft a Narrative to Instill Optimism” (Baldoni). According to Baldoni, leaders have a choice in creating the narrative of our world. Thus, leaders serve as the primary meaning managers in the workplace. Leadership and the Management of Meaning Kelly begins our discussion toward an ongoing discursive turn in leadership research. Much like hope, optimism, and resilience, Kelly proposes that leadership has been wrongly categorised and therefore has been inadequately observed. That is, due to focusing on trait-based leadership models espoused by leadership psychology the area of leadership has been left with significant deficits surrounding the very core of leadership. The lessons learned about the reductionist treatment of leadership can be applied to our understanding of resilience. Thus, we draw on discursive leadership because it provides an example for how leaders can foster resilience in various settings. The discursive turn stems from the incongruity seen in these traditional trait or style-based leadership approaches. From a social constructionist perspective, researchers are able to explore the forms in which leadership contributes to the meaning construction process, much in the same way that a communication perspective, outlined above, emphasises resilience as a process. This ontological shift in leadership research not only re-categorises leadership but also changes the ways in which leadership is studied. Kelly’s emphasis on a socially constructed view of leadership combined with alternative methodological approaches contributes to our aim to explore how a discursive leadership orientation can contribute to communicative construction of resilience. Discursive Leadership Discursive leadership views leadership as more of an art rather than a science, one that is contested and inventive (Fairhurst, Discursive Leadership). Where leadership psychology emphasises the individual and cognitive, discursive leadership highlights the cultural and the communicative (Fairhurst, Discursive Leadership). Leadership psychology is analogous to common, social scientific understandings of resilience that typically confines resilience into something easily attainable by individuals. The traditional leadership psychology literature attempts to determine causality among the cognitive, emotional, and behavioural elements of leader actors, whereas, discursive leadership takes discourse as the object of study to view how we think, see, and attribute leadership. Discursive leadership offers an optimal resource to view the communicative practices involved in the management of meaning and communicative construction of reality, including resilient systems and processes. Thus, we draw everything together now, and introduce practical interventions organisations can implement to foster hope, optimism, and resilience. An Alternate Model in Practice Attention to human capabilities and adaptive systems that promote healthy development and functioning have the potential to inform policy and programs that foster competence and human capital and aim to improve the health of communities and nations while also preventing problems (Masten 235). Masten’s words point to the tremendous potential of resilience. Thus, we wish to conclude with the implications of our perspective for individuals, groups, and communities. In what follows we briefly explain framing, and end with two interventions leaders can use to help foster resilience in the workplace. A common and practical example of language creating reality is framing. Fairhurst, in her book The Power of Framing explores framing as a leader’s ability to construct the reality of a subject or situation. A frame is simply defined as a mental picture where framing is the process of communicating this picture to others. Although words or language cannot alter any physical conditions, they may, however, influence our perceptions of them. Fairhurst goes on to “frame” leadership as co-created and not necessarily found in specific concrete acts. That is, leadership emerges when leader actors are deemed to have performed or demonstrated leadership by themselves and/or others. Leadership in this case is determined by attribution. For Fairhurst, leaders are able to shape and co-create meaning and reality by influencing the here and now. From this perspective interventions should be designed around the idea of creating alternative logics (Buzzanell) by emphasizing the elements of framing. For the sake of brevity, we wish to emphasise two fundamental areas surrounding process-oriented and communicative constructed resilience. It is our hope that leaders may use these takeaways and build upon them as they reflect how to position resilience at the individual and organisational level. First, interventions should focus on identifying the supportive adaptive systems at the individual, group, and societal level (e.g., family, work teams, community coalitions). This could be done through a series of dialogue sessions with an aim of challenging participants to not only identify systems but to also reflect upon how these systems contribute toward resilience. These could be duplicated in work settings and community settings (e.g., community forums and the like). Second, to emphasise framing, interventions should involve meaningful dialogue to help identify the particular conditions within a significant threat that will (a) lead to productive action and (b) enable individuals, groups, and communities to endure. Overall, an increased emphasis should be placed on helping participants understand how they are able to metaphorically and linguistically (Buzzanell) create the conditions surrounding adverse events. Our aim in this essay was to present an alternate model of various human processes that help people cope and bounce back from troubling times or events. Toward this end, we argued that media and popular portrayals of constructs such as hope, optimism, and resilience lack the complexity to account for how these can be put into practice. To fill this gap, we hope our communication-based model of resilience, with its emphasis on interaction will provide leaders and community members a method for engaging people in the process of coping and communicating resilience. Honoring the processual nature of these ideas is one step toward bettering individuals, groups, and communities. References Baldoni, John. “Craft a Narrative to Instill Optimism.” Harvard Business Review 17 Dec. 2009: 1. Berger, Peter L., and Thomas Luckmann. The Social Construction of Reality. New York: Anchor Books, 1966. Brown Kirschman, Keri J., Rebecca J. Johnson., Jade A. Bender., and Michael C. Roberts. “Positive Psychology for Children and Adolescents: Development, Prevention, and Promotion.” Oxford Handbook of Positive Psychology. Eds. Shane J. Lopez and Charles R. Snyder. New York: Oxford. 2009. 133-148. Buzzanell, Patrice M. “Resilience: Talking, Resisting, and Imagining New Normalcies into Being.” Journal of Communication 60 (2010): 1-14. 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Lopez and Charles R. Snyder. New York: Oxford UP, 2009. 117-132. McKee, Annie. “Doing the Hard Work of Hope.” HBR Blog Network Oct. 2008: 1-2. Mills-Scofield, Deborah. “Hope Is a Strategy (Well, Sort Of).” Harvard Business Review 9 Oct. 2012: 1-2. Poole, Marshall S. “On the Study of Process in Communication Research.” Montreal, Quebec, Canada. May 2008. Fellows address at the International Communication Association annual meeting. Postman, Neil. Conscientious Objections: Stirring Up Trouble about Language, Technology, and Education. New York: Vintage Books, 1988. Schwartz, Tony. “Fueling Positive Emotions in a World Gone Mad.” Harvard Business Review 2 Nov. 2010: 1-2 Seligman, Martin E., et al. The Optimist Child. Boston, MA: Houghton Mifflin, 1995. Snyder, Charles R., et al. “Hope and Health: Measuring the Will and the Ways.” Handbook of Social and Clinical Psychology: The Health Perspective. Eds. Charles R. Snyder and Donelson R. Forsyth. Elmsford: Pergamon, 1991. 285-305. Tjan, Anthony K. “Lead with Optimism.” HBR Blog Network May 2010: 1-2. Youssef, Carolyn M., and Luthans, Fred. “Positive Organizational Behavior in the Workplace: The Impact of Hope, Optimism, and Resilience.” Journal of Management 33.5 (2007): 774-800.

Introduction Eating is one of the most quintessential activities of human life. Because of this primacy, eating is, as food anthropologist Sidney Mintz has observed, “not merely a biological activity, but a vibrantly cultural activity as well” (48). This article posits that the current awareness of climate change in the Western world is animating such cultural activity as the Slow Food movement and is, as a result, stimulating what could be seen as an evolutionary change in popular foodways. Moreover, this paper suggests that, in line with modelling provided by the Slow Food example, an increased awareness of the connections of climate change to the social injustices of food production might better drive social change in such areas. This discussion begins by proposing that contemporary foodways—defined as “not only what is eaten by a particular group of people but also the variety of customs, beliefs and practices surrounding the production, preparation and presentation of food” (Davey 182)—are changing in the West in relation to current concerns about climate change. Such modification has a long history. Since long before the inception of modern Homo sapiens, natural climate change has been a crucial element driving hominidae evolution, both biologically and culturally in terms of social organisation and behaviours. Macroevolutionary theory suggests evolution can dramatically accelerate in response to rapid shifts in an organism’s environment, followed by slow to long periods of stasis once a new level of sustainability has been achieved (Gould and Eldredge). There is evidence that ancient climate change has also dramatically affected the rate and course of cultural evolution. Recent work suggests that the end of the last ice age drove the cultural innovation of animal and plant domestication in the Middle East (Zeder), not only due to warmer temperatures and increased rainfall, but also to a higher level of atmospheric carbon dioxide which made agriculture increasingly viable (McCorriston and Hole, cited in Zeder). Megadroughts during the Paleolithic might well have been stimulating factors behind the migration of hominid populations out of Africa and across Asia (Scholz et al). Thus, it is hardly surprising that modern anthropogenically induced global warming—in all its’ climate altering manifestations—may be driving a new wave of cultural change and even evolution in the West as we seek a sustainable homeostatic equilibrium with the environment of the future. In 1962, Rachel Carson’s Silent Spring exposed some of the threats that modern industrial agriculture poses to environmental sustainability. This prompted a public debate from which the modern environmental movement arose and, with it, an expanding awareness and attendant anxiety about the safety and nutritional quality of contemporary foods, especially those that are grown with chemical pesticides and fertilizers and/or are highly processed. This environmental consciousness led to some modification in eating habits, manifest by some embracing wholefood and vegetarian dietary regimes (or elements of them). Most recently, a widespread awareness of climate change has forced rapid change in contemporary Western foodways, while in other climate related areas of socio-political and economic significance such as energy production and usage, there is little evidence of real acceleration of change. Ongoing research into the effects of this expanding environmental consciousness continues in various disciplinary contexts such as geography (Eshel and Martin) and health (McMichael et al). In food studies, Vileisis has proposed that the 1970s environmental movement’s challenge to the polluting practices of industrial agri-food production, concurrent with the women’s movement (asserting women’s right to know about everything, including food production), has led to both cooks and eaters becoming increasingly knowledgeable about the links between agricultural production and consumer and environmental health, as well as the various social justice issues involved. As a direct result of such awareness, alternatives to the industrialised, global food system are now emerging (Kloppenberg et al.). The Slow Food (R)evolution The tenets of the Slow Food movement, now some two decades old, are today synergetic with the growing consternation about climate change. In 1983, Carlo Petrini formed the Italian non-profit food and wine association Arcigola and, in 1986, founded Slow Food as a response to the opening of a McDonalds in Rome. From these humble beginnings, which were then unashamedly positing a return to the food systems of the past, Slow Food has grown into a global organisation that has much more future focused objectives animating its challenges to the socio-cultural and environmental costs of industrial food. Slow Food does have some elements that could be classed as reactionary and, therefore, the opposite of evolutionary. In response to the increasing homogenisation of culinary habits around the world, for instance, Slow Food’s Foundation for Biodiversity has established the Ark of Taste, which expands upon the idea of a seed bank to preserve not only varieties of food but also local and artisanal culinary traditions. In this, the Ark aims to save foods and food products “threatened by industrial standardization, hygiene laws, the regulations of large-scale distribution and environmental damage” (SFFB). Slow Food International’s overarching goals and activities, however, extend far beyond the preservation of past foodways, extending to the sponsoring of events and activities that are attempting to create new cuisine narratives for contemporary consumers who have an appetite for such innovation. Such events as the Salone del Gusto (Salon of Taste) and Terra Madre (Mother Earth) held in Turin every two years, for example, while celebrating culinary traditions, also focus on contemporary artisanal foods and sustainable food production processes that incorporate the most current of agricultural knowledge and new technologies into this production. Attendees at these events are also driven by both an interest in tradition, and their own very current concerns with health, personal satisfaction and environmental sustainability, to change their consumer behavior through an expanded self-awareness of the consequences of their individual lifestyle choices. Such events have, in turn, inspired such events in other locations, moving Slow Food from local to global relevance, and affecting the intellectual evolution of foodway cultures far beyond its headquarters in Bra in Northern Italy. This includes in the developing world, where millions of farmers continue to follow many traditional agricultural practices by necessity. Slow Food Movement’s forward-looking values are codified in the International Commission on the Future of Food and Agriculture 2006 publication, Manifesto on the Future of Food. This calls for changes to the World Trade Organisation’s rules that promote the globalisation of agri-food production as a direct response to the “climate change [which] threatens to undermine the entire natural basis of ecologically benign agriculture and food preparation, bringing the likelihood of catastrophic outcomes in the near future” (ICFFA 8). It does not call, however, for a complete return to past methods. To further such foodway awareness and evolution, Petrini founded the University of Gastronomic Sciences at Slow Food’s headquarters in 2004. The university offers programs that are analogous with the Slow Food’s overall aim of forging sustainable partnerships between the best of old and new practice: to, in the organisation’s own words, “maintain an organic relationship between gastronomy and agricultural science” (UNISG). In 2004, Slow Food had over sixty thousand members in forty-five countries (Paxson 15), with major events now held each year in many of these countries and membership continuing to grow apace. One of the frequently cited successes of the Slow Food movement is in relation to the tomato. Until recently, supermarkets stocked only a few mass-produced hybrids. These cultivars were bred for their disease resistance, ease of handling, tolerance to artificial ripening techniques, and display consistency, rather than any culinary values such as taste, aroma, texture or variety. In contrast, the vine ripened, ‘farmer’s market’ tomato has become the symbol of an “eco-gastronomically” sustainable, local and humanistic system of food production (Jordan) which melds the best of the past practice with the most up-to-date knowledge regarding such farming matters as water conservation. Although the term ‘heirloom’ is widely used in relation to these tomatoes, there is a distinctively contemporary edge to the way they are produced and consumed (Jordan), and they are, along with other organic and local produce, increasingly available in even the largest supermarket chains. Instead of a wholesale embrace of the past, it is the connection to, and the maintenance of that connection with, the processes of production and, hence, to the environment as a whole, which is the animating premise of the Slow Food movement. ‘Slow’ thus creates a gestalt in which individuals integrate their lifestyles with all levels of the food production cycle and, hence to the environment and, importantly, the inherently related social justice issues. ‘Slow’ approaches emphasise how the accelerated pace of contemporary life has weakened these connections, while offering a path to the restoration of a sense of connectivity to the full cycle of life and its relation to place, nature and climate. In this, the Slow path demands that every consumer takes responsibility for all components of his/her existence—a responsibility that includes becoming cognisant of the full story behind each of the products that are consumed in that life. The Slow movement is not, however, a regime of abstention or self-denial. Instead, the changes in lifestyle necessary to support responsible sustainability, and the sensual and aesthetic pleasure inherent in such a lifestyle, exist in a mutually reinforcing relationship (Pietrykowski 2004). This positive feedback loop enhances the potential for promoting real and long-term evolution in social and cultural behaviour. Indeed, the Slow zeitgeist now informs many areas of contemporary culture, with Slow Travel, Homes, Design, Management, Leadership and Education, and even Slow Email, Exercise, Shopping and Sex attracting adherents. Mainstreaming Concern with Ethical Food Production The role of the media in “forming our consciousness—what we think, how we think, and what we think about” (Cunningham and Turner 12)—is self-evident. It is, therefore, revealing in relation to the above outlined changes that even the most functional cookbooks and cookery magazines (those dedicated to practical information such as recipes and instructional technique) in Western countries such as the USA, UK and Australian are increasingly reflecting and promoting an awareness of ethical food production as part of this cultural change in food habits. While such texts have largely been considered as useful but socio-politically relatively banal publications, they are beginning to be recognised as a valid source of historical and cultural information (Nussel). Cookbooks and cookery magazines commonly include discussion of a surprising range of issues around food production and consumption including sustainable and ethical agricultural methods, biodiversity, genetic modification and food miles. In this context, they indicate how rapidly the recent evolution of foodways has been absorbed into mainstream practice. Much of such food related media content is, at the same time, closely identified with celebrity mass marketing and embodied in the television chef with his or her range of branded products including their syndicated articles and cookbooks. This commercial symbiosis makes each such cuisine-related article in a food or women’s magazine or cookbook, in essence, an advertorial for a celebrity chef and their named products. Yet, at the same time, a number of these mass media food celebrities are raising public discussion that is leading to consequent action around important issues linked to climate change, social justice and the environment. An example is Jamie Oliver’s efforts to influence public behaviour and government policy, a number of which have gained considerable traction. Oliver’s 2004 exposure of the poor quality of school lunches in Britain (see Jamie’s School Dinners), for instance, caused public outrage and pressured the British government to commit considerable extra funding to these programs. A recent study by Essex University has, moreover, found that the academic performance of 11-year-old pupils eating Oliver’s meals improved, while absenteeism fell by 15 per cent (Khan). Oliver’s exposé of the conditions of battery raised hens in 2007 and 2008 (see Fowl Dinners) resulted in increased sales of free-range poultry, decreased sales of factory-farmed chickens across the UK, and complaints that free-range chicken sales were limited by supply. Oliver encouraged viewers to lobby their local councils, and as a result, a number banned battery hen eggs from schools, care homes, town halls and workplace cafeterias (see, for example, LDP). The popular penetration of these ideas needs to be understood in a historical context where industrialised poultry farming has been an issue in Britain since at least 1848 when it was one of the contributing factors to the establishment of the RSPCA (Freeman). A century after Upton Sinclair’s The Jungle (published in 1906) exposed the realities of the slaughterhouse, and several decades since Peter Singer’s landmark Animal Liberation (1975) and Tom Regan’s The Case for Animal Rights (1983) posited the immorality of the mistreatment of animals in food production, it could be suggested that Al Gore’s film An Inconvenient Truth (released in 2006) added considerably to the recent concern regarding the ethics of industrial agriculture. Consciousness-raising bestselling books such as Jim Mason and Peter Singer’s The Ethics of What We Eat and Michael Pollan’s The Omnivore’s Dilemma (both published in 2006), do indeed ‘close the loop’ in this way in their discussions, by concluding that intensive food production methods used since the 1950s are not only inhumane and damage public health, but are also damaging an environment under pressure from climate change. In comparison, the use of forced labour and human trafficking in food production has attracted far less mainstream media, celebrity or public attention. It could be posited that this is, in part, because no direct relationship to the environment and climate change and, therefore, direct link to our own existence in the West, has been popularised. Kevin Bales, who has been described as a modern abolitionist, estimates that there are currently more than 27 million people living in conditions of slavery and exploitation against their wills—twice as many as during the 350-year long trans-Atlantic slave trade. Bales also chillingly reveals that, worldwide, the number of slaves is increasing, with contemporary individuals so inexpensive to purchase in relation to the value of their production that they are disposable once the slaveholder has used them. Alongside sex slavery, many other prevalent examples of contemporary slavery are concerned with food production (Weissbrodt et al; Miers). Bales and Soodalter, for example, describe how across Asia and Africa, adults and children are enslaved to catch and process fish and shellfish for both human consumption and cat food. Other campaigners have similarly exposed how the cocoa in chocolate is largely produced by child slave labour on the Ivory Coast (Chalke; Off), and how considerable amounts of exported sugar, cereals and other crops are slave-produced in certain countries. In 2003, some 32 per cent of US shoppers identified themselves as LOHAS “lifestyles of health and sustainability” consumers, who were, they said, willing to spend more for products that reflected not only ecological, but also social justice responsibility (McLaughlin). Research also confirms that “the pursuit of social objectives … can in fact furnish an organization with the competitive resources to develop effective marketing strategies”, with Doherty and Meehan showing how “social and ethical credibility” are now viable bases of differentiation and competitive positioning in mainstream consumer markets (311, 303). In line with this recognition, Fair Trade Certified goods are now available in British, European, US and, to a lesser extent, Australian supermarkets, and a number of global chains including Dunkin’ Donuts, McDonalds, Starbucks and Virgin airlines utilise Fair Trade coffee and teas in all, or parts of, their operations. Fair Trade Certification indicates that farmers receive a higher than commodity price for their products, workers have the right to organise, men and women receive equal wages, and no child labour is utilised in the production process (McLaughlin). Yet, despite some Western consumers reporting such issues having an impact upon their purchasing decisions, social justice has not become a significant issue of concern for most. The popular cookery publications discussed above devote little space to Fair Trade product marketing, much of which is confined to supermarket-produced adverzines promoting the Fair Trade products they stock, and international celebrity chefs have yet to focus attention on this issue. In Australia, discussion of contemporary slavery in the press is sparse, having surfaced in 2000-2001, prompted by UNICEF campaigns against child labour, and in 2007 and 2008 with the visit of a series of high profile anti-slavery campaigners (including Bales) to the region. The public awareness of food produced by forced labour and the troubling issue of human enslavement in general is still far below the level that climate change and ecological issues have achieved thus far in driving foodway evolution. This may change, however, if a ‘Slow’-inflected connection can be made between Western lifestyles and the plight of peoples hidden from our daily existence, but contributing daily to them. Concluding Remarks At this time of accelerating techno-cultural evolution, due in part to the pressures of climate change, it is the creative potential that human conscious awareness brings to bear on these challenges that is most valuable. Today, as in the caves at Lascaux, humanity is evolving new images and narratives to provide rational solutions to emergent challenges. As an example of this, new foodways and ways of thinking about them are beginning to evolve in response to the perceived problems of climate change. The current conscious transformation of food habits by some in the West might be, therefore, in James Lovelock’s terms, a moment of “revolutionary punctuation” (178), whereby rapid cultural adaption is being induced by the growing public awareness of impending crisis. It remains to be seen whether other urgent human problems can be similarly and creatively embraced, and whether this trend can spread to offer global solutions to them. References An Inconvenient Truth. 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Eshel, Gidon, and Pamela A. Martin. “Diet, Energy, and Global Warming.” Earth Interactions 10, paper 9 (2006): 1–17. Fowl Dinners. Exec. Prod. Nick Curwin and Zoe Collins. Dragonfly Film and Television Productions and Fresh One Productions, 2008. Freeman, Sarah. Mutton and Oysters: The Victorians and Their Food. London: Gollancz, 1989. Gould, S. J., and N. Eldredge. “Punctuated Equilibrium Comes of Age.” Nature 366 (1993): 223–27. (ICFFA) International Commission on the Future of Food and Agriculture. Manifesto on the Future of Food. Florence, Italy: Agenzia Regionale per lo Sviluppo e l’Innovazione nel Settore Agricolo Forestale and Regione Toscana, 2006. Jamie’s School Dinners. Dir. Guy Gilbert. Fresh One Productions, 2005. Jordan, Jennifer A. “The Heirloom Tomato as Cultural Object: Investigating Taste and Space.” Sociologia Ruralis 47.1 (2007): 20-41. Khan, Urmee. “Jamie Oliver’s School Dinners Improve Exam Results, Report Finds.” Telegraph 1 Feb. 2009. 24 Aug. 2009 < http://www.telegraph.co.uk/education/educationnews/4423132/Jamie-Olivers-school-dinners-improve-exam-results-report-finds.html >. Kloppenberg, Jack, Jr, Sharon Lezberg, Kathryn de Master, G. W. Stevenson, and John Henrickson. ‘Tasting Food, Tasting Sustainability: Defining the Attributes of an Alternative Food System with Competent, Ordinary People.” Human Organisation 59.2 (Jul. 2000): 177–86. (LDP) Liverpool Daily Post. “Battery Farm Eggs Banned from Schools and Care Homes.” Liverpool Daily Post 12 Jan. 2008. 24 Aug. 2009 < http://www.liverpooldailypost.co.uk/liverpool-news/regional-news/2008/01/12/battery-farm-eggs-banned-from-schools-and-care-homes-64375-20342259 >. Lovelock, James. The Ages of Gaia: A Biography of Our Living Earth. New York: Bantam, 1990 (first published 1988). Mason, Jim, and Peter Singer. The Ethics of What We Eat. 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Beuning, Jeanette Gomez, and James Pierson. “East African Megadroughts between 135 and 75 Thousand Years Ago and Bearing on Early-modern Human Origins.” PNAS: Proceedings of the National Academy of the Sciences of the United States of America 104.42 (16 Oct. 2007): 16416–21. Sinclair, Upton. The Jungle. New York: Doubleday, Jabber & Company, 1906. Singer, Peter. Animal Liberation. New York: HarperCollins, 1975. (SFFB) Slow Food Foundation for Biodiversity. “Ark of Taste.” 2009. 24 Aug. 2009 < http://www.fondazioneslowfood.it/eng/arca/lista.lasso >. (UNISG) University of Gastronomic Sciences. “Who We Are.” 2009. 24 Aug. 2009 < http://www.unisg.it/eng/chisiamo.php >. Vileisis, Ann. Kitchen Literacy: How We Lost Knowledge of Where Food Comes From and Why We Need to Get It Back. Washington: Island Press/Shearwater Books, 2008. Weissbrodt, David, and Anti-Slavery International. Abolishing Slavery and its Contemporary Forms. 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The Alt Right Are Not Alright Academic explorations complicating both the Internet and whiteness have often focussed on the rise of the “alt-right” to examine the co-option of digital technologies to extend white supremacy (Daniels, “Cyber Racism”; Daniels, “Algorithmic Rise”; Nagle). The term “alt-right” refers to media organisations, personalities, and sarcastic Internet users who promote the “alternative right”, understood as extremely conservative, political views online. The alt-right, in all of their online variations and inter-grouping, are infamous for supporting white supremacy online, “characterized by heavy use of social media and online memes. Alt-righters eschew ‘establishment’ conservatism, skew young, and embrace white ethnonationalism as a fundamental value” (Southern Poverty Law Center). Theoretical studies of the alt-right have largely focussed on its growing presence across social media and websites such as Twitter, Reddit, and notoriously “chan” sites 4chan and 8chan, through the political discussions referred to as “threads” on the site (Nagle; Daniels, “Algorithmic Rise”; Hawley). As well, the ability of online users to surpass national boundaries and spread global white supremacy through the Internet has also been studied (Back et al.). The alt-right have found a home on the Internet, using its features to cunningly recruit members and to establish a growing community that mainstream politically extreme views (Daniels, “Cyber Racism”; Daniels, “Algorithmic Rise; Munn). This body of knowledge shows that academics have been able to produce critically relevant literature regarding the alt-right despite the online anonymity of the majority of its members. For example, Conway et al., in their analysis of the history and social media patterns of the alt-right, follow the unique nature of the Christchurch Massacre, encompassing the use and development of message boards, fringe websites, and social media sites to champion white supremacy online. Positioning my research in this literature, I am interested in contributing further knowledge regarding the alt-right, white supremacy, and the Internet by exploring the sinister conducting of Zoom-bombing anti-racist events. Here, I will investigate how white supremacy through the Internet can lead to violence, abuse, and fear that “transcends the virtual world to damage real, live humans beings” via Zoom-bombing, an act that is situated in a larger co-option of the Internet by the alt-right and white supremacists, but has been under theorised as a hate crime (Daniels; “Cyber Racism” 7). Shitposting I want to preface this chapter by acknowledging that while I understand the Internet, through my own external investigations of race, power and the Internet, as a series of entities that produce racial violence both online and offline, I am aware of the use of the Internet to frame, discuss, and share anti-racist activism. Here we can turn to the work of philosopher Michel de Certeau who conceived the idea of a “tactic” as a way to construct a space of agency in opposition to institutional power. This becomes a way that marginalised groups, such as racialised peoples, can utilise the Internet as a tactical material to assert themselves and their non-compliance with the state. Particularly, shitposting, a tactic often associated with the alt-right, has also been co-opted by those who fight for social justice and rally against oppression both online and offline. As Roderick Graham explores, the Internet, and for this exploration, shitposting, can be used to proliferate deviant and racist material but also as a “deviant” byway of oppositional and anti-racist material. Despite this, a lot can be said about the invisible yet present claims and support of whiteness through Internet and digital technologies, as well as the activity of users channelled through these screens, such as the alt-right and their digital tactics. As Vikki Fraser remarks, “the internet assumes whiteness as the norm – whiteness is made visible through what is left unsaid, through the assumption that white need not be said” (120). It is through the lens of white privilege and claims to white supremacy that online irony, by way of shitposting, is co-opted and understood as an inherently alt-right tool, through the deviance it entails. Their sinister co-option of shitposting bolsters audacious claims as to who has the right to exist, in their support of white identity, but also hides behind a veil of mischief that can hide their more insidious intention and political ideologies. The alt-right have used “shitposting”, an online style of posting and interacting with other users, to create a form of online communication for a translocal identity of white nationalist members. Sean McEwan defines shitposting as “a form of Internet interaction predicated upon thwarting established norms of discourse in favour of seemingly anarchic, poor quality contributions” (19). Far from being random, however, I argue that shitposting functions as a discourse that is employed by online communities to discuss, proliferate, and introduce white supremacist ideals among their communities as well as into the mainstream. In the course of this article, I will introduce racist Zoom-bombing as a tactic situated in shitposting which can be used as a means of white supremacist discourse and an attempt to block anti-racist efforts. By this line, the function of discourse as one “to preserve or to reproduce discourse (within) a closed community” is calculatingly met through shitposting, Zoom-bombing, and more overt forms of white supremacy online (Foucault 225-226). Using memes, dehumanisation, and sarcasm, online white supremacists have created a means of both organising and mainstreaming white supremacy through humour that allows insidious themes to be mocked and then spread online. Foucault writes that “in every society the production of discourse is at once controlled, selected, organised and redistributed according to a certain number of procedures, whose role is to avert its powers and danger, to cope with chance events, to evade ponderous, awesome materiality” (216). As Philippe-Joseph Salazar recontextualises to online white supremacists, “the first procedure of control is to define what is prohibited, in essence, to set aside that which cannot be spoken about, and thus to produce strategies to counter it” (137). By this line, the alt-right reorganises these procedures and allocates a checked speech that will allow their ideas to proliferate in like-minded and growing communities. As a result, online white supremacists becoming a “community of discourse” advantages them in two ways: first, ironic language permits the mainstreaming of hate that allows sinister content to enter the public as the severity of their intentions is doubted due to the sarcastic language employed. Second, shitposting is employed as an entry gate to more serious and dangerous participation with white supremacist action, engagement, and ideologies. It is important to note that white privilege is embodied in these discursive practices as despite this exploitation of emerging technologies to further white supremacy, there are approaches that theorise the alt-right as “crazed product(s) of an isolated, extremist milieu with no links to the mainstream” (Moses 201). In this way, it is useful to consider shitposting as an informal approach that mirrors legitimised white sovereignties and authorised white supremacy. The result is that white supremacist online users succeed in “not only in assembling a community of actors and a collective of authors, on the dual territory of digital communication and grass-roots activism”, but also shape an effective fellowship of discourse that audiences react well to online, encouraging its reception and mainstreaming (Salazar 142). Continuing, as McBain writes, “someone who would not dream of donning a white cap and attending a Ku Klux Klan meeting might find themselves laughing along to a video by the alt-right satirist RamZPaul”. This idea is echoed in a leaked stylistic guide by white supremacist website and message board the Daily Stormer that highlights irony as a cultivated mechanism used to draw new audiences to the far right, step by step (Wilson). As showcased in the screen capture below of the stylistic guide, “the reader is at first drawn in by curiosity or the naughty humor and is slowly awakened to reality by repeatedly reading the same points” (Feinburg). The result of this style of writing is used “to immerse recruits in an online movement culture built on memes, racial panic and the worst of Internet culture” (Wilson). Figure 1: A screenshot of the Daily Stormer’s playbook, expanding on the stylistic decisions of alt-right writers. Racist Zoom-Bombing In the timely text “Racist Zoombombing”, Lisa Nakamura et al. write the following: Zoombombing is more than just trolling; though it belongs to a broad category of online behavior meant to produce a negative reaction, it has an intimate connection with online conspiracy theorists and white supremacy … . Zoombombing should not be lumped into the larger category of trolling, both because the word “trolling” has become so broad it is nearly meaningless at times, and because zoombombing is designed to cause intimate harm and terrorize its target in distinct ways. (30) Notwithstanding the seriousness of Zoom-bombing, and to not minimise its insidiousness by understanding it as a form of shitposting, my article seeks to reiterate the seriousness of shitposting, which, in the age of COVID-19, Zoom-bombing has become an example of. I seek to purport the insidiousness of the tactical strategies of the alt-right online in a larger context of white violence online. Therefore, I am proposing a more critical look at the tactical use of the Internet by the alt-right, in theorising shitposting and Zoom-bombing as means of hate crimes wherein they impose upon anti-racist activism and organising. Newlands et al., receiving only limited exposure pre-pandemic, write that “Zoom has become a household name and an essential component for parties (Matyszczyk, 2020), weddings (Pajer, 2020), school and work” (1). However, through this came the strategic use of co-opting the application by the alt-right to digitise terror and ensure a “growing framework of memetic warfare” (Nakamura et al. 31). Kruglanski et al. label this co-opting of online tools to champion white supremacy operations via Zoom-bombing an example of shitposting: Not yet protesting the lockdown orders in front of statehouses, far-right extremists infiltrated Zoom calls and shared their screens, projecting violent and graphic imagery such as swastikas and pornography into the homes of unsuspecting attendees and making it impossible for schools to rely on Zoom for home-based lessons. Such actions, known as “Zoombombing,” were eventually curtailed by Zoom features requiring hosts to admit people into Zoom meetings as a default setting with an option to opt-out. (128) By this, we can draw on existing literature that has theorised white supremacists as innovation opportunists regarding their co-option of the Internet, as supported through Jessie Daniels’s work, “during the shift of the white supremacist movement from print to digital online users exploited emerging technologies to further their ideological goals” (“Algorithmic Rise” 63). Selfe and Selfe write in their description of the computer interface as a “political and ideological boundary land” that may serve larger cultural systems of domination in much the same way that geopolitical borders do (418). Considering these theorisations of white supremacists utilising tools that appear neutral for racialised aims and the political possibilities of whiteness online, we can consider racist Zoom-bombing as an assertion of a battle that seeks to disrupt racial justice online but also assert white supremacy as its own legitimate cause. My first encounter of local Zoom-bombing was during the Institute for Culture and Society (ICS) Seminar titled “Intersecting Crises” by Western Sydney University. The event sought to explore the concatenation of deeply inextricable ecological, political, economic, racial, and social crises. An academic involved in the facilitation of the event, Alana Lentin, live tweeted during the Zoom-bombing of the event: Figure 2: Academic Alana Lentin on Twitter live tweeting the Zoom-bombing of the Intersecting Crises event. Upon reflecting on this instance, I wondered, could efforts have been organised to prevent white supremacy? In considering who may or may not be responsible for halting racist shit-posting, we can problematise the work of R David Lankes, who writes that “Zoom-bombing is when inadequate security on the part of the person organizing a video conference allows uninvited users to join and disrupt a meeting. It can be anything from a prankster logging on, yelling, and logging off to uninvited users” (217). However, this beckons two areas to consider in theorising racist Zoom-bombing as a means of isolated trolling. First, this approach to Zoom-bombing minimises the sinister intentions of Zoom-bombing when referring to people as pranksters. Albeit withholding the “mimic trickery and mischief that were already present in spaces such as real-life classrooms and town halls” it may be more useful to consider theorising Zoom-bombing as often racialised harassment and a counter aggression to anti-racist initiatives (Nakamura et al. 30). Due to the live nature of most Zoom meetings, it is increasingly difficult to halt the threat of the alt-right from Zoom-bombing meetings. In “A First Look at Zoom-bombings” a range of preventative strategies are encouraged for Zoom organisers including “unique meeting links for each participant, although we acknowledge that this has usability implications and might not always be feasible” (Ling et al. 1). The alt-right exploit gaps, akin to co-opting the mainstreaming of trolling and shitposting, to put forward their agenda on white supremacy and assert their presence when not welcome. Therefore, utilising the pandemic to instil new forms of terror, it can be said that Zoom-bombing becomes a new means to shitpost, where the alt-right “exploits Zoom’s uniquely liminal space, a space of intimacy generated by users via the relationship between the digital screen and what it can depict, the device’s audio tools and how they can transmit and receive sound, the software that we can see, and the software that we can’t” (Nakamura et al. 29). Second, this definition of Zoom-bombing begs the question, is this a fair assessment to write that reiterates the blame of organisers? Rather, we can consider other gaps that have resulted in the misuse of Zoom co-opted by the alt-right: “two conditions have paved the way for Zoom-bombing: a resurgent fascist movement that has found its legs and best megaphone on the Internet and an often-unwitting public who have been suddenly required to spend many hours a day on this platform” (Nakamura et al. 29). In this way, it is interesting to note that recommendations to halt Zoom-bombing revolve around the energy, resources, and attention of the organisers to practically address possible threats, rather than the onus being placed on those who maintain these systems and those who Zoom-bomb. As Jessie Daniels states, “we should hold the platform accountable for this type of damage that it's facilitated. It's the platform's fault and it shouldn't be left to individual users who are making Zoom millions, if not billions, of dollars right now” (Ruf 8). Brian Friedberg, Gabrielle Lim, and Joan Donovan explore the organised efforts by the alt-right to impose on Zoom events and disturb schedules: “coordinated raids of Zoom meetings have become a social activity traversing the networked terrain of multiple platforms and web spaces. Raiders coordinate by sharing links to Zoom meetings targets and other operational and logistical details regarding the execution of an attack” (14). By encouraging a mass coordination of racist Zoom-bombing, in turn, social justice organisers are made to feel overwhelmed and that their efforts will be counteracted inevitably by a large and organised group, albeit appearing prankster-like. Aligning with the idea that “Zoombombing conceals and contains the terror and psychological harm that targets of active harassment face because it doesn’t leave a trace unless an alert user records the meeting”, it is useful to consider to what extent racist Zoom-bombing becomes a new weapon of the alt-right to entertain and affirm current members, and engage and influence new members (Nakamura et al. 34). I propose that we consider Zoom-bombing through shitposting, which is within “the location of matrix of domination (white supremacy, heteropatriarchy, ableism, capitalism, and settler colonialism)” to challenge the role of interface design and Internet infrastructure in enabling racial violence online (Costanza-Chock). Conclusion As Nakamura et al. have argued, Zoom-bombing is indeed “part of the lineage or ecosystem of trollish behavior”, yet these new forms of alt-right shitposting “[need] to be critiqued and understood as more than simply trolling because this term emerged during an earlier, less media-rich and interpersonally live Internet” (32). I recommend theorising the alt-right in a way that highlights the larger structures of white power, privilege, and supremacy that maintain their online and offline legacies beyond Zoom, “to view white supremacy not as a static ideology or condition, but to instead focus on its geographic and temporal contingency” that allows acts of hate crime by individuals on politicised bodies (Inwood and Bonds 722). This corresponds with Claire Renzetti’s argument that “criminologists theorise that committing a hate crime is a means of accomplishing a particular type of power, hegemonic masculinity, which is described as white, Christian, able-bodied and heterosexual” – an approach that can be applied to theorisations of the alt-right and online violence (136). This violent white masculinity occupies a hegemonic hold in the formation, reproduction, and extension of white supremacy that is then shared, affirmed, and idolised through a racialised Internet (Donaldson et al.). Therefore, I recommend that we situate Zoom-bombing as a means of shitposting, by reiterating the severity of shitposting with the same intentions and sinister goals of hate crimes and racial violence. References Back, Les, et al. “Racism on the Internet: Mapping Neo-Fascist Subcultures in Cyber-Space.” Nation and Race: The Developing Euro-American Racist Subculture. Eds. Jeffrey Kaplan and Tore Bjørgo. 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