Academic literature on the topic 'My Future is My Choice (Program : Namibia)'

Gender inequalities still affect the health and well-being of young people worldwide. Given the apprehensions among government and educators in a conservative context like Panama to implement comprehensive sexual education, there is a need for other educational efforts to stimulate healthy and respectful intimate relationships between adolescents. This article examines to what extent a newly developed Social-Emotional Learning (SEL) program, Me and My New World, provides a context in which students can learn to recognize and manage emotions, to care about others and themselves, make responsible decisions, develop social awareness. The program could additionally facilitate behavioral changes of young people towards more gender equality. Specifically, we focused on equal gender roles, equal rights in relationships and nonviolent problem solving, and present the qualitative effect evaluation among adolescents in Panama. The findings suggest that SEL-based lessons might broaden views on how young people experience the process of exploring identity formation, how assumptions of inequalities can be recreated through the lessons, and that SEL can emphasize the significance of choice and decision-making in interpersonal relationships. The perspectives, needs, and limitations highlighted by the adolescents living in a conservative context are highly valuable for improving future learning strategies for the development of healthier relationships.

This essay is written from my perspective as a program officer for research and training activities at the National Institute of General Medical Sciences (NIGMS) for almost 27 yr. It gives a bird's-eye view of the job of a program officer, which includes providing advice to applicants and grantees, making funding recommendations, overseeing grantees' progress, facilitating scientific opportunities in specific areas of program responsibility, and shaping NIGMS and National Institutes of Health (NIH) policy. I have highlighted the numerous rewards of serving as a program officer, as well as some of the difficulties. For those who may be considering a position as an NIH program officer now or in the future, I've also described the qualities and qualifications that are important for such a career choice. Finally, this essay addresses some of the challenges for the NIH and the research community in the years ahead as we simultaneously face exciting scientific opportunities and tighter budgets.

As a professor of theology with expertise in interreligious issues, I designed a January Term course on Hinduism set in south India. The course met liberal arts requirements and was designed for predominantly upper Midwestern students with Catholic and Protestant backgrounds. The focus was not on major sites but on meeting people in the countryside. Also, the course moved traditional learning and pedagogy into a living space by staying for six nights, during the Pongal harvest festival, in rural homes in Tamil Nadu. In terms of academics, the course was originally designed to focus on asceticism, the worship of Shiva, village goddesses, and the role of hill shrines in Tamil Nadu. The students would learn about these topics directly through the town, its inhabitants, and nearby religious sites. I did my best to prepare students for the experience, utilizing interviews, orientation sessions, on-site orientations, and assigned readings. My plans and preparations might seem to have been good, but at the midpoint of the course, on the first day in the small town, the program ground to a halt. Many students were emotionally devastated by the level of poverty. In this context, my lectures on asceticism, Shiva, goddesses, and hill shrines rang hollow and empty. Instead, the minds of the students were flooded by a host of other issues, including poverty, race, class, gender, environmental pollution. Although initially devastated by poverty, the students were quickly drawn into the life of the town. After only two days many frowns and tears turned into smiles. They were drawn in by the hospitality, the highly relational nature of the Tamil people, the exuberance and color of the Pongal celebrations, and the town’s rituals. Religion was a main facet of the experiences of the students, and this was key in terms of transforming their stay into a positive one, but my lectures on Shiva nevertheless rang empty. The students were experiencing a different aspect of the religion than what I had learned about in graduate school or was prepared to teach. Westerners tend to think of Asian religions in terms of meditation, asceticism, and philosophy, but the students were experiencing religion in terms of family intimacy, obedience to the elders, and hospitality to the stranger. I later found that the sixth century Tamil classic, the Tirukkural or “Holy Speech,” addresses the experiences of the students. The text gives instructions on how to live a virtuous life, and it discusses two main lifestyles, those of the ascetic and the householder. The former pertains to material that I was prepared to teach and the latter to the world my students were experiencing. There were a variety of lessons which the students, and students in future years, learned from the lifestyle of a Hindu householder. Lessons they wrote about in their journals included generosity to outsiders and guests, valuing family relations, that great joy can exist in the midst of poverty, and that Americans value individual choice, whereas Indians value collective decision making.

Chronic disease self-management (CDSM) courses have been shown to be effective in improving self-management, quality of life and clinical outcomes; however, participation rates in both generic and disease-specific courses are low. The objective of this qualitative study was to explore the attitudes, perceived behavioural control (PBC) and subjective norms of general practice patients with chronic diseases towards future participation in a CDSM course. The study, conducted in 2 006, used semi-structured interviews with a purposive sample of eight men and 11 women who had a chronic disease. The theory of planned behaviour provided a framework for a thematic analysis of the data identifying themes related to attitude, PBC and subjective norms. Nine themes were identified related to attitude. These included a desire for the opportunity to share/gain support; willingness to participate if they were provided with more/new information; basing their choice on severity of disease; trying the program out first; individual coping strategies; reliance on medical practitioner advice; needing some certainty or being afraid of future prospects; doing things in their own particular way; and deciding on the basis of proven results. Six themes emerged related to PBC, which revolved around structural barriers, time, transport, cost, mobility, convenient time and location. Three subjective norms were identified including encouragement from family/friends, medical practitioner and others with the same condition. Several positive attitudes such as the provision of information, opportunities to share and gain support and help with coping - which CDSM courses offer - could be capitalised on when promoting the courses. However, understanding other attitudes such as the importance of disease severity and a need to 'do it my way', reveal misconceptions about the aims of CDSM courses that need to be more clearly communicated when promoting courses. Structural barriers to participating in CDSM courses can easily be overcome by careful planning and adequate funding. Finally, general practitioner encouragement to attend CDSM courses could improve participation rates.

In my postgraduate formation during the last years of the 80’s, we had close to thirty hospital beds in a pavilion called “sépticas” (1). In Colombia, where abortion was completely penalized, the pavilion was mostly filled with women with insecure, complicated abortions. The focus we received was technical: management of intensive care; performance of hysterectomies, colostomies, bowel resection, etc. In those times, some nurses were nuns and limited themselves to interrogating the patients to get them to “confess” what they had done to themselves in order to abort. It always disturbed me that the women who left alive, left without any advice or contraceptive method. Having asked a professor of mine, he responded with disdain: “This is a third level hospital, those things are done by nurses of the first level”. Seeing so much pain and death, I decided to talk to patients, and I began to understand their decision. I still remember so many deaths with sadness, but one case in particular pains me: it was a woman close to being fifty who arrived with a uterine perforation in a state of advanced sepsis. Despite the surgery and the intensive care, she passed away. I had talked to her, and she told me she was a widow, had two adult kids and had aborted because of “embarrassment towards them” because they were going to find out that she had an active sexual life. A few days after her passing, the pathology professor called me, surprised, to tell me that the uterus we had sent for pathological examination showed no pregnancy. She was a woman in a perimenopausal state with a pregnancy exam that gave a false positive due to the high levels of FSH/LH typical of her age. SHE WAS NOT PREGNANT!!! She didn’t have menstruation because she was premenopausal and a false positive led her to an unsafe abortion. Of course, the injuries caused in the attempted abortion caused the fatal conclusion, but the real underlying cause was the social taboo in respect to sexuality. I had to watch many adolescents and young women leave the hospital alive, but without a uterus, sometime without ovaries and with colostomies, to be looked down on by a society that blamed them for deciding to not be mothers. I had to see situation of women that arrived with their intestines protruding from their vaginas because of unsafe abortions. I saw women, who in their despair, self-inflicted injuries attempting to abort with elements such as stick, branches, onion wedges, alum bars and clothing hooks among others. Among so many deaths, it was hard not having at least one woman per day in the morgue due to an unsafe abortion. During those time, healthcare was not handled from the biopsychosocial, but only from the technical (2); nonetheless, in the academic evaluations that were performed, when asked about the definition of health, we had to recite the text from the International Organization of Health that included these three aspects. How contradictory! To give response to the health need of women and guarantee their right when I was already a professor, I began an obstetric contraceptive service in that third level hospital. There was resistance from the directors, but fortunately I was able to acquire international donations for the institution, which facilitated its acceptance. I decided to undertake a teaching career with the hope of being able to sensitize health professionals towards an integral focus of health and illness. When the International Conference of Population and Development (ICPD) was held in Cairo in 1994, I had already spent various years in teaching, and when I read their Action Program, I found a name for what I was working on: Sexual and Reproductive Rights. I began to incorporate the tools given by this document into my professional and teaching life. I was able to sensitize people at my countries Health Ministry, and we worked together moving it to an approach of human rights in areas of sexual and reproductive health (SRH). This new viewpoint, in addition to being integral, sought to give answers to old problems like maternal mortality, adolescent pregnancy, low contraceptive prevalence, unplanned or unwanted pregnancy or violence against women. With other sensitized people, we began with these SRH issues to permeate the Colombian Society of Obstetrics and Gynecology, some universities, and university hospitals. We are still fighting in a country that despite many difficulties has improved its indicators of SRH. With the experience of having labored in all sphere of these topics, we manage to create, with a handful of colleagues and friend at the Universidad El Bosque, a Master’s Program in Sexual and Reproductive Health, open to all professions, in which we broke several paradigms. A program was initiated in which the qualitative and quantitative investigation had the same weight, and some alumni of the program are now in positions of leadership in governmental and international institutions, replicating integral models. In the Latin American Federation of Obstetrics and Gynecology (FLASOG, English acronym) and in the International Federation of Obstetrics and Gynecology (FIGO), I was able to apply my experience for many years in the SRH committees of these association to benefit women and girls in the regional and global environments. When I think of who has inspired me in these fights, I should highlight the great feminist who have taught me and been with me in so many fights. I cannot mention them all, but I have admired the story of the life of Margaret Sanger with her persistence and visionary outlook. She fought throughout her whole life to help the women of the 20th century to be able to obtain the right to decide when and whether or not they wanted to have children (3). Of current feminist, I have had the privilege of sharing experiences with Carmen Barroso, Giselle Carino, Debora Diniz and Alejandra Meglioli, leaders of the International Planned Parenthood Federation – Western Hemisphere Region (IPPF-RHO). From my country, I want to mention my countrywoman Florence Thomas, psychologist, columnist, writer and Colombo-French feminist. She is one of the most influential and important voices in the movement for women rights in Colombia and the region. She arrived from France in the 1960’s, in the years of counterculture, the Beatles, hippies, Simone de Beauvoir, and Jean-Paul Sartre, a time in which capitalism and consumer culture began to be criticized (4). It was then when they began to talk about the female body, female sexuality and when the contraceptive pill arrived like a total revolution for women. Upon its arrival in 1967, she experimented a shock because she had just assisted in a revolution and only found a country of mothers, not women (5). That was the only destiny for a woman, to be quiet and submissive. Then she realized that this could not continue, speaking of “revolutionary vanguards” in such a patriarchal environment. In 1986 with the North American and European feminism waves and with her academic team, they created the group “Mujer y Sociedad de la Universidad Nacional de Colombia”, incubator of great initiatives and achievements for the country (6). She has led great changes with her courage, the strength of her arguments, and a simultaneously passionate and agreeable discourse. Among her multiple books, I highlight “Conversaciones con Violeta” (7), motivated by the disdain towards feminism of some young women. She writes it as a dialogue with an imaginary daughter in which, in an intimate manner, she reconstructs the history of women throughout the centuries and gives new light of the fundamental role of feminism in the life of modern women. Another book that shows her bravery is “Había que decirlo” (8), in which she narrates the experience of her own abortion at age twenty-two in sixty’s France. My work experience in the IPPF-RHO has allowed me to meet leaders of all ages in diverse countries of the region, who with great mysticism and dedication, voluntarily, work to achieve a more equal and just society. I have been particularly impressed by the appropriation of the concept of sexual and reproductive rights by young people, and this has given me great hope for the future of the planet. We continue to have an incomplete agenda of the action plan of the ICPD of Cairo but seeing how the youth bravely confront the challenges motivates me to continue ahead and give my years of experience in an intergenerational work. In their policies and programs, the IPPF-RHO evidences great commitment for the rights and the SRH of adolescent, that are consistent with what the organization promotes, for example, 20% of the places for decision making are in hands of the young. Member organizations, that base their labor on volunteers, are true incubators of youth that will make that unassailable and necessary change of generations. In contrast to what many of us experienced, working in this complicated agenda of sexual and reproductive health without theoretical bases, today we see committed people with a solid formation to replace us. In the college of medicine at the Universidad Nacional de Colombia and the College of Nursing at the Universidad El Bosque, the new generations are more motivated and empowered, with great desire to change the strict underlying structures. Our great worry is the onslaught of the ultra-right, a lot of times better organized than us who do support rights, that supports anti-rights group and are truly pro-life (9). Faced with this scenario, we should organize ourselves better, giving battle to guarantee the rights of women in the local, regional, and global level, aggregating the efforts of all pro-right organizations. We are now committed to the Objectives of Sustainable Development (10), understood as those that satisfy the necessities of the current generation without jeopardizing the capacity of future generations to satisfy their own necessities. This new agenda is based on: - The unfinished work of the Millennium Development Goals - Pending commitments (international environmental conventions) - The emergent topics of the three dimensions of sustainable development: social, economic, and environmental. We now have 17 objectives of sustainable development and 169 goals (11). These goals mention “universal access to reproductive health” many times. In objective 3 of this list is included guaranteeing, before the year 2030, “universal access to sexual and reproductive health services, including those of family planning, information, and education.” Likewise, objective 5, “obtain gender equality and empower all women and girls”, establishes the goal of “assuring the universal access to sexual and reproductive health and reproductive rights in conformity with the action program of the International Conference on Population and Development, the Action Platform of Beijing”. It cannot be forgotten that the term universal access to sexual and reproductive health includes universal access to abortion and contraception. Currently, 830 women die every day through preventable maternal causes; of these deaths, 99% occur in developing countries, more than half in fragile environments and in humanitarian contexts (12). 216 million women cannot access modern contraception methods and the majority live in the nine poorest countries in the world and in a cultural environment proper to the decades of the seventies (13). This number only includes women from 15 to 49 years in any marital state, that is to say, the number that takes all women into account is much greater. Achieving the proposed objectives would entail preventing 67 million unwanted pregnancies and reducing maternal deaths by two thirds. We currently have a high, unsatisfied demand for modern contraceptives, with extremely low use of reversible, long term methods (intrauterine devices and subdermal implants) which are the most effect ones with best adherence (14). There is not a single objective among the 17 Objectives of Sustainable Development where contraception does not have a prominent role: from the first one that refers to ending poverty, going through the fifth one about gender equality, the tenth of inequality reduction among countries and within the same country, until the sixteenth related with peace and justice. If we want to change the world, we should procure universal access to contraception without myths or barriers. We have the moral obligation of achieving the irradiation of extreme poverty and advancing the construction of more equal, just, and happy societies. In emergency contraception (EC), we are very far from reaching expectations. If in reversible, long-term methods we have low prevalence, in EC the situation gets worse. Not all faculties in the region look at this topic, and where it is looked at, there is no homogeneity in content, not even within the same country. There are still myths about their real action mechanisms. There are countries, like Honduras, where it is prohibited and there is no specific medicine, the same case as in Haiti. Where it is available, access is dismal, particularly among girls, adolescents, youth, migrants, afro-descendent, and indigenous. The multiple barriers for the effective use of emergency contraceptives must be knocked down, and to work toward that we have to destroy myths and erroneous perceptions, taboos and cultural norms; achieve changes in laws and restrictive rules within countries, achieve access without barriers to the EC; work in union with other sectors; train health personnel and the community. It is necessary to transform the attitude of health personal to a service above personal opinion. Reflecting on what has occurred after the ICPD in Cairo, their Action Program changed how we look at the dynamics of population from an emphasis on demographics to a focus on the people and human rights. The governments agreed that, in this new focus, success was the empowerment of women and the possibility of choice through expanded access to education, health, services, and employment among others. Nonetheless, there have been unequal advances and inequality persists in our region, all the goals were not met, the sexual and reproductive goals continue beyond the reach of many women (15). There is a long road ahead until women and girls of the world can claim their rights and liberty of deciding. Globally, maternal deaths have been reduced, there is more qualified assistance of births, more contraception prevalence, integral sexuality education, and access to SRH services for adolescents are now recognized rights with great advances, and additionally there have been concrete gains in terms of more favorable legal frameworks, particularly in our region; nonetheless, although it’s true that the access condition have improved, the restrictive laws of the region expose the most vulnerable women to insecure abortions. There are great challenges for governments to recognize SRH and the DSR as integral parts of health systems, there is an ample agenda against women. In that sense, access to SRH is threatened and oppressed, it requires multi-sector mobilization and litigation strategies, investigation and support for the support of women’s rights as a multi-sector agenda. Looking forward, we must make an effort to work more with youth to advance not only the Action Program of the ICPD, but also all social movements. They are one of the most vulnerable groups, and the biggest catalyzers for change. The young population still faces many challenges, especially women and girls; young girls are in particularly high risk due to lack of friendly and confidential services related with sexual and reproductive health, gender violence, and lack of access to services. In addition, access to abortion must be improved; it is the responsibility of states to guarantee the quality and security of this access. In our region there still exist countries with completely restrictive frameworks. New technologies facilitate self-care (16), which will allow expansion of universal access, but governments cannot detach themselves from their responsibility. Self-care is expanding in the world and can be strategic for reaching the most vulnerable populations. There are new challenges for the same problems, that require a re-interpretation of the measures necessary to guaranty the DSR of all people, in particular women, girls, and in general, marginalized and vulnerable populations. It is necessary to take into account migrations, climate change, the impact of digital media, the resurgence of hate discourse, oppression, violence, xenophobia, homo/transphobia, and other emergent problems, as SRH should be seen within a framework of justice, not isolated. We should demand accountability of the 179 governments that participate in the ICPD 25 years ago and the 193 countries that signed the Sustainable Development Objectives. They should reaffirm their commitments and expand their agenda to topics not considered at that time. Our region has given the world an example with the Agreement of Montevideo, that becomes a blueprint for achieving the action plan of the CIPD and we should not allow retreat. This agreement puts people at the center, especially women, and includes the topic of abortion, inviting the state to consider the possibility of legalizing it, which opens the doors for all governments of the world to recognize that women have the right to choose on maternity. This agreement is much more inclusive: Considering that the gaps in health continue to abound in the region and the average statistics hide the high levels of maternal mortality, of sexually transmitted diseases, of infection by HIV/AIDS, and the unsatisfied demand for contraception in the population that lives in poverty and rural areas, among indigenous communities, and afro-descendants and groups in conditions of vulnerability like women, adolescents and incapacitated people, it is agreed: 33- To promote, protect, and guarantee the health and the sexual and reproductive rights that contribute to the complete fulfillment of people and social justice in a society free of any form of discrimination and violence. 37- Guarantee universal access to quality sexual and reproductive health services, taking into consideration the specific needs of men and women, adolescents and young, LGBT people, older people and people with incapacity, paying particular attention to people in a condition of vulnerability and people who live in rural and remote zone, promoting citizen participation in the completing of these commitments. 42- To guarantee, in cases in which abortion is legal or decriminalized in the national legislation, the existence of safe and quality abortion for non-desired or non-accepted pregnancies and instigate the other States to consider the possibility of modifying public laws, norms, strategies, and public policy on the voluntary interruption of pregnancy to save the life and health of pregnant adolescent women, improving their quality of life and decreasing the number of abortions (17).

OBJECTIVES/SPECIFIC AIMS: Electronic health records have become the fulcrum for efforts by institutions to reduce errors, improve safety, reduce cost, and improve compliance with recommended guidelines. In recent times they are also being considered as a potential game changer for improving patient recruitment for clinical trials (CT). Although the use of CDS for clinical care is partially understood, its use for CT patient identification and recruitment is young and a great deal of experimental and theoretical research is needed in this area to optimize the use of CDS tools that personalize patient care by identifying relevant clinical trials and other research interventions. The use of CDS tools for CT recruitment offers a great deal of possibilities, but some initial usage has been disappointing. This may not be surprising because, while the implementation of these interventions is somewhat simple, ensuring that they are embedded into the right point of the care providers workflow is highly complex and may affect many actors in a clinical care setting, including patients, nurses, physicians, clinical coordinators, and investigators. Overcoming the challenges of alerting providers regarding their patient’s eligibility for clinical trials is an important and difficult challenge. Translating that effort into effective recruitment will require understanding of the psychological and workflow barriers and facilitators for how providers respond to automated alerts requesting patient referrals. Evidence from using CDS for clinical care that shows alerts become increasingly ignored over time or with more exposure (1, 2). The features, timing, and method of these alerts are important usability factors that may influence effectiveness of the referral process. Focus group methods capture the shared perspectives of a phenomenon and have been shown to be an effective method for identifying perceptions, attitudes, information needs, and other human factors effecting workflow (3, 4). Our objective was to develop a generalizable method for measuring physician and clinic level factors defining a successful point of care recruitment program in an outpatient care setting. To achieve this we attempted to (a) Characterize provider’s attitudes regarding CTs referrals and research. (b) Identify perceived workflow strategies and facilitators relevant to CT recruitment in primary care. (c) Develop and test a pilot instrument. METHODS/STUDY POPULATION: The methods had 3 phases: focus groups, development of item pool, and tool development. Focus group topics were developed by 4 experienced investigators, with training in biomedical informatics, cognitive psychology, human factors, and workflow analysis, based upon a knowledge of the literature. A script was developed and the methods were piloted with a group of 4 clinicians. In all, 16 primary care providers, 5 clinic directors, and 6 staff supervisors participated in 6 focus groups, with an average of 5 participants each, to discuss clinical trial recruitment at the point of care. Focus groups were conducted by the development team. Audio recording were content coded and analyzed to identify themes by consensus of 3 authors. Item Pool generation involved extracting items identified in the focus group analysis, selecting a subset deemed most interesting based on knowledge of the recruitment literature and iteratively writing and refining questions. Instrument development consisted of piloting an initial 7-item questionnaire with a local primary provider sample. Questions were correlated with the item pool and limited to reduce provider burden, based on those that the study team deemed most applicable to information technology supported recruitment. Descriptive statistical analysis was performed on the pilot survey results. An online survey was developed based on the findings of the focus groups and emailed to 127 primary care providers who were invited to participate. In total, 36 questionnaires were completed. This study was approved by the University of Utah Institutional Review Board. RESULTS/ANTICIPATED RESULTS: The results section is organized into 3 sections: (a) Focus groups, (b) Item generation; and (c) Questionnaire pilot. (I) (1) Focus Groups. Themes identified through a qualitative review are presented below with illustrative comments of participants. The diversity of attitudes and willingness to support clinical trial recruitment varied so substantially that no single pattern emerged. Attitudes ranged from enthusiastic support, to interest in some trials to disinterest or distrust in trials in general. Compensation for time spent, which could be monetary, informational, or through professional recognition; and provider relationship with the study team or pre-selection of specific trials by a clinic oversight committee, and importance to providers practice positively affected willingness to help recruit. “I would love to get people into clinical trials as much as possible... If it works for them you are going to help a whole lot of other people.” If we felt like we have done every possible thing that was already established as evidence-based and it didn’t work out, then we would consider the trials. I think that studies are more beneficial for specific specialists... There might be a whole slew of things that I never deal with or don’t care about because it’s not prevalent for my patient population. Local and reputable... A long distance someone asking to do something is just not the same as someone in the trenches with you. The bottom line is how much work is involved at our end and if there is going to be any compensation for that. I think also the providers would like have feedback on what they referred them to. And how did it go? So did we pick the right patient? ... It helps us to know, did they even sign up for the study? Getting your name on a research paper would be nice too. Lack of information regarding trials reduced support for recruitment of patients. Providers stated that they do not know how to quickly find information about studies, nor do they have time to find the information, and therefore cannot efficiently council patients regarding trial participation. Notifications regarding clinical trials that were deemed to be important included: Trial coordinator intention to recruit patients, enrollment of a patient in a clinical drug trial, trial progress and result updates, and reports of effectiveness of provider recruitment efforts. Perceived information needs regarding trials that providers are referring patients to included: trial purpose, design, benefits and risks, potential side effects, intervention details, medication class (mechanism of action), drug interactions with study drug, study timeline, coordinator contact information, link to print off patient handouts, enrollment instructions, and a link to study website. (2) It’s just we don’t know any of the information ... and it can’t take any of our time. ... I don’t have time to research it. Sometimes the patients ask me questions about it and I would like to be in a position where I have some information about it before I am asked. It would be nice to be notified if they [my patients] are enrolled in the trial, when it turns into actual recruitment. I do like to know if they’re in [a trial] so that when they come in for problems, I at least know that they might be on a study medication so I can be safe. I’ll get an ER message, “The patient got admitted. There blood pressure’s, you know, tanked, because they’re on a study drug I didn’t know anything about.” if there’s certain side effects that I need to be watching out for. It would also be good to have a contact person from the study in case we need to notify them of. “this person’s possible having an adverse event. Look into it more.” (3) Provider burden associated with patient recruitment appeared to be a deterrent. These burdens included adding to the providers task list, increasing the time required to complete a visit, and usurpation of control over the patients care plan with the associated effect on provider quality scores. We don’t have time. I mean, we don’t even take a lunch break. I have 15 minutes and now this is taking this many minutes away from my 15 minutes. I am just sick of extra work. We already have so much extra work. It’s just more stuff to do. We are maxed out on stuff to do. Right now, part of our compensation depends on having our patients A1Cs controlled. And so if we’re taking a chance that maybe they’re getting a medicine, maybe they’re not, maybe it’ll help, maybe it won’t, its gonna further delay our ability to get paid. Cause they’re like “I’m not going to let you go mess up my patient and I’m going to have to deal with the consequences is kind of the way they think. If you’re going to put the patient in a study, being able drop them from our registry so we don’t get penalized for a negative outcome [is important]. (4) Patient’s needs were a priority among factors influencing likelihood to help recruitment patients. Providers considered perceived benefit or risk to the patient, such as additional healthcare services, increased monitoring, financial assistance, or access to new treatments when other options have been ineffective, important; as well as continuance of established care that has proven effective, and ethical recruitment that addresses language and mental health to ensure that patients can make decisions regarding study participation. If there’s something great that’s gonna benefit a patient, I would definitely wanna know about it to give them that option. You know that’s what we wanna try to do is make our patients better. Someone who is really well controlled and doing well, I would not tend to put them toward the study. Just keep going with what’s working right now. Sometimes there’s financial incentives for them to participate, so you know, if its a good fit its easy to at least offer that to the patient. They get treatment maybe that they can’t afford. You don’t want to be seen as somebody who's forcing a patient... if their provider is telling them this is a good idea you are more likely to get your patient to do it. I think they have to understand what a clinical trial is, first of all, in that it’s a trial. Right? We’re trying to figure out if a certain treatment is good or not. It may not work. It may work. With many patients, they don’t only have medical problems, but significant mental illness that sometimes interferes a lot with just our treatment of them here for their clinical problems. And so, that probably would interfere with someone’s ability to understand and consent to a trial. And the patients have the right to make that choice. I don’t need to be—I don’t mind influencing them on things I know about, I think are invaluable, but I don’t need to be a barrier to them. (5) Perceived responsibility in trial recruitment varied substantially, from no involvement at all, to prescreening, counseling, or recruiting patients. Some providers felt that they should have the right to say “no” to recruitment of their patients while others believed prescreening was an unnecessary burden, outside of their role as a primary care provider. if someone prescreens and thinks its appropriate and gives me that judgment call to say, do you think it would be a good fit? I think one of them, they sent, and I said, Oh, I don’t think it would be a good fit because of this...So that would be fine. I don’t think I need to be a gatekeeper for studies. I mean, if there’s people that qualify for a study, and there’s a great study that’s been approved, and they can recruit them without me knowing, that doesn’t bother me in the slightest. I liked how it was—I could do a simple referral ... someone else figured out the qualifications. if we knew of ongoing studies and if we thought a certain patient may qualify for a certain study, we just contact the coordinator, and then they just take care of the rest. I think that appropriate ... from our perspective, would be, “Are you interested?” “This is the number for a person who can sit with you, talk with you about a trial, tell you everything about it, answer your questions, and then you can make a decision.” I’m not going to let you go mess up my patient and I’m going to have to deal with the consequences. (6) A clinic-implementation approach that systemizes workflow, limits the number of trials providers are asked to recruit for, and minimizes provider time burden is needed. Suggested methods for informing providers of patient clinical trial eligibility included: email, alerts, in-basket messages, texts, phone-calls, and in-person contact. People are so sick of change, change, change, change ... if there’s no stability whatsoever, then people get frustrated and start to burn out. Having my staff remember how to do it correctly and I remember what studies we have going ... it becomes somewhat of a burden... it’s hard for us to remember as we are flying through our day. There just needs to be a clear understanding with those roles... Who does the patient call? We don’t want to look like we don’t know what we are doing. There probably should be a selection committee put together from various people who have stakes in the community, at least who can say, “This would be applicable for xx clinic.” (7) Provider Suggestions Providers had multiple suggestions regarding notification methods. (II) Development of item pool and construction of questionnaire The specific items were constructed from literature review on physician’s attitudes and results from the focus group. The overarching concern was on readability, brief questionnaire size, and relevance. A large item were constructed and then reduced through piloting. (III) Questionnaire Pilot Results: The 7-item pilot questionnaire was completed by 36 physicians (28% response rate). In this section, we report the empirical results. DISCUSSION/SIGNIFICANCE OF IMPACT: Discussion Relevance of Methods. Overall, the described methods for determining components for a recruitment program in primary care shows early promise. The focus groups that consisted of providers, staff and administrators resulted in insights as to workflows, attitudes, and clinical processes. These insights significantly varied across clinics. This variation supported the need for an individualized clinic-based approach that will meet local needs. During the course of the study, participants were willing to participate in all activities (although some requested payment). We were able to conduct the focus groups as scheduled and obtained the desired input. The analysis of the focus group transcripts was performed using iterative discussions and did not needed any special adaptation for this area of study. The pilot survey response rate was within the expected for this type of study. Focus groups can rapidly provide rich information regarding attitudes and other factors affecting provider participation at the point of care. However, findings from focus groups must always be confirmed through larger studies. It is important to keep the focus groups small and to hold multiple focus groups to offset the more vocal participants that may influence comments of others. This study shows that using our 3-step approach it is possible to gather important information on clinician’s and staff perceptions and needs to participate in point of care patient recruitment for CT. The focus groups also provide an important step for survey construction. Designing surveys empirically requires multiple validation efforts, which will be conducted in the future. However, we can draw preliminary conclusions from the results of the pilot study which are quite informative and they are discussed below. Near future work will be to expand the response rate through additional local survey and conduct formal psychometric testing and validation both locally and nationally. A final validation will be proposed through the CTSA consortiums. Variation in responses. There was a lack of normal curves in our survey results. This points to the need to target education and recruitment efforts by provider type (with similar perspectives). Identification of these types would be useful. Some specific points regarding variability that should be considered in program design. Preferences for trail recruitment methods. Many trial recruitment notification methods have the potential to be successful when used judiciously and done well, particularly if the trial coordinator/provider relationship is supported by reciprocal benefits to the provider. Consistency in workflow within seems paramount to success. Providers can pull some notifications at a time they choose, while other notifications interrupt and must be used sparingly. Some allow review of multiple patients at the same time, and some foster easy access to the patient’s medical record. Conclusions. The authors recommend that recruitment HIT be customizable at the clinic and provider level by responsibility and interest to allow selection of level of information, delivery method, that is, email, text, in-basket, alert, dashboard, mail; frequency of notification, and an opt out feature. These customizable options will allow for better support of clinic workflow or goals. There is the potential with machine learning technology to monitor provider interactions with trial notifications and for the system to automatically make adjustments to the method and level that best supports each physician. Limitations: The major limitation is the focus on one site only and one delivery system (university based). The low response makes generalization difficult. Efforts to improve the rate are underway. Many populations are under-represented in Utah. Full psychometric analysis was not conducted but will part of the final project.

There are different apprehensions regarding the contemporary assessment system. Often, I listen to my colleagues saying that multiple-choice questions are seen as easier to score. Why can’t all assessments be multiple-choice tests? Some others would say, whether the tests given reflect what students will need to know as competent professionals? What evidence can be collected to make sure that test content is relevant? Others come up with concerns that there is a perception amongst students that some examiners are harsher than others and some tasks are easier than others. What can be done to evaluate whether this is the case? Sometimes, the students come up with queries that they are concerned about being observed when interacting with patients. They are not sure why this is needed. What rationale is there for using workplace-based assessment? Some of the students worry if the pass marks for the assessments are ‘correct’, and what is the evidence for the cut-off scores? All these questions are important, and I would deliberate upon them with evidence from the literature. Deliberating on the first query of using multiple-choice questions for everything, we know that assessment of a medical student is a complex process as there are multiple domains of learning such as cognition, skills, and behaviors (Norcini and McKinley, 2007)(Boulet and Raymond, 2018). Each of the domains further has multiple levels from simple to complex tasks (Norcini and McKinley, 2007). For example, the cognition is further divided into six levels, starting from recall (Cognition level 1 or C1) up to creativity (Cognition level 6 or C6) (Norcini and McKinley, 2007). Similarly, the skills and behaviors also have levels starting from observation up to performance and practice (Norcini and McKinley, 2007). Moreover, there are different competencies within each domain that further complicates our task as an assessor to appropriately assess a student (Boulet and Raymond, 2018). For instance, within the cognitive domain, it is not just making the learning objectives based on Bloom’s Taxonomy that would simplify our task because the literature suggests that individuals have different thinking mechanisms, such as fast and slow thinking to perform a task (Kahneman, 2011). We as educationalists do not know what sort of cognitive mechanism have we triggered through our exam items (Swanson and Case, 1998). Multiple Choice Questions is one of the assessment instruments to measure competencies related to the cognitive domain. This means that we cannot use multiple-choice questions to measure the skills and behaviors domains, so clearly multiple-choice questions cannot assess all domains of learning (Vleuten et al, 2010). Within the cognitive domain, there are multiple levels and different ways of thinking mechanisms (Kahneman, 2011). Each assessment instrument has its strength and limitations. Multiple-choice questions may be able to assess a few of the competencies, also with some added benefits in terms of marking but there always are limitations. The multiple-choice question is no different when it comes to the strengths and limitations profile of an assessment instrument (Swanson and Case, 1998). There are certain competencies that can be easily assessed using multiple-choice questions (Swanson and Case, 1998). For example, content that requires recall, application, and analysis can be assessed with the help of multiple-choice questions. However, creativity or synthesis which is cognition level six (C6) as per Blooms’ Taxonomy, cannot be assessed with closed-ended questions such as a multiple-choice question. This means that we need some additional assessment instruments to measure the higher levels of cognition within the cognitive domain. For example, asking students to explore an open-ended question as a research project can assess the higher levels of cognition because the students would be gathering information from different sources of literature, and then synthesizing it to answer the question. It is reported that marking and reading the essay questions would be time-consuming for the teachers (McLean and Gale, 2018). Hence, the teacher to student’s ratio in assessing the higher levels of cognition needs to be monitored so that teachers or assessors can give appropriate time to assess the higher levels of cognition of their students. Hence, we have to use other forms of assessment instruments along with multiple-choice questions to assess the cognitive domain. This will help to assess the different levels of cognition and will also incite the different thinking mechanisms. Regarding the concerns, whether the tests given reflect what students will need to know as competent professionals? What evidence can be collected to make sure that test content is relevant? It is one of an important issue for medical education and assessment directors whether the tests that they are taking are reflective of the students being competent practitioners? It is also quite challenging as some of the competencies such as professionalism or professional identity formation are difficult to be measured quantitatively with the traditional assessment instruments (Cruess, Cruess, & Steinert, 2016). Moreover, there is also a question if all the competencies that are required for a medical graduate can be assessed with the assessment instruments presently available? Hence, we as educationalists have to provide evidence for the assessment of required competencies and relevant content. One of the ways that we can opt is to carefully align the required content with their relevant assessment instruments. This can be done with the help of assessment blueprints, or also known as the table of specifications in some of the literature (Norcini and McKinley, 2013). An assessment blueprint enables us to demonstrate our planned curriculum, that is, what are our planned objectives, and how are we going to teach and assess them (Boulet and Raymond, 2018). We can also use the validity construct in addition to the assessment blueprints to provide evidence for testing the relevant content. Validity means that the test is able to measure what it is supposed to measure (Boulet and Raymond, 2018). There are different types of validity but one of the validity that is required in this situation to establish the appropriateness of the content is the Content Validity. Content validity is established by a number of subject experts who comment on the appropriateness and relevance of the content (Lawshe, 1975). The third method by which the relevance of content can be established is through standard-setting. A standard is a single cut-off score to qualitatively declare a student competent or incompetent based on the judgment of subject experts (Norcini and McKinley, 2013). There are different ways of standard-setting for example Angoff, Ebel, Borderline method, etc. (Norcini and McKinley, 2013). Although the main purpose is the establishment and decides the cut-off score during the process, the experts also debate on the appropriateness and relevance of the content. This means that the standard-setting methods also have validity procedures that are in-built in their process of establishing the cut-off score. These are some of the methods by which we can provide evidence of the relevance of the content that is required to produce a competent practitioner. The next issue is the perception amongst students that some examiners are harsher than others and some tasks are easier than others. Both these observations have quite a lot of truth in them and can be evaluated following the contemporary medical education evaluation techniques. The first issue reported is that some examiners are harsher than others. In terms of assessment, it has been reported in the literature as ‘hawk dove effect’ (McManus et al, 2006, Murphy et al, 2009). There are different reasons identified in the literature for some of the examiners to be more stringent than others such as age, ethnic background, behavioral reasons, educational background, and experience in a number of years (McManus et al, 2006). Specifically, those examiners who are from ethnic minorities and have more experience show more stringency (McManus et al, 2006). Interestingly, it has been reported elsewhere how the glucose levels affect the decision making of the pass-fail judgments (Kahneman, 2011). There are psychometric methods reported in the literature, such as Rasch modeling that can help determine the ‘hawk dove effect’ of different examiners, and whether it is too extreme or within a zone of normal deviation (McManus et al, 2006, Murphy, et al, 2009). Moreover, the literature also suggests ways to minimize the hawk-dove effect by identifying and paring such examiners so the strictness of one can be compensated by the leniency of the other examiner (McManus et al, 2006). The other issue in this situation is that the students find some tasks easier than others. This is dependent on the complexity of tasks and also on the competence level of students. For example, a medical student may achieve independent measuring of blood pressure in his/her first year but even a consultant surgeon may not be able to perform complex surgery such as a Whipple procedure. This means that while developing tasks we as educationalists have to consider both the competence level of our students and the complexity of the tasks. One way to theoretically understand it is by taking help from the cognitive load theory (Merrienboer 2013). The cognitive load theory suggests that there are three types of cognitive loads; namely, the Intrinsic, Extraneous, and Germane loads (Merrienboer 2013). The intrinsic load is associated with the complexity of the task. The extraneous load is added to the working memory of students due to a teacher who does not plan his/her teaching session as per students' needs (Merrienboer 2013). The third load is the germane or the good load that helps the student to understand the task and is added by using teaching methods that helps students understand the task (Merrienboer 2013). The teachers can use different instructional designs such as the 4CID model to plan their teaching session of the complex tasks (Merrienboer 2013). One of the ways to understand the difficulty of the task can be to pilot test the task with few students or junior colleagues. Another way to determine the complexity of the task can be through standard-setting methods where a cut-off score is established after the experts discuss each task and determine its cut-off score based on their judgments (Norcini and McKinley, 2013). However, it is important that the experts who have been called for setting standards have relevant experience so as to make credible judgments (Norcini and McKinley, 2013). A third way to evaluate the complexity of tasks is by applying the post-exam item analysis techniques. The difficulty of the task is evaluated after the performance of students in the exam. Each item’s difficulty in the exam can be measured. The items can be placed from extremely easy (100% students correctly answered the item) to extremely difficult (100% students failed on that specific item). The item analysis enables the teachers to determine which tasks were easier in exams as compared to more difficult tasks. Another concern that comes from students is about their observation when interacting with patients. Health professions training programs require the interaction of students with patients. The student-patient interaction is not very often in initial years of student’s training due to the issues of patient safety, and due to the heavy workload on clinical faculty. However, with the passage of time in the training program, these student patient interactions increase. There is also a strong theoretical basis for better learning when the students are put in a context or a given situation (Wenger, 1998). For example, infection control can be taught through a lecture however the learning can be more effective if the students practically learn it in an operation theatre. Moreover, the undergraduate students or foundation year house job doctors are yet not competent enough to practice independently and require supervision for the obvious reasons of patient safety. Although, some of the students may not like being observed it is one of the requirements for their training. The examiners observing them can give them constructive feedback to further improve their performance (Etheridge and Boursicot, 2013). Feedback is one of the essential components of workplace-based assessments, and it is suggested in the literature that the time for feedback to the student should be almost equal to one-third of the procedure or task time (Etheridge and Boursicot, 2013), that is, for a fifteen minutes tasks, there should be at least five minutes for the feedback hence having a total of twenty minutes time on the whole. Further, it is important for the examiners and senior colleagues to establish trust in the competence of their students or trainees. The ‘trust’ is one of the behavioral constructs that also starts initially with an observation (Etheridge and Boursicot, 2013). Hence, observation of students or house officers by senior colleagues or teachers during clinical encounters is important to establish trust in student’s competence levels. Additionally, in the workplace, there are different skills that are required by the students to demonstrate, and each skill is quite different to others. There are different workplace-based assessment instruments and each of them assesses only certain aspects of student’s performance during clinical practice. For instance, the Mini Clinical Evaluation Exercise (Mini-CEX) can primarily assess the history taking and physical examination skills of students (Etheridge and Boursicot, 2013). Similarly, the Directly Observed Procedural Skills (DOPS) is required to assess the technical and procedural skills of students (Etheridge and Boursicot, 2013). More so, the Case-based Discussion (CBD) is required to assess clinical reasoning skills, decision-making skills, ethics, and professionalism (Etheridge and Boursicot, 2013). Further, multi-source feedback (MSF) or 360-degree assessment collects feedback about a student on their performance from multiple sources such as patients, senior and junior colleagues, nursing staff, and administrative staff (Etheridge and Boursicot, 2013). All these workplace-based assessments require observation of students so they can be given appropriate feedback on their technical and nontechnical skills (Etheridge and Boursicot, 2013). Hence, clinical encounters at the workplace are quite complex and require training of students from different aspects to fully train them that cannot be accomplished without observation. Some students also worry whether the pass marks for the assessments are ‘correct’, and what is the evidence for the cut-off score in their exams? A standard is a single cut-off score that determines the competence of a student in a particular exam (Norcini and McKinley, 2013). The cut-off score is decided by experts who make a qualitative judgment (Norcini and McKinley, 2013). The purpose is not to establish an absolute truth but to demonstrate the creditability of pass-fail decisions in an exam (Norcini and McKinley, 2013). There are certain variables related to standard setters that may affect the creditability of the standard-setting process; such as age, gender, ethnicity, their understanding of the learners, their educational qualification, and their place of work. Moreover, the definition of competence varies with time, place and person (Norcini and McKinley, 2013). Hence, it is important that the standard setters must know the learners and the competence level expected from them and the standard setters must be called from different places. This is one of the first requirements to have the profile of the standard setters to establish their credibility. Moreover, the selection of the method of standard setting is important, and how familiar are the standard setters with the method of standard-setting. There are many standard-setting methods for different assessment instruments and types of exams (Norcini and McKinley, 2013). It is essential to use the appropriate standard-setting method, and also to train the standard setters on that method of standard setting so they know the procedure. The training can be done by providing them certain data to solve it following the steps of the standard-setting procedure. The record of these exercises is important and can be required at later stages to show the experience of the standard setters. Further, every standard-setter writes a cut-off score for each item (Norcini and McKinley, 2013). The mean score of all the standard setters is calculated to determine the cut-off score for each item (Norcini and McKinley, 2013). The total cut-off score is calculated by adding the pass marks of each individual item (Norcini and McKinley, 2013). The cut-off scores for items would also help in differentiating the hawks from doves, that is, those examiners who are quite strict from those who are lenient (McManus et al, 2006). Hence, it is important to keep the record of these cut-off scores of each item for future records and to have a balanced standard-setting team for future exams (Norcini and McKinley, 2013). Additionally, the meeting minutes is an important document to keep the record for the decisions made during the meeting. Lastly, the exam results and post-exam item analysis is an important document to see the performance of students on each item and to make comparisons with the standard-setting meeting (Norcini and McKinley, 2013). It would be important to document the items that behaved as predicted by the standard setters and those items that would show unexpected responses; for example, the majority of the borderline students either secured quite high marks than the cut-off score or vice versa (Norcini and McKinley, 2013). All the documents mentioned above would ensure the creditability of the standard-setting process and would also improve the quality of exam items. There are many other aspects that could not be discussed in this debate on the contemporary assessment system in medical education. Another area that needs deliberations is the futuristic assessment system and how it would address the limitations of the current system? Disclaimer: This work is derived from one of the assignments of the author submitted for his certificate from Keele University. -------------------------------------------------------------------------- References Boulet, J. and Raymond, M. (2018) ‘Blueprinting: Planning your tests. FAIMER-Keele Master’s in Health Professions Education: Accreditation and Assessment. Module 1, Unit 2.’, FAIMER Centre for Distance Learning, CenMEDIC. 6th edn. London, pp. 7–90. Cruess, R. L., Cruess, S. R., & Steinert, Y. (2016). ‘Amending Miller’s pyramid to include professional identity formation’. Acad Med, 91(2), pp. 180–185. Etheridge, L. and Boursicot, K. (2013) ‘Performance and workplace assessment’, in Dent, J. A. and Harden, R. M. (eds) A practical guide for medical teachers. 4th edn. London: Elsevier Limited. Kahneman, D. (2011) Thinking, fast and slow. New York: Farrar, Straus and Giroux. Lawshe, CH. (1975) A quantitative approach to content validity. Pers Psychol, 28(4), pp. 563–75. McLean, M. and Gale, R. (2018) Essays and short answer questions. FAIMER-Keele Master’s in Health Professions Education: Accreditation and Assessment. Module 1, Unit 5, 5th edition. FAIMER Centre for Distance Learning, CenMEDIC, London. McManus, IC. Thompson, M. and Mollon, J. (2006) ‘ Assessment of examiner leniency and stringency (‘hawk-dove effect’) in the MRCP(UK) clinical examination (PACES) using multi-facet Rasch modelling’ BMC Med Educ. 42(6) doi:10.1186/1472- 6920-6-42 Merrienboer, J.J.G. (2013) ‘Instructional Design’, in Dent, J. A. and Harden, R. M. (eds) A practical guide for medical teachers. 4th edn. London: Elsevier Limited. Murphy, JM. Seneviratne, R. Remers, O and Davis, M. (2009) ‘Hawks’ and ‘doves’: effect of feedback on grades awarded by supervisors of student selected components, Med Teach, 31(10), e484-e488, DOI: 10.3109/01421590903258670 Norcini, J. and McKinley, D. W. (2007) ‘Assessment methods in medical education’, Teaching and Teacher Education, 23(3), pp. 239–250. doi: 10.1016/j.tate.2006.12.021. Norcini, J. and Troncon, L. (2018) Foundations of assessment. FAIMER-Keele Master’s in Health Professions Education: Accreditation and Assessment. Module 1, Unit 1. 6th edn. London: FAIMER Centre for Distance Learning CenMEDIC. Norcini, J. and McKinley, D. W. (2013) ‘Standard Setting’, in Dent, J. A. and Harden, R. M. (eds) A practical guide for medical teachers. 4th edn. London: Elsevier Limited. Swanson, D. and Case, S. (1998) Constructing written test questions for the basic and clincial sciences. 3rd Ed. National Board of Medical Examiners. 3750 Market Street Philadelphia, PA 19104. Van Der Vleuten, C. Schuwirth, L. Scheele, F. Driessen, E. and Hodges, B. (2010) ‘The assessment of professional competence: building blocks for theory development’, Best Practice & Research Clinical Obstetrics and Gynecology, pp. 1-17. doi:10.1016/j. bpobgyn.2010.04.001 Wenger, E. (1998). Communities of practice: Learning, meaning, and identity. Cambridge university press.

This study aimed to explore the perceived barriers to physical activity among college students Study Design: Qualitative research design Eight focus group discussions on 67 college students aged 18-24 years (48 females, 19 males) was conducted on College premises. Data were analysed using inductive approach. Participants identified a number of obstacles to physical activity. Perceived barriers emerged from the analysis of the data addressed the different dimensions of the socio-ecological framework. The result indicated that the young adults perceived substantial amount of personal, social and environmental factors as barriers such as time constraint, tiredness, stress, family control, safety issues and much more. Understanding the barriers and overcoming the barriers at this stage will be valuable. Health professionals and researchers can use this information to design and implement interventions, strategies and policies to promote the participation in physical activity. This further can help the students to deal with those barriers and can help to instil the habit of regular physical activity in the later adult years.

IntroductionThis paper addresses two separate notions of embodiment – western maternal embodiment and art making as a form of embodied critical resistance. It takes as its subject breeder; my unpublished five minute video installation from 2012, which synthesises these two separate conceptual framings of embodiment as a means to visually and conceptually rupture dominant ideologies surrounding Australian motherhood. Emerging from a paradoxical landscape of fear, loathing and desire, breeder is my dark satirical take on ambivalent myths surrounding suburban Australian motherhood. Portraying my white, heavily pregnant body breeding, cooking and consuming pink, sugar-coated butterflies, breeder renders literal the Australian mother as both idealised nation-builder and vilified, self-indulgent abuser. A feminine reification of Goya’s Saturn Devouring His Children, breeder attempts to make visible my own grapplings with maternal ambivalence, to complicate even further, the already strained position of motherhood within the Australian cultural imaginary. Employing the mediums of video and performance to visually manifest an ambivalent protagonist who displays both nurturing maternal ideals and murderous inclinations, breeder pushes contradictory maternal expectations to their breaking point and challengingly offers the following proposition: “This is what you want; but what you’ll get is so much more than you bargained for” (Grosz 136). Drawing upon critical, feminist theorising that challenges idealised views of motherhood; accounts of motherhood by mothers themselves; as well as my own personal grapplings with maternal expectations, this paper weaves reflexive writing with textual analysis to explore how an art-based methodology of embodied critical resistance can problematise representations of motherhood within Australia. By visualising the disjuncture between dominant representations of motherhood that have saturated Australian mainstream media since the late 1990s and the complex ambivalent reality of some women’s actual experiences of mothering, this paper discusses how breeder’s intimate portrayal of maternal domesticity at the limits of tolerability, critically resists socially acceptable mothering practices by satirising the cultural construct of motherhood as a means “to use it, deform it, and make it groan and protest” (Nietzsche qtd. in Gutting).Contradictory Maternal KnowledgeImages of motherhood are all around us; communicating ideals and stereotypes that tell us how mothers should feel, think and act. But these images and the concepts of motherhood that underpin them are full of contradictions. Cultural representations of the idealised and sometimes “yummy mummy” - middle class, attractive, healthy, sexy and heterosexual – (see Fraser; Johnson), contrast with depictions of “bad” mothers, leading to motherhood being simultaneously idealised and demonised within the popular press (Bullen et al.; McRobbie, Top Girls; McRobbie, In the Aftermath; McRobbie, Reflections on Feminism; Walkerdine et al.). Mothers own accounts of motherhood reflect these unsettling contradictions (Miller; Thomson et al.; Wilkinson). Claiming the maternal experience is both “heaven and hell” due to the daily experience of irreconcilable and contradictory feelings (Coward), mothers (myself included), silently struggle between feelings of extreme love and opposing feelings of failure, despair and hate as we get caught up in trying to achieve a set of ideals that promulgate standards of perfection that are beyond our reach. Surrounded by images of motherhood that do not resonate with the contradictory nature of the lived maternal experience, mothers are “torn in two” as we desperately try to reconcile or find absolution for maternal emotions that dominant cultural representations of motherhood render unacceptable. According to Roszika Parker, this complicated and contradictory experience where a mother has both loving and hating feelings for her child is that of maternal ambivalence; a form of exquisite suffering that oscillates between the overwhelming affect of blissful gratification and the raw edges of bitter resentment (Parker 1). As Parker states, maternal ambivalence refers to:Those fleeting (or not so fleeting) feelings of hatred for a child that can grip a mother, the moment of recoil from a much loved body, the desire to abandon, to smash the untouched plate of food in a toddler’s face, to yank a child’s arm while crossing the road, scrub too hard with a face cloth, change the lock on an adolescent or the fantasy of hurling a howling baby out of the window (5).However, it is not only feelings of hatred that stir up ambivalence in the mother, so too can the overwhelming intensity of love itself render the rush of ambivalence so surprising and so painful. Commenting on the extreme contradictory emotions that fill a mother and how not only excessive hatred, but excessive love can turn dangerously fatal, Parker turns to Simone De Beauvoir’s idea of “carnal plenitude”; that is, where the child elicits from the mother, the emotion of domination; where the child becomes the “other” who is both prey and double (30). For Parker, De Beauvoir’s “carnal plenitude” is imaged by mothers in a myriad of ways, from a desire to gobble up the child, to feelings of wanting to gather the child into a fatal smothering hug. Commenting on her own unsettling love/hate relationship with her child, Adrienne Rich describes her experiences of maternal ambivalences as “the murderous alternation between bitter resentment and raw-edged nerves and blissful gratification and tenderness” (363). Unable to come to terms with this paradox at the core of the unfolding process of motherhood, our culture defends itself against this illogical ambivalence in the mother by separating the good nurturing mother from the bad neglectful mother in an attempt to deny the fact that they are one and the same. Resulting in a culture that either denigrates or idealises mothers, we are constantly presented with images of the good perfect nurturing mother and her murderous alter ego; the bad fatal mother who neglects and smothers. This means that how a mother feels about mothering or the meaning it has for her, is heavily determined by cultural representations of motherhood. Arguing for a creative transformation of the maternal that breaches the mutual exclusivities that separate motherhood, I am called to action by Susan Rubin Suleiman, who writes (quoting psychoanalyst Helene Deutsch): “Mothers don’t write, they are written” (Suleiman 5). As a visual attempt to negotiate, translate and thus “write” my lived experience of Australian motherhood, breeder gives voice to the raw material of contradictory (and often taboo experiences) surrounding maternal embodiment and subjectivity. Hijacking and redeploying contradictory understandings and representations of Australian motherhood to push maternal ideals to their breaking point, breeder seeks to create a kind of “mother trouble” that challenges the disjuncture between dominant social constructions of motherhood designed to keep us assigned to our proper place. Viscerally embracing the reality that much of life with small children revolves around loss of control and disintegration of physical boundaries, breeder visually explores the complex and contradictory performances surrounding lived experiences of mothering within Australia to complicate even further the already strained position of western maternal embodiment.Situated Maternal KnowledgeOver the last decade and a half, women’s bodies and their capacity to reproduce have become centre stage in the unfolding drama of Australian economic policy. In 1999 fears surrounding dwindling birth-rates and less future tax revenue, led then Victorian Premier Jeff Kennett to address a number of exclusive private girls’ schools. Making Australia-wide headlines, Kennett urged these affluent young women to abandon their desire for a university degree and instead invited them to consider motherhood as the ultimate career choice (Dever). In 2004, John Howard’s Liberal government made headlines as they announced the new maternity allowance; a $3000 lump-sum financial incentive for women to leave work and have babies. Ending this announcement by urging the assembled gathering of mostly male reporters to go home and have “one for the Dad, one for the Mum and one for the Country” (Baird and Cutcher 103), Federal Treasurer Peter Costello made a last ditch effort to save Baby Boomers from their imminent pensionless doom. Failing to come to terms with the impending saturation of the retirement market without the appropriate tax payer support, the Liberal Government turned baby-making into the ultimate Patriotic act as they saw in women bodies, the key to prevent Australia’s looming economic crisis. However, not all women’s bodies were considered up to the job of producing the longed for “Good tax-paying Citizen” (Tyler). Kennett only visited exclusive private girls’ schools (Ferrier), headhunting only the highest calibre of affluent breeders. Blue-collar inter-mingling was to be adamantly discouraged. Costello’s 2004 “baby bonus” catch-cry not only caused international ire, but also implicitly relegated the duty of child-bearing patriotism to a normalised heterosexual, nuclear family milieu. Unwed or lesbian mothers need not apply. Finally, as government spokespeople repeatedly proclaimed that the new maternity allowance was not income tested, this suggested that the target nation-builder breeder demographic was the higher than average income earner. Let’s get it straight people – only highly skilled, high IQ’s, heterosexual, wedded, young, white women were required in this exclusive breeding program (see Allen and Osgood; Skeggs; Tyler). And if the point hadn’t already been made perfectly clear, newspaper tabloids, talkback radio and current affairs programs all over the country were recruited to make sure the public knew exactly what type of mother Australia was looking for. Out of control young, jobless single mothers hit the headlines as fears abounded that they were breeding into oblivion. An inherently selfish and narcissistic lot, you could be forgiven for thinking that Australia was running rampant with so-called bogan single mothers, who left their babies trapped in hot airless cars in casino carparks all over the country as they spent their multiple “baby bonus’” on booze, ciggies, LCD’s and gambling (see Milne; O’Connor; Simpson and Dowling). Sucking the economy dry as they leeched good tax-payer dollars from Centrelink, these undesirables were the mothers Australia neither needed nor wanted. Producing offspring relegated to the category of bludgerhood before they could even crawl, these mothers became the punching bag for the Australian cultural imaginary as newspaper headlines screamed “Thou Shalt Not Breed” (Gordon). Seen as the embodiment of horror regarding the ever out-of-control nature of women’s bodies, these undesirable mothers materialised out of a socio-political landscape that although idealised women’s bodies as Australia’s economic saviour, also feared their inability to be managed and contained. Hoarding their capacity to reproduce for their own selfish narcissistic desires, these white trash mothers became the horror par excellence within the Australian cultural imaginary as they were publically regarded as the vilified evil alter-ego of the good, respectable white affluent young mother Australian policy makers were after. Forums all over the country were inundated. “Yes,” the dominant voices seemed to proclaim: “We want to build our population. We need more tax-paying citizens. But we only want white, self-less, nurturing, affluent mothers. We want women who can breed us moral upstanding subjects. We do not want lazy good for nothing moochers.” Emerging from this paradoxical maternal landscape of fear, loathing and desire, breeder is a visual and performative manifestation of my own inability to come to terms with the idealisation and denigration of motherhood within Australia. Involving a profound recognition that the personal is still the political, I not only attempt to visually trace the relationship between popular Australian cultural formations and individual experiences, but also to visually “write” my own embodied grapplings with maternal ambivalence. Following the premise that “critique without resistance is empty and resistance without critique is blind” (Hoy 6), I find art practice to be a critically situated and embodied act that can openly resist the power of dominant ideologies by highlighting maternal corporeal transgressions. A creative destablising action, I utilise the mediums of video and performance within breeder to explore personal, historical and culturally situated expectations of motherhood within Australia as a means to subvert dominant ideologies of motherhood within the Australian cultural imaginary. Performing Maternal KnowledgeReworking Goya’s Romantic Gothic vision of fatherhood in Saturn Devouring His Children, breeder is a five minute two-screen video performance that puts an ironic twist to the “good” and “bad” myths of Australian motherhood. Depicting myself as the young white heavily pregnant protagonist breeding monarch butterflies in my suburban backyard, sugar-coating, cooking and then eating them, breeder uses an exaggerated kitsch aesthetic to render literal the Australian mother as both idealistic nation-builder and self-indulgent abuser. Selfishly hoarding my breeding potential for myself, luxuriating and devouring my “offspring” for my own pleasure and delight rather than for the common good, breeder simultaneously defies and is complicit with motherhood expectations within the suburban Australian imaginary. Filmed in my backyard in the southern suburbs of Perth, Western Australia, breeder manifests my own maternal ambivalence and deliberately complicates the dichotomous and strained position motherhood holds in western society. Breeder is presented as a two screen video installation. The left screen is a fast-paced, brightly coloured, jump-cut narrative with a pregnant protagonist (myself). It has three main scenes or settings: garden, kitchen and terrace. The right screen is a slow-moving flow of images that shows the entire monarch butterfly breeding cycle in detail; close ups of eggs slowly turning into caterpillars, caterpillars creating cocoons and the gradual opening of wings as butterflies emerge from cocoons. All the while, the metamorphic cycle is aided by the pregnant protagonist, who cares for them until she sets them free of their breeding cage. In the left screen, apricot roses, orange trees, yellow hibiscus bushes, lush green lawns, a swimming pool and an Aussie backyard garden shed are glimpsed as the pregnant protagonist runs, jumps and sneaks up on butterflies while brandishing a red-handled butterfly net; dressed in red high heels and a white lace frock. Bunnies with pink bows jump, dogs in pink collars bark and a very young boy dressed in a navy-blue sailor suit all make cameo appearances as large monarch butterflies are collected and placed inside a child’s cherry red insect container. In a jump-cut transition, the female protagonist appears in a stark white kitchen; now dressed in a bright pink and apricot floral apron and baby-pink hair ribbon tied in a bow in her blonde ponytail. Standing behind the kitchen bench, she carefully measures sugar into a bowl. She then adds pink food colouring into the crystal white sugar, turning it into a bright pink concoction. Cracking eggs and separating them, she whisks the egg whites to form soft marshmallow peaks. Dipping a paint brush into the egg whites, she paints the fluffy mixture onto the butterflies (now dead), which are laid out on a well-used metal biscuit tray. Using her fingers to sprinkle the bright pink sugar concoction onto the butterflies, she then places them into the oven to bake and stands back with a smile. In the third and final scene, the female protagonist sits down at a table in a garden terrace in front of French-styled doors. Set for high tea with an antique floral tea pot and cup, lace table cloth and petit fours, she pours herself a cup of tea. Adding a teaspoon of sugar, she stirs and then selects a strawberry tart from a three-tiered high-tea stand that holds brightly iced cupcakes, cherry friands, tiny lemon meringue pies, sweet little strawberry tarts and pink sugar coated butterflies. Munching her way through tarts, pies, friands and cupcakes, she finally licks her lips and fuchsia tipped fingers and then carefully chooses a pink sugar coated butterfly. Close ups of her crimson coated mouth show her licking the pink sugar-crumbs from lips and fingers as she silently devours the butterfly. Leaning back in chair, she smiles, then picks up a pink leather bound book and relaxes as she begins to read herself into the afternoon. Screen fades to black. ConclusionAs a mother I am all fragmented, contradictory; full of ambivalence, love, guilt and shame. After seventeen years and five children, you would think that I would be used to this space. Instead, it is a space that I battle to come to terms with each and every day. So how to strategically negotiate engrained codes of maternity and embrace the complexities of embodied maternal knowledge? Indeed, how to speak of the difficulties and incomparable beauties of the maternal without having those variously inflected and complex experiences turn into clichés of what enduring motherhood is supposed to be? Visually and performatively grappling with my own fallout from mothering ideals and expectations where sometimes all I feel I am left with is “a monster of selfishness and intolerance” (Rich 363), breeder materialises my own experiences with maternal ambivalence and my inability to reconcile or negotiate multiple contradictory identities into a single maternal position. Ashamed of my self, my body, my obsessions, my anger, my hatred, my rage, my laughter, my sorrow and most of all my oscillation between a complete and utter desire to kill each and every one of my children and an overwhelming desire to gobble them all up, I make art work that is embedded in the grime and grittiness of my everyday life as a young mother living in the southern suburbs of Western Australia. A life that is most often mundane, sometimes sad, embarrassing, rude and occasionally heartbreaking. A life filled with such simple joy and such complicated sorrow. A life that in reality, is anything but manageable and contained. Although this is my experience, I know that I am not the only one. As an artist I engage in the embodied and critically resistant practice of sampling from my “mother” identities in order to bring out multiple, conflictive responses that provocatively encourage new ways of thinking and acknowledging embodied maternal knowledge. Although claims abound that this results in a practice that is “too personal” or “too specific” (Liss xv), I do not believe that this in fact risks reifying essentialism. Despite much feminist debate over the years regarding essentialist/social constructivist positions, I would still rather use my body as a site of embodied knowledge then rhetorically give it up. Acting as a disruption and challenge to the concepts of idealised or denigrated maternal embodiment, the images and performances of motherhood in breeder then, are more than simple acknowledgements of the reality of the good and bad mother, or acts reclaiming an identity that they taught me to despise (Cliff) or rebelling against having to be a "woman" at all. Instead, breeder is a lucid and explicit declaration of intent that politely refuses to keep every maternal body in its place.References Allen, Kim, and Jane Osgood. “Young Women Negotiating Maternal Subjectivities: The Significance of Social Class.” Studies in the Maternal. 1.2 (2009). 30 July 2012 ‹www.mamsie.bbk.ac.uk›.Almond, Barbara. The Monster Within. Berkeley: University of California Press, 2011.Baird, Marian, and Leanne Cutcher. “’One for the Father, One for the Mother and One for the Country': An Examination of the Construction of Motherhood through the Prism of Paid Maternity Leave.” Hecate 31.2 (2005): 103-113. Bullen, Elizabeth, Jane Kenway, and Valerie Hey. “New Labour, Social Exclusion and Educational Risk Management: The Case of ‘Gymslip Mums’.” British Educational Research Journal. 26.4 (2000): 441-456.Cliff, Michelle. Claiming an Identity They Taught Me to Despise. Michigan: Persephone Press, 1980.Coward, Ross. “The Heaven and Hell of Mothering: Mothering and Ambivalence in the Mass Media.” In Wendy Hollway and Brid Featherston, eds. Mothering and Ambivalence. London: Routledge, 1997.Dever, Maryanne. “Baby Talk: The Howard Government, Families and the Politics of Difference.” Hecate 31.2 (2005): 45-61Ferrier, Carole. “So, What Is to Be Done about the Family?” Australian Humanities Review (2006): 39-40.Fraser, Liz. The Yummy Mummy Survival Guide. New York: Harper Collins, 2007.Gutting, Gary. Foucault: A Very Short Introduction. New York: Oxford University Press, 2005.Gordon, Josh. “Thou Shalt Not Breed.” The Age, 9 May 2010.Grosz, Elizabeth. Volatile Bodies. St Leonards: Allen and Unwin, 1986.Hoy, David C. Critical Resistance. Cambridge: MIT Press, 2005.Johnson, Anna. The Yummy Mummy Manifesto: Baby, Beauty, Body and Bliss. New York: Ballantine, 2009.Liss, Andrea. Feminist Art and the Maternal. Minneapolis: University of Minnesota Press, 2009.McRobbie, Angela. “Top Girls: Young Women and the Post-Feminist Sexual Contract.” Cultural Studies. 21. 4. (2007): 718-737.---. In the Aftermath of Feminism: Gender, Culture and Social Change. London: Sage. 2008.---. “Reflections on Feminism, Immaterial Labour and the Post-Fordist Regime.” New Formations 70 (Winter 2011): 60-76. 30 July 2012 ‹http://dx.doi.org.dbgw.lis.curtin.edu.au/10.3898/NEWF.70.04.2010›.Miller, Tina. Making Sense of Motherhood: A Narrative Approach. Cambridge: Cambridge University Press. 2005.Milne, Glenn. “Baby Bonus Rethink.” The Courier Mail 11 Nov. 2006. 30 Sep. 2011 ‹http://www.couriermail.com.au/news/national-old/baby-bonus-rethink/story-e6freooo-1111112507517›.O’Connor, Mike. “Baby Bonus Budget Handouts a Luxury We Can Ill Afford.” The Courier Mai. 5 Dec. 2011. 30 Apr. 2012 ‹http://www.couriermail.com.au/news/opinion/handouts-luxury-we-can-ill-afford/story-e6frerdf-1226213654447›.Parker, Roszika. Mother Love/Mother Hate, London: Virago Press, 1995.Rich, Adrienne. “Anger and Tenderness.” In M. Davey, ed. Mother Reader. New York: Seven Stories Press, 2001.Simpson, Kirsty, and Jason Dowling. “Gambling Soars in Child Bonus Week”. The Sunday Age Aug. 2004. 28 Apr. 2012 ‹http://www.couriermail.com.au/news/opinion/handouts-luxury-we-can-ill-afford/story-e6frerdf-1226213654447›.Skeggs, Beverly. Formations of Class and Gender: Becoming Respectable. London: Sage, 1997.Suleiman, Susan. “Writing and Motherhood,” Mother Reader Ed. Moyra Davey. New York: Seven Stories Press, 2001. 113-138Thomson, Rachel, Mary Jane Kehily, Lucy Hadfield, and Sue Sharpe. Making Modern Mothers. Bristol: Policy Press, 2011. 30 July 2012 ‹http://www.policypress.co.uk/display.asp?K=9781847426055&sf1=keyword&st1=motherhood&m=1&dc=16›.Tyler, Imogen. “’Chav Mum, Chav Scum’: Class Disgust in Contemporary Britain.” Feminist Media Studies 8.2. (2008): 17-34. 31 July 2012 http://dx.doi.org/10.1080/14680770701824779›.Walkerdine, Valerie, Helen Lucey, and Melody June. Growing Up Girl: Psychosocial Explorations of Gender and Class. London: Palgrave. 2001. Wilkinson, Tony. Uncertain Surrenders: The Coexistence of Beauty and Menace in the Maternal Bond and Photography. PhD thesis. Perth: Edith Cowan University, 2012. 31 July 2012 ‹http://ro.ecu.edu.au/cgi/viewcontent.cgi?article=1458&context=theses›.

The ProjectThe Hand Up Linkage project focuses on the family as a communication context through which to explore the dynamics of intergenerational welfare dependency. In particular, it explores ways that creative life-course interventions might allow children in welfare dependent families to construct alternative realities for themselves and alternative views of their future. Formed through an alliance between a key Western Australian social welfare not-for-profit organisation, St Vincent de Paul WA (SVDPWA and also, in the context of volunteers, ‘Vinnies’), and Edith Cowan University, the project aims to address the organisation’s vision to provide “a hand up” (St Vincent 1) rather than ‘a hand out’, so that people can move forward with their lives without becoming dependent upon welfare. Prior to the start of the research, SVDPWA already had a whole of family focus in its outreach to poverty-impacted families including offering homework clubs and school holiday children’s camps run by their youth services division. Selected families supported by SVDPWA have been invited to participate in an in-depth interview for the project (Seidman), partly so that researchers can help identify “turning points” (King et al.) that might disrupt the communication of welfare dependency and inform more generalised intervention strategies; but also in order to explore the response to creative interventions within the children’s daily lives, including investigation of how strategies the child (and family) employed might help them to imagine alternative realities and futures for themselves. This paper closely examines the way that one 10 year old child from a non-English-speaking background family has employed alternative ways of viewing her life, through the camp program provided by the Linkage Partner St Vincent de Paul WA, and through reading novels such as Harry Potter and the Lemony Snicket Unfortunate Incidents series. Such activities help fuel hope for a different future which, in Snyder’s view has “two main components: the ability to plan pathways to desired goals despite obstacles, and agency or motivation to use those pathways” (Carr 96).The FamilyKani is a 10 year old girl living in a migrant sole parent family. The parents had moved to Australia from Bangladesh on student visas when Kani was 5 years old, however due to domestic violence the mother had recently separated from her husband, first into a women’s refuge then into private rental accommodation. The mother is in protracted negotiations with the Department of Immigration for permanent residency, which she had to recommence due to her separation. There are also family court negotiations for child custody and which restrict her leaving Australia. She receives no government benefits and minimal child support, works fulltime and pays full childcare fees for Kani’s 3 year old brother Adil and full primary school fees for Kani at a local religious school, given that Kani had experienced bullying and social aggression in previous schools. Kani was referred to SVDPWA by the women’s refuge and she began attending SVDPWA Kids’ Camps thereafter. (NB: Whilst the relevant specifics of this description are accurate, non-relevant material has been added or changed to protect the child’s and family’s identity.)Creative Life-Course InterventionsThe creative engagement that Kani experienced in the Hand Up project is constructed as one component in a larger model of creativity which includes “intrapersonal insights and interpretations, which often live only within the person who created them,” (Kaufman and Beghetto 4). Such an approach also acknowledges Csikszentmihalyi’s work on the concept of “flow”, whereby optimal experiences can result from positive absorption in a creative activity. Relevant Australian research such as the YouthWorx project has identified participatory engagement in creativity as one means of engaging with young people at risk (Hopkins; Podkalicka). The creative interventions in the Hand Up project take two forms; one is the predesigned and participatory creative activities delivered as part of the SVDPWA Kids’ Camp program. The second is a personalised intervention, identified by way of an in-depth interview with the child and parent, and is wholly dependent on the interests expressed by the child, the ability for the family to engage in that activity, and the budget restraints of the project.Reading as an Alternative RealityA key creative intervention embedded in the Hand Up Linkage project is determined by the interests expressed by the child during their in-depth interview. Also taken into account is the ability for the family to engage in that activity. For example, Kani’s mother works fulltime at a location which is an hour by public transport from home and does not have a car or driver’s license, so the choice of creative opportunity was restricted to a home-based activity or a weekend activity accessible by public transport. A further restriction is the limited budget available for this intervention in the project, along with an imperative that such interventions should be equitable between families and within families, and be of benefit to all the children in addition to the interviewed child. Fortunately, transport was not an issue because Kani expressed her interest very emphatically as books and reading. When asked what she liked doing most in life, Kani replied: “Reading. I like reading like big books, like really thick books and stuff. I have like 30 in my room. Like those really big books. And I'm starting to read Harry Potter now. Okay, the books that I like reading is Harry Potter, the entire set Roald Dahl books and the Baudelaire Orphans by Lemony Snicket. I like reading David Walliams. I like Little Women” (Kani). Her excitement in listing these books further animated the interview and was immediately emphasised because Kani took the interviewer (second author) and her mother into her room to demonstrate the truth of her statement. When asked again at the close of the interview “what’s a favourite thing that makes you feel good inside?” Kani’s answer was “Family and reading”. The energy and enthusiasm with which Kani talked about her reading and books made these the obvious choice as her creative intervention. However, participation in book-related courses or after-school activities was restricted by Kani’s mother’s transportation limitations. Taking into account how the financial constraints of her sole parent family impacted upon their capacity to buy books, and the joy that Kani clearly experienced from having books of her own, it was decided that a book voucher would be provided for her at a local bookstore easily accessible by bus. The research team negotiated with the bookstore to try to ensure that Kani could choose a book a month until the funds were expended so that the intervention would last most of the coming six months.What Kani was expressing in her love of books was partly related to the raw material they provide that help her to imagine the alternative reality of the fictional worlds she loved reading about. Kani’s passionate engagement in these alternative realities reflects theories of narrative immersion in one’s chosen medium: “One key element of an enjoyable media experience is that it takes individuals away from their mundane reality and into a story world. We call the process of becoming fully engaged in a story transportation into a narrative world” (Green et al. 311–12). Kani said: “Reading is everything, yeah. Like getting more books and like those kind of things and making me read more... ‘cause I really love reading, it’s like watching a movie. Do you know ... have you watched Harry Potter? … the book is nothing like the movie, nothing, they’ve missed so many parts so the book is more enjoyable than the movie. That’s why I like reading more. ‘Cause like I have my own adventures in my head.” This process of imagining her own adventures in her head echoes Green and Brock’s explanation of the process of being transported into alternative realities through reading as a result of “an integrative melding of attention, imagery, and feelings” (701).Constructing Alternative Realities for Herself and an Alternative Possible FutureLike many 10 year olds, Kani has a challenging time at school, exacerbated by the many school moves brought about by changes in her family circumstances. Even though she is in a school which supports her family’s faith, her experience is one of being made to feel an outsider: “all the boys and the girls in our class are like friends, they’re like ... it’s a group. But I’m not in their group. I have my friends in other classes and they’re [my classmates are] not happy with it, that’s why they tease me and stuff. And like whenever I play with my friends they’re like ... yeah”. The interviewer asked her what she liked about her special friends. “They’re fun. Creative like, enjoyable, yeah, those kind of things …they have lots of cool ideas like plans and stuff like that.” As Hawkins et al. argue, the capacity to develop and maintain good relationships with peers (and parents) is a key factor in helping children be resilient. It is likely that Kani also shares her creativity, ideas and plans with her friendship group as part of her shared contribution to its existence.A domestication of technology framework (Silverstone et al.) can be useful as part of the explanation for Kani’s use of imaginative experience in building her social relationships. Silverstone et al. argue that technology is domesticated via four interlocking activities: ‘appropriation’ (where it embraced, purchased, taken into the household), ‘objectification’ (where a physical space is found for it), ‘incorporation’ (the spaces through which it is inserted into the everyday activities of the household or users) and ‘conversion’ (whereby the experience and fact of the technology use – or lack of use – becomes material through which family members express themselves and their priorities to the social world beyond the home). Arguably, Kani ‘converts’ her engagement with books and associated imaginative experiences into social currency through which she builds relationships with the like-minded children with whom she makes friends. At the same time, those children feed into her ideas of what constitutes a creative approach to life and help energise her plans for the future.Kani’s views of her future (at the age of 10) are influenced by the traditional occupations favoured by high achieving students, and by the fact that her parents are themselves educational high achievers, entering Australia on student visas. “I want to be a doctor … my cousin wants to be a doctor too. Mum said lawyer but we want to be a doctors anywhere. We want to be a ...me and my cousin want to be doctors like ...we like being doctors and like helping people.” Noting the pressures on the household of the possible fees and costs of high school, Kani adds “I need to work even harder so I get a scholarship. ‘Cause like my mum can’t pay for like four terms, you know how much money that will be? Yeah.” Kani’s follow-on statement, partly to justify why she wants “a big house”, adds some poignancy to her reference to a cousin (one of many), who still lives in Bangladesh and whom Kani hasn’t seen since 2011. “Like I want to live with my mum and like yeah and like I live with my cousin too because like I have a cousin ... she’s a girl, yeah? And like yeah, she’s in Bangladesh, I haven’t seen her for very long time so yeah.” In the absence of her extended family overseas, Kani adds her pets to those with whom she shares her family life: “And my mum and my uncle and then our cat Dobby. I named it [for Harry Potter’s house elf] ...and the goldfish. The goldfish are Twinkle, Glitter, Glow and Bobby.”Kani’s mum notes the importance of an opportunity to dream a future into existence: “maybe she’s too young or she hasn’t really kind of made up her mind as yet as to what she wants to do in life but just going out and just you know doing stuff and just giving them the opportunity”. The SVDPWA Kids’ Camp is an important part of this “they [the refuge] kind of told us like ‘there’s this child camp’. … I was like yeah, sure, why not?” Providing Alternative Spaces at the SVDPWA Kids’ CampThe SVDPWA Kids’ Camps themselves constitute a creative intervention in offering visions of alternative realities to their young participants. Their benefit is delivered via anticipation, as well as the reality of the camp experience. As Kani said “I forget all about the things that’s just past, like all the hard things, you know like I go through and stuff and it just makes me forget it and it makes me like think about camp, things we’re going to do at camp”. The Kids’ Camps take place three times a year and are open to children aged between 8 and 13, with follow-on Teen Camps for older age groups. Once a child is part of the program she or he can continue to participate in successive camps while they are in the target age group. Consisting of a four day activity-based experience in a natural setting, conducted by Vinnies Youth and staffed by key SVDPWA employees and Youth volunteers, the camps offer children a varied schedule of activities in a safe and supported environment, with at least one volunteer for every two child participants. The camps are specifically made available to children from disadvantaged families and are provided virtually free to participants. (A nominal $10 enrolment fee is applied per child). Kani was initially reticent about attending her first camp. She explained: “I was shy, scared because I sleep with my mum so it’s different sleeping without Mum. I know it’s kind of embarrassing ‘cause, sleeping with my mum like, but I just get scared at night”. Kani went on to explain how the camp facilitators were able to allay her fears “I knew I was safe. And I had people I could talk to so yeah ...like the leader”. As one Vinnies Youth volunteer explains, the potential of offering children like Kani time out from the pressures of everyday life is demonstrated when “towards the end of every camp we always see that progression of, they came out of their shell … So I think it’s really just a journey for everyone and it’s understandable if they did feel stuck. It’s about what we can do to help them progress forward” (VY1). Kani was empowered to envision an alternative idea of herself at camp, one which was unexpectedly intuited by the research interviewer.When the interviewer closed the interview by expressing that it had been lovely to talk to Kani as she was “such a bundle of energy”, Kani grinned and replied “Do you know the warm fuzzies, yeah? [When positive thoughts about others are exchanged at the SVDPWA Kids’ Camp]. The bundle ... all the leaders say I’m a bundle of happiness”. The Kids’ Camp provided Kani with a fun and positive alternative reality to the one she experienced as a child handling the considerable challenges experienced by social isolation, domestic violence and parental separation, including the loss of her home, diminished connection to her overseas extended family, legal custody issues, and several school changes. Taking the role of cultural intermediary, by offering the possibility of alternative realities via their camp, SVDPWA offered Kani a chance that supported her work on creating a range of enticing possible futures for herself. This was in contrast to some commercial holiday camp experiences which might more centrally use their “cultural authority as shapers of taste and … new consumerist dispositions” (Nixon and Du Gay 497). Even so, Kani’s interview made clear that her experience with the SVDPWA Kids’ Camps were only part of the ways in which she was crafting a range of possible visions for her adult life, adding to this her love of books and reading, her fun, creative friends, and her vision for a successful future which would reunite her with her distant cousin and offer security to her mother. ConclusionUnderstandably, Kani at 10 lacks the critical insight required to interpret how her imaginative and creative life provides the raw materials from which she crafts her visions for the future. Further, the interviewer is careful not to introduce words like ‘creative’ into her work with the participant families, so that when Kani used it to talk about her friends she did so drawing upon her own store of descriptions and not as a result of having recently been reminded of creativity as a desirable attribute. The interview with this young person indicates, however, how greatly she values the imaginative and cultural inputs into her life and how she converts them in ways which help ensure access to further such creative currency. Apart from referencing her reading in the naming of her cat, Kani’s vision for herself reflects both the conventional idea of success (“a doctor”) and a very specific idea of her future living as an adult in house large enough to include her mum and her cousin.Kani’s love of reading, her pleasure in books, her choice of friends and her aspirations to scholarly excellence all offer her ways to escape the restricted options available to families who seek support from organisations such as SVDPWA. At the same time the Kids’ Camps themselves, like Kani’s books, provide an escape from the difficulties of the present. Kani’s appropriation of the cultural raw materials that she draws into her life, and her conversion of these inputs into a creative, social currency, offers her an opportunity to anticipate a better future, and some tools she can use to help bring it into existence.ReferencesCarr, A. Positive Psychology: The Science of Happiness and Human Strengths. 2nd ed. Hove, UK: Routledge, 2011.Csikszentmihalyi, M. Creativity: Flow and the Psychology of Discovery and Invention. New York: HarperCollins, 1996.Green, M., and T. Brock. “The Role of Transportation in the Persuasiveness of Public Narratives.”. Journal of Personality and Social Psychology 79 (2000): 701–21.———, T. Brock, and G. Kaufman. “Understanding Media Enjoyment: The Role of Transportation into Narrative Worlds." Communication Theory 14.4 (2004): 311–27.Hawkins, J.D., R. Kosterman, R.F. Catalano, K.G. Hill, and R.D. 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Du Gay. “Who Needs Cultural Intermediaries?” Cultural Studies 16.4 (2002): 495–500.Podkalicka, A. “Young Listening: An Ethnography of YouthWorx Media’s Radio Project.” Continuum 23.4 (2009): 561–72.St Vincent de Paul Society (WA). St Vincent de Paul Society, Annual Report 2013. Perth, WA: St Vincent de Paul Society (WA), 2013. 5 Jan 2017 <http://www.vinnies.org.au/icms_docs/169819_Vinnies_WA_2012_Annual_Report.pdf>.Seidman, I. Interviewing as Qualitative Research: A Guide for Researchers in Education and the Social Sciences. New York: Teachers College Press, Columbia University, 2006.Silverstone, R., E. Hirsch, and D. Morley. “Information and Communication Technologies and the Moral Economy of the Household.” Consuming Technologies: Media and Information in Domestic Spaces. Eds. R. Silverstone and E. Hirsch. London: Routledge, 1992. 9–17.Snyder, C.R. Handbook of Hope. Orlando, FL: Academic Press, 2000.VY1. In-depth interview with Vinnies Youth volunteer, de-identified, 2016.

The HIV and AIDS crisis can be presented as a socio-ecological issue, with an ever-increasing impact on both human beings and the environment. Teaching about socio-ecological issues and the consideration of individual capabilities has become crucial within HIV and AIDS education programmes. Issues of deforestation, land degradation and other environmental problems have worsened since the advent of HIV and AIDS, especially in developing countries. The My Future is My Choice (MFMC) programme has been identified as an important HIV and AIDS education initiative that caters for young people in Namibian secondary schools (Grades 8-12). One of the themes within the programme (Facing HIV and AIDS) is highlighted in this study. This study was constituted as a case study of one school in rural Omuthiya, in the Oshikoto region. The study investigated the opportunities for the integration of a focus on socio-ecological issues and risks, within the MFMC education programme. The study also investigated the way in which the program develops learners‟ capabilities to respond to HIV and AIDS related socio-ecological issues and risks/vulnerabilities. The study also presents the constraints and enabling factors influencing the implementation of the programme. This study used a qualitative, interpretive case study methodology. The research methods included the analysis of eight documents and nineteen semi-structured interviews, with the Programme Coordinator, the Programme Facilitator, the School Principal and with the programme participants. The analysis also included two focus group discussions with a group of learners; and two classroom observations; and the learners' submissions (reflection sheets). Convenience sampling was used, and ethical issues were taken into consideration throughout the study. The study revealed the following as key findings:  The aims and objectives of the HIV and AIDS education programme can enhance and constrain the development of capabilities, as well as opportunities and challenges for the integration of a focus on socio-environmental issues and risks as additional learning content.  Teaching and learning methods that are participatory and rooted within the learner centered approach can make the integration of HIV and AIDS inherent socio-environmental issues and risks into the MFMC education programme possible.  The values and beliefs inherent within the MFMC education programme stand as opportunities for the successful development of capabilities in the education programme. The study concluded by recommending that capabilities within the MFMC programme be developed through teaching learners about their rights, respect for human dignity, and the right to health and to living the life free from discriminatory practices, as a moral entitlement of each and every individual. While teaching learners about their right to health and the importance of healthy diets, this study found that the programme could include learning about food production and handling practices for the benefit of those living with HIV and AIDS, while caring for the environment. Another recommendation was that future research should consider actively involving young people in decision-making with regard to the programme, as this will allow them to choose and decide on what knowledge and skills they need and want to acquire. The study further explained that this will promote the programme participants‟ sense of agency, and their freedom to choose what they value being and doing as an important element in enhancing learner capabilities. Ultimately, this will also enable the learners to acquire the necessary skills and knowledge they need in order to respond to the socio-ecological problems they face in their communities.

Thesis (MPA)--Stellenbosch University, 2011.
ENGLISH ABSTRACT: “My Future is My Choice” (MFMC) is an extra-curricular life skills programme in Na-mibia aimed at minimising the impact of HIV and AIDS among young people. The pro-gramme was introduced fourteen years ago and is believed to have had a significant im-pact on young people who were enrolled in and graduated from it. The programme tar-gets young people from grades 8 to 12. The purpose of this study was to assess how the “My Future is My Choice” Programme imparts knowledge and skills to young people in the Ompundja Circuit of the Oshana Directorate of Education, in Northern Namibia. This was an implementation evaluation study, following a qualitative approach to collect in-depth information. Data was collect-ed by two means: focus group interviews with an interview guide as an instrument, and analysis of documents. Purposeful sampling was used to select twenty young people from the population of young people who graduated from the programme. Young people from three secondary schools and one combined school were interviewed. The outcome of the study indicated that young people who graduated from the pro-gramme were better equipped with knowledge and skills that enable them to protect themselves from HIV infection. The study also indicated that the strategies used to im-plement the programme are crucial to the successful transfer of information to young people enrolled in the programme. However, some challenges which need immediate attention for improvement concern the number of participants, the content, a review of topics and the time allocated to the implementation of the programme. It is therefore recommended that recipients be consulted for input on what their needs are with regard to HIV and AIDS prevention. As the programme began fourteen years ago, its strategies now require updating and revision of the programme has become necessary. The revision of the programme will enable its facilitators to incorporate new ideas and methods of HIV prevention gained from over a decade of experience. It would also allow for the identification of young people’s needs and incorporate relevant topics that are not currently covered in the manual. Hence, collaboration between facilitators, learners, teachers, parents, communities and programme designers is a key element in ensuring the continued success of the “My Future is My Choice” Programme.
AFRIKAANSE OPSOMMING: “My Future is My Choice” (MFMC) is ʼn bykomende lewensvaardigheidsprogram in Namibië wat die impak van MIV en VIGs onder jongmense wil verminder. Die program is 14 jaar gelede ingestel en het na bewering ʼn beduidende uitwerking gehad op jongmense wat daarvoor ingeskryf het en dit voltooi het. Die program is afgestem op jongmense in graad 8 tot 12. Die doel van die studie was om te bepaal in watter mate die MFMC-program die jongmense in die Ompundja-distrik in die Onderwysdirektoraat van Oshana in Noord-Namibië met kennis en vaardighede toerus. Die studie het ʼn implementeringsevaluering behels, en het diepte-inligting met behulp van ʼn kwalitatiewe benadering ingesamel. Data is met behulp van fokusgroeponderhoude aan die hand van ʼn onderhoudsgids sowel as deur middel van dokumentontleding bekom. Twintig jongmense uit die groep wat die program suksesvol voltooi het, is met behulp van doelgerigte steekproewe gekies en onderhoude is met jeugdiges van drie hoërskole en een gekombineerde skool gevoer. Die uitkoms van die studie dui daarop dat jongmense wat die program voltooi het oor beter kennis en vaardighede beskik waarmee hulle hulle teen MIV-besmetting kan beskerm. Die studie het ook getoon dat die strategieë wat gebruik word om die program in werking te stel deurslaggewend is vir die suksesvolle oordrag van inligting aan diegene wat vir die program ingeskryf is. Tog is daar bepaalde uitdagings wat onmiddellike aandag verg, soos die aantal deelnemers, die inhoud, die onderwerpe, en die tyd wat vir die inwerkingstelling van die program beskikbaar gestel word. Daarom word aanbeveel dat, ten einde die MFMC-program te verbeter, diegene wat die program volg oor hulle behoeftes met betrekking tot MIV/vigs-voorkoming geraadpleeg word. Nou, 14 jaar nadat die program die eerste keer in werking gestel is, is dit duidelik dat die strategieë wat gebruik word verouderd is en dat die program dringend hersien moet word. Sodanige hersiening sal die programaanbieders in staat stel om nuwe idees en metodes vir MIV-voorkoming wat nie 14 jaar gelede bekend was nie, by die program in te sluit. Dit sal ook ʼn geleentheid bied om jongmense se werklike behoeftes te bepaal en ander onderwerpe aan te roer wat nie tans in die handleiding verskyn nie dog tersaaklik is. Daarom is samewerking tussen fasiliteerders, leerders, onderwysers, ouers, gemeenskappe en programsamestellers ʼn sleutelelement om die voortgesette sukses van die MFMC-program te verseker.