We argue that people will often eschew explicit victim blame  because it is counternormative and socially undesirable, yet they might still engage in subtle victim blame by attributing victims’ suffering to behaviors the victims can control . We found support for this argument in three online studies with US residents. In Studies 1 and 2, participants viewed a victim posing either a high threat to the need to believe in a just world, which should heighten the motivation to engage in victim blame, or a low threat. They then rated explicit blame items and attributions for the victim’s suffering. Explicit blame was low overall and not influenced by victim threat. However, participants attributed the high threat victim’s suffering, more than the low threat victim’s suffering, to high control causes, thus showing a subtle blame effect. In Study 2, explicit blame and subtle blame were less strongly associated (in the high threat condition) for individuals high in socially desirable responding. These results are consistent with our argument that explicit and subtle blame diverge in part due to social desirability concerns. In Study 3, most participants believed others viewed the explicit blame items, but not the attribution items, as assessing blame. Thus, attributions to high control causes can be seen as “subtle” in the sense that people believe others will view such statements as reflecting constructs other than blame. Our studies suggest a way of responding to innocent victims that could be particularly relevant in a modern context, given increasing social undesirability of various negative responses to disadvantaged and victimized individuals. The phenomenon of blaming innocent victims for their fate  has received intensive study in several scholarly literatures see –3). Rese. Rese3])In most victim blame studies, researchers assess explicit blame, with items such as “To what extent do you think that [victim’s name]’s behavior is to blame for [victim’s condition]?” e.g., ,9). One . One 9])Only a few researchers have investigated subtle, negative appraisals of innocent victims. For example, although not assessing victim blame per se, Aguiar, Vala, Correia, and Pereira  and DawtIn the current research, we add to the nascent literature on subtle, negative appraisals of innocent victims by investigating subtle blame of innocent victims. Specifically, we examine whether, in the absence of obvious cues about cause, people attribute victims’ suffering to a cause that is under the victims’ control; that is, a “high control cause.” For instance, a person sustains injuries from driving into a lamppost. An example of a high control cause is reckless driving, whereas an example of a less controllable cause is swerving when an animal darts into traffic. For a victim suffering concussion, playing a high-risk sport without protective headgear is a high control cause, whereas slipping on the ice outside one’s home is a less controllable cause.Research on Weiner’s theory of responsibility and stigma e.g., ,22) show show22])The closest research to the present studies was conducted by Bal and van den Bos . Though In the present studies, we investigated subtle victim blame from a justice motive theory perspective, as did Bal and van den Bos . Our resIn Studies 1 and 2, we manipulated the threat that a victim posed to the need to believe in a just world. We then measured attributions to high control causes  and low control causes (a control variable), as well as explicit blame. The high threat condition should heighten the motivation to defensively blame the victim. Thus, one might expect participants to blame the victim more in the high threat than in the low threat condition. We predicted such evidence of victim blame, but only on our measure of subtle blame. Specifically, we predicted that participants in the high threat condition would attribute high control causes to the victim to a greater degree than participants in the low threat condition, thus showing a subtle blame effect; and we predicted that this effect should occur controlling for attributions to low control causes (Hypothesis 1). Note that, if the subtle blame effect reflects merely an underlying desire to find any cause for the high threat victim , then it should not occur when controlling for attributions to low control causes. Given that explicit blame is often counternormative, at least in a modern context, we predicted that participants would report low levels of explicit blame in both the high and low threat condition (Hypothesis 2).In Study 2, we also assessed individual differences in socially desirable responding. If explicit blame is counternormative and socially undesirable, whereas attribution to high control causes  is not, then the relation between these two variables should be moderated by individual differences in socially desirable responding. Our reasoning for this claim is based on the finding that social desirability concerns moderate the correlation between explicit and subtle  forms of various constructs . For exaIn Study 3, we tested whether attributions to high control causes can be seen as “subtle” blame in the sense that people do not think others will view such statements in terms of victim blame. Participants were asked open-ended questions about the meaning of the attribution and explicit blame items from Studies 1 and 2. We predicted that participants would view the explicit blame, but not the attribution items, as meant to assess victim blame (Hypothesis 4).In summary, our aim was to examine one way in which people might engage in subtle victim blame; specifically, by attributing a victim’s suffering to causes perceived to be under the victim’s control. We conducted three studies to achieve this aim. In Study 1, we tested whether people would subtly blame the victim when their motivation to engage in victim blame is heightened, and whether this would occur in the absence of a similar effect for explicit blame. In Study 2, we attempted to replicate the findings of Study 1 and test our reasoning that explicit and subtle blame diverge due to the social undesirability of the former. In Study 3, we attempted to clarify that the form of subtle blame investigated in these studies is subtle in the sense that people do not believe others will see such attributions in terms of blame. In each study we found support for our hypotheses.10.17605/OSF.IO/GZ3WH.We report all measures, manipulations, and exclusions in these studies. In addition, sample sizes were determined before any data collection, and were based on a priori power analyses, except for Study 3, for which we recruited enough participants to yield at least 30 individuals per condition. Data and materials for all studies are publicly available and can be found at DOI For each study in this paper, participants gave informed consent by reading an online informed consent letter, and then clicking on “Yes.” All studies were reviewed and approved by Brock University’s Social Science Research Ethics Board.completely unavoidable/no control to 7 = completely avoidable/complete control). Avoidability and control ratings were highly correlated (mean r = .71), thus we averaged them to create a composite measure of control. Participants also rated how likely they thought it was that each behavior could cause sepsis, the illness contracted by the victim in our studies . Sepsis was defined as a bacterial infection of the blood . Finally, participants were debriefed and paid $0.50.Fifty US residents were recruited over Amazon’s Mechanical Turk (MTurk). After providing informed consent, participants rated the extent to which each of 12 behaviors are avoidable and under a person’s control  was greater than the scale midpoint, t(49) = 25.43, d = 3.60, p < .001, indicating relatively high control. For the low control behaviors, average control  was less than the midpoint, t(49) = -2.39, d = -0.34, p = .02, indicating relatively low control. Average control for the high control behaviors was greater than for the low control behaviors, t(49) = 14.77, d = 2.09, p < .001. However, the high control  versus low control behaviors  were seen as equally likely to cause sepsis, t(49) = -1.28, d = -0.18, p = .21. Finally, a principal components analysis with varimax rotation yielded two components. The low control behaviors had high loadings on Component 1 (> .86) and low loadings on Component 2 (< +/-.14), whereas the high control behaviors had high loadings on Component 2 (> .75) and low loadings on Component 1 (< +/-.05).We selected two high control behaviors  and two low control behaviors . For the high control behaviors, the average for the composite control measure .We recruited 254 US residents through MTurk . The woman was said to be 21 years old and about to enter nursing school. She was still in hospital and was extremely distressed. After this video, participants were told they would soon view a second video offering further information about the victim’s situation. We manipulated threat to the need to believe in a just world through these instructions by varying participants’ expectations about the severity of the victim’s suffering . I). I27]).Before watching the second video, participants completed the following measures: a manipulation check; attribution items (including those assessing subtle blame), which were presented in random order; explicit victim blame items; and filler questions disguising the focus of the study . Attribution items preceded the explicit blame items.All participants viewed the video described in the low threat condition. At the end of the study, participants provided demographics, and were debriefed and paid $1.00.very poorly to 7 = very well).As a manipulation check, participants rated how well the victim was doing (1 = r = .41) was the reason the victim had contracted sepsis . Participants similarly rated the two low control behaviors (r = .51). We averaged the ratings for the two high control and the two low control behaviors to yield two composite scores. The high and low control behaviors were presented along with two of the unselected behaviors from the pretest that were seen as unlikely to cause sepsis. These extra behaviors masked our focus on only a few causes.Subtle blame was assessed by having participants rate the likelihood that each of the two high control behaviors . Responses were averaged to create a composite, explicit blame score (Cronbach’s α = .80).Explicit blame was assessed with four items  than the mild suffering condition , t(252) = -1.72, p = .09. Finally, responses to an open-ended question asking how the victim likely contracted sepsis were not analyzed because we failed to establish a reliable coding scheme for high versus low control causes.Aside from the explicit blame items, there were two items assessing character derogation and four items assessing psychological distancing from the victim and her situation. Neither of these variables was significantly affected by the suffering manipulation (or the purpose manipulation), though victim character derogation was marginally greater in the severe suffering condition  thought the victim was doing better than did participants in the severe suffering condition , t(252) = 8.76, d = 1.10, p < .001. Thus, our manipulation of victim suffering  was effective. Correlations among the variables used to test hypotheses are in Participants in the mild suffering condition  than did participants in the mild suffering condition , F = 9.55, p = .002, ηp2 = .04, 95% CImean diff . An ancillary ANCOVA showed that ratings for the low control behaviors (controlling for high control behaviors) did not differ by condition , F = 0.83, p = .37, ηp2 = .003, 95% CImean diff . An ancillary Victim Suffering (mild vs. severe) X Controllability of Causes (low vs. high control behaviors) mixed ANOVA yielded a significant interaction, F = 5.07, p = .03, ηp2 = .02, showing that victim suffering affected the ratings for high control behaviors, p = .003, d = 0.38, 95% CImean diff , independent of the (null) effect on ratings for low control behaviors, p = .61, d = 0.07, 95% CImean diff . Details for the mixed ANOVA are in the Supporting Information (We conducted an ANCOVA with Victim Suffering (mild vs. severe) as the independent variable and the perceived likelihood that the high control behaviors caused the victim’s sepsis as the dependent variable. We controlled for the perceived likelihood that the low control behaviors caused the victim’s sepsis. A sensitivity analysis showed that the ANCOVA had 80% power to detect an effect size of ηormation . Taken tt test to test Hypothesis 2. A sensitivity analysis showed that the t test had 80% power to detect an effect size of d = 0.35, with α = .05. Victim suffering did not affect explicit blame, t(252) = .44, d = 0.06, p = .66, 95% CI , and explicit blame was low overall . Thus, as hypothesized, participants did not appear to resolve the threat posed by the severely suffering victim by explicitly blaming her, presumably because of the counternormative nature of victim blame.We used a In summary, we found evidence that, under conditions that should heighten the desire to engage in victim blame, people will subtly blame a victim by attributing the victim’s suffering to a behavior that the victim could have avoided. Furthermore, our findings suggest that this subtle blame can occur in the absence of similarly motivated, explicit blame.For Study 2, we attempted to replicate the effect of victim suffering on the perceived likelihood that high control behaviors caused the victim’s illness. We also tested Hypothesis 3: Subtle blame  will be less strongly associated with explicit blame for participants high versus low in socially desirable responding, especially in the severe suffering  condition.Mage = 36.54, SDage = 12.87; 78% White; 48% Christian, 44% atheist/agnostic).We recruited 300 US residents through MTurk. Four participants’ data were removed—two in the severe and one in the mild suffering condition—because they did not watch the complete videos, leaving 296 cases  and self-deceptive enhancement (α = .82) subscales .M = 5.35, SD = 1.29) thought the victim was doing better compared to participants in the severe suffering condition , t(294) = 12.02, d = 1.39, p < .001. Thus, the manipulation of victim suffering  was effective. Correlations among the variables used to test hypotheses are in Participants in the mild suffering condition  than did participants in the mild suffering condition , F = 5.65, p = .02, ηp2 = .02, 95% CImean diff . An ancillary ANCOVA showed that ratings for the low control behaviors (controlling for high control behaviors) did not differ by condition, , F = 2.55, p = .11, ηp2 = .01, 95% CImean diff . An ancillary mixed ANOVA yielded a significant Victim Suffering X Controllability of Causes interaction, F = 6.73, p = .01, ηp2 = .02, showing that ratings for high control behaviors were affected by victim suffering, p = .03, d = 0.24, 95% CI , independent of the (null) effect on low control behaviors, p = .21, d = -0.15, 95% CI . Details are in the Supporting Information (An ANCOVA with Victim Suffering (mild vs. severe) as the independent variable was conducted on the perceived likelihood that the high control behaviors caused the victim to contract sepsis. We controlled for the perceived likelihood that the low control behaviors caused the victim’s sepsis. The analysis had 80% power to detect an effect size of ηormation .t test used to test Hypothesis 2 had 80% power to detect an effect size of d = 0.33, with α = .05. As predicted, victim suffering did not affect explicit blame , t(294) = 1.53, d = 0.18, p = .13, 95% CI .A f2 = .03, with α = .05, and 8 predictors.To test Hypothesis 3, we ran one hierarchical regression for each BIDR subscale. The victim suffering manipulation, individual differences in socially desirable responding (centered), subtle blame , and the perceived likelihood ratings of low control behaviors were entered on the first step; the two-way interactions were entered on the second step; and the three-way interaction was entered on the third step. Explicit blame was the criterion. The analyses had 80% power to detect an effect size of b = -0.34, t(287) = -1.77, p = .08, sr2 = .01, 95% CI . Though only marginal, the pattern is consistent with Hypothesis 3, in that subtle blame predicted explicit blame to a lesser extent for individuals high (M + 1 SD), b = 0.25, t(287) = 3.55, p < .001, sr2 = .03, 95% CI  versus low (M—1 SD), b = 0.39, t(287) = 4.72, p < .001, sr2 = .06, 95% CI , in self-deceptive enhancement. Moreover, this interaction was superseded by a significant three-way interaction, b = -0.77, t(286) = -2.00, p = .046, sr2 = .01, 95% CI  that was also consistent with Hypothesis 3  = -2.68, p = .008, 95% CI , but not the mild suffering, b = 0.02, t(286) = .09, p = .93, 95% CI , condition. Within the severe condition, again subtle blame predicted explicit blame to a lesser extent for individuals high, b = 0.20, t(286) = 2.71, p = .007, sr2 = .02, 95% CI , versus low, b = 0.50, t(286) = 5.50, p < .001, sr2 = .08, 95% CI , in self-deceptive enhancement. The analysis involving the impression management subscale yielded no interactions, all ps > .23. Detailed statistics for the regressions are in the Supporting Information  and explicit constructs (see ). SpecifStudies 1 and 2 show evidence of subtle victim blame via the attribution of high control causes. We argued that these attributions constitute subtle blame in the sense that participants do not think the attribution items are meant to assess blame, and thus are not viewed as victim blame in the eyes of others. In Study 3, we asked participants open-ended questions about the meaning of either the explicit blame or the attribution items. If our claim is correct, consistent with Hypothesis 4, participants given the explicit items should be more likely to say the items assess blame, whereas participants given the attribution items should be more likely to say the items assess other constructs.Mage = 37.22, SDage = 11.47; 77% White; 49% Christian, 41% atheist/agnostic).We recruited 64 US residents through MTurk  video. They then answered filler items followed by either the explicit blame or the high and low control attribution items from Studies 1 and 2. Following the blame/attribution items, participants answered two open-ended questions: “Why do you think we are asking this question?,” and “What do you think this question is measuring?” Participants then viewed the video in which the victim was doing well, provided demographics, and were debriefed and paid $1.00.Two individuals who were blind to participants’ condition independently coded the open-ended responses into those reflecting “blame and related constructs,” and “other.” Interrater reliabilities were Κ = .96 for the first open-ended question, and Κ = .87 for the second question. Disagreements were resolved through discussion. The most common “other” responses indicated that the study or measures assessed health knowledge  or indicated uncertainty .w = .35, with α = .05, df = 1. For “Why do you think we are asking this question?,” χ2 = 18.67, p < .001, phi = -.54, and “What do you think this question is measuring?,” χ2 = 17.07, p < .001, phi = -.52, the proportion of participants endorsing each response category varied by the type of measure  X 2  contingency table analysis for each open-ended question. The analysis had 80% power to detect an effect size of sure see . As hypoVictim blame has a long history of study in the social sciences, with the vast majority of studies focussed on explicit blame. We investigated one way in which people more subtly engage in victim blame—by attributing victims’ fate to a cause that is under their control. In two experiments (Studies 1 & 2), we found evidence of this phenomenon. Supporting Hypothesis 1, participants exposed to a victim who presumably threatened a need to see the world as just, compared to participants exposed to a less threatening victim, reported a greater likelihood that the victim had contracted her illness through behaviors over which she had a high degree of control. Supporting Hypothesis 2, this effect occurred despite no similar effects for explicit blame , and despite no obvious cues regarding the cause of the victim’s illness. Our interpretation of these findings is that explicitly blaming innocent victims for their fate is often counternormative e.g., –12), inh, inh12])These studies add to previous work by Bal and van den Bos . Bal andAlso unlike Bal and van den Bos , we measWe argue that the blame expressed in attributions to high control causes is subtle because perceivers’ causal statements about an individual’s suffering can be construed as reflecting a construct other than blame; in the present case, perceivers’ objective knowledge of the victim’s affliction. Indeed, supporting Hypothesis 4, results from Study 3 suggested that participants believed others view the attributions as indicative of constructs other than their tendency to blame the victim; most notably, their health knowledge. Although attributions can partly reflect knowledge, perceivers can also hide a desire to blame victims behind the mantle of expressing their knowledge of the causes of various conditions (see ).Our findings extend justice motive theory by suggesting a strategy for defending a belief in a just world other than those commonly investigated (see ). As sucThe implications of our research reach beyond justice motive theory. We examined victim blame in the context of a threat to the need to believe in a just world. However, we expect that subtle blame, in the absence of explicit blame, could also occur under other forces that compel individuals to engage in victim blame, as long as explicit blame is viewed as counternormative. Other forces include a heightened desire to engage in system justification , certainOur findings also add to the general literature on subtle versus explicit judgments. For example, in the attitude literature, there is evidence of greater correspondence between implicit evaluations (a form of subtle judgment) and explicit evaluations when concerns about self-presentation are weak . In theFrom a practical perspective, our results suggest that, in the absence of explicit blame, innocent victims might yet be subject to subtle blame. Interestingly, subtle blame could be as damaging to victims as explicit blame, given that attributions to high control causes can negatively affect the desire to help victims . Thus, rThe extremity of our victim stimulus (a woman who suffered amputations) likely maximized the chance of certain results. The more extreme the victimization, perhaps the more counternormative is victim blame, and thus the more people will express subtle blame in the absence of explicit blame. Aguiar et al.  found noIt is unclear whether our findings generalize to other victim situations. However, we believe that our findings would generalize beyond our specific scenario given that Bal and van den Bos  found siOur findings do not address whether endorsing high control causes as a form of subtle blame is a conscious or unconscious act of victim blaming. In Study 2, participants prone to self-deception  showed greater divergence of explicit and subtle blame. Thus, perhaps people engaging in subtle blame via attributions to high control causes believe others will not see their attributions as blaming the victim (as suggested by our Study 3), and do not consciously view their appraisals as victim blame. Furthermore, the fact that we found moderation by self-deceptive enhancement but not impression management presents the intriguing possibility that people avoid explicit blame primarily due to a tendency to see themselves in an overly positive light rather than a desire to make a good impression on others. These issues warrant further investigation.In conclusion, victim blame can come in many forms. We found evidence that people will eschew explicitly blaming a victim yet, when compelled by motivational forces, will still subtly blame that individual for his or her fate. Interestingly, if explicit victim blame is becoming more counternormative, the prevalence of subtle blame in the absence of explicit blame could increase.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file. 31 Oct 2019PONE-D-19-24829Experimental evidence of subtle victim blame in the absence of explicit blamePLOS ONEDear Dr. Hafer,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.I have received reviews from two experts related to justice reasoning and responses to victims. As you can see from their comments below, both reviewers had very positive things to say about your manuscript. I also read the paper prior to reading their reviews to form my own independent impression and my response mirrored that of the reviewers. Most of the suggestions the reviewers made were fairly minor, so I will not restate them here. Reviewer 1, for example, thought more discussion of why the “self-deception” subscale, specifically, of the BIDR moderated the effects would be beneficial. Similarly, Reviewer 2 wondered if some examples of high versus low control causes might be helpful in the introduction.https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.We would appreciate receiving your revised manuscript by Dec 15 2019 11:59PM. 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Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at [Note: HTML markup is below. Please do not edit.]Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: YesReviewer #2: Yes**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: Thank you for the opportunity to review this paper. Across three studies, the authors investigated whether people engage in subtle victim blaming by attributing victims’ suffering to high control behaviors despite eschewing overt blame, and whether this is explained by social desirability concerns (because overtly blaming victims is counter-normative).The findings complement and extend recent research on overt and covert responses to victims and other stigmatized groups. This is an interesting topic, and the findings have important methodological (in terms of how responses to victims are measured/what we can expect given different means of measuring them) and theoretical implications.Overall, the paper is well written and a pleasure to read. The studies are well and designed, complementary to each other, and the findings clearly support for the authors’ arguments and hypotheses. I have only a few, relatively minor suggestions.- Effect of suffering on attributions to low and high control causes in Studies 1 and 2. I appreciate the appropriateness of ANCOVA given hypothesis 1. It would be informative to show also whether the effect of suffering on low and high control causes differs in the way that the ANCOVA’s (on high control) and t-test’s (low control) might imply, but do not confirm – i.e., whether there is an interaction such that suffering increases attributions to high (compared to low) control causes more strongly. The results clearly suggest that greater suffering motivated ppts. to find fault with the victim’s behavior in particular, rather than more strongly endorse any old cause. If suffering does increase high control attributions significantly over and above low control attributions, I think a stronger conclusion can be drawn. These additional analyses could be reported briefly in a footnote or supplementary materials.- Self-deception vs. impression management. In Study 2, the relation between implicit and explicit blame was moderated (under high suffering) by the self-deception, but not the impression management subscale, of the BIDR. The pattern of results supports the idea that people resort to subtle over overt blame due to social desirability concerns in general. Yet, might this pattern also suggest something about the specific locus of these concerns? My understanding is that the self-deception subscale measures the tendency to maintain a positive self-image (I don’t want to see myself as counter-normative/a person who blames victims), whereas the impression management subscale pertains to managing others’ impressions of the self (I don’t want to be seen by others as behaving counter-normatively). Space permitting, I think it would be good to briefly address this.Minor Comments- It would be helpful to provide intercorrelations between measures in Study 1- There is a (presumed) typo on line 177 - A reference is needed on line 384 (research on relation between explicit/implicit constructs)Reviewer #2: Review of PONE-19-24829The authors report three studies testing subtle victim blame effects. In Study 1, they found that under conditions of just world threat, participants subtlety blamed the victim by attributing the victim’s suffering to a behaviour that the victim could have avoided (high control cause). Study 2 found that the Study 1 effect was modulated by self-deception. Study 3 shed light on the idea that people don’t perceive subtle blame as blame (vs. explicit blame judgments).Taken together, the studies are providing important new insights into how people respond to the suffering of innocent victims. Although some recent work has begun to explore similar ideas in the context of subtle victim derogation , none have examined how subtle victim blame can manifest as one response to the suffering of an innocent victims. The authors show that one way such subtle blame can manifest is through people endorsing causes for someone’s suffering that don’t, prima facie, seem like blame judgments.I only have a few suggestions that might help improve the work:1) I think some concrete examples of high vs. low control causes might help provide the reader with a bit more context for the work. Somewhere around line 83.2) Lerner’s theorizing about the two forms of the justice motive—basically, implicit vs. explicit--doesn’t seem to be given much coverage here. It might not be exactly relevant to the current work, but mention of this theorizing might provide a bit more theoretical grounding for the research.3) I wondered whether it would have been more appropriate to control for high control variables when testing the effect of suffering status on low control behaviors (as was done for low control behaviors)4) Most of the theorizing in the introduction about the role of SDR was in general terms but the authors analysed impression management and self-deception separately. I think this is fine given the known two subcomponents of the BIDR, but it would be good to see more discussion of why the effects were observed for SDE and not impression management. What are the differences between these forms of SDR that might shed light on why effects were observed for one and not the other?Signed reviewMitch Callan**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  6 Dec 2019Reviewer #11) - Effect of suffering on attributions to low and high control causes in Studies 1 and 2. I appreciate the appropriateness of ANCOVA given hypothesis 1. It would be informative to show also whether the effect of suffering on low and high control causes differs in the way that the ANCOVA’s (on high control) and t-test’s (low control) might imply, but do not confirm – i.e., whether there is an interaction such that suffering increases attributions to high (compared to low) control causes more strongly. The results clearly suggest that greater suffering motivated ppts. to find fault with the victim’s behavior in particular, rather than more strongly endorse any old cause. If suffering does increase high control attributions significantly over and above low control attributions, I think a stronger conclusion can be drawn. These additional analyses could be reported briefly in a footnote or supplementary materials.Our response: The analysis suggested by Reviewer #1 is a Victim Suffering (mild vs. severe) X Controllability of Causes (low control vs. high control behaviors) mixed ANOVA with repeated measures on the second factor. The dependent variable is the perceived likelihood that the behaviors caused the victim’s sepsis. We conducted this mixed ANOVA for Studies 1 and 2. In both cases, there is a significant interaction between victim suffering and controllability of causes: Participants in the severe suffering condition rated the high control behaviors as more likely to have caused the victim’s sepsis than did participants in the mild suffering condition, whereas ratings for the low control behaviors did not differ by condition. Thus, as Reviewer #1 suggests should be the case, greater suffering increases high control attributions significantly, independent of any such effect on low control attributions. In the revised manuscript, we briefly state the findings of these mixed ANOVAs in the first paragraph of the “Victim blame” section of the Results for Studies 1 and 2. We refer to new supplemental information files  for details.2) - Self-deception vs. impression management. In Study 2, the relation between implicit and explicit blame was moderated (under high suffering) by the self-deception, but not the impression management subscale, of the BIDR. The pattern of results supports the idea that people resort to subtle over overt blame due to social desirability concerns in general. Yet, might this pattern also suggest something about the specific locus of these concerns? My understanding is that the self-deception subscale measures the tendency to maintain a positive self-image (I don’t want to see myself as counter-normative/a person who blames victims), whereas the impression management subscale pertains to managing others’ impressions of the self (I don’t want to be seen by others as behaving counter-normatively). Space permitting, I think it would be good to briefly address this.Our response: Reviewer 1’s point is related to our comment at the end of the “Limitations and future directions” section regarding the conscious versus unconscious nature of subtle blame. Thus, we added a sentence to this paragraph stating one implication of our finding that only self-deceptive enhancement moderated the relation between subtle and explicit blame.3) - It would be helpful to provide intercorrelations between measures in Study 1Our response: We revised Table 1 so that it now contains intercorrelations for Study 1 and Study 2. We also moved Table 1 to immediately after its first mention (the end of the 1st paragraph for the Results and Discussion of Study 1). 4) - There is a (presumed) typo on line 177 Our response: The Reviewer is correct. We have changed “data analysis” to “data collection” (see the 1st paragraph of Study 1).5) - A reference is needed on line 384 (research on relation between explicit/implicit constructs)Our response: We have added a citation (see 2nd paragraph of the Discussion for Study 2).Reviewer #21) I think some concrete examples of high vs. low control causes might help provide the reader with a bit more context for the work. Somewhere around line 83.Our response: We have included two examples of high and low control causes (see the end of the 4th paragraph of the Introduction).2) Lerner’s theorizing about the two forms of the justice motive—basically, implicit vs. explicit--doesn’t seem to be given much coverage here. It might not be exactly relevant to the current work, but mention of this theorizing might provide a bit more theoretical grounding for the research.Our response: We have added Lerner’s notion of deliberative/rational versus intuitive/defensive processes with respect to the justice motive (see the 3rd paragraph of the Introduction).3) I wondered whether it would have been more appropriate to control for high control variables when testing the effect of suffering status on low control behaviors (as was done for low control behaviors)Our response: We have replaced the t tests using low control behaviors as the dependent variable with ANCOVAs, as Reviewer #2 suggests (see the 1st paragraph of the “Victim blame” section of the Results for Studies 1 and 2).4) Most of the theorizing in the introduction about the role of SDR was in general terms but the authors analysed impression management and self-deception separately. I think this is fine given the known two subcomponents of the BIDR, but it would be good to see more discussion of why the effects were observed for SDE and not impression management. What are the differences between these forms of SDR that might shed light on why effects were observed for one and not the other?Our response: See our response to Reviewer #1’s Point 2.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 16 Dec 2019Experimental evidence of subtle victim blame in the absence of explicit blamePONE-D-19-24829R1Dear Dr. Hafer,We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact With kind regards,Daniel WisneskiAcademic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments: 18 Dec 2019PONE-D-19-24829R1 Experimental evidence of subtle victim blame in the absence of explicit blame Dear Dr. Hafer:I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. 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Background: Despite extensive research in the field of psychotherapies, few studies have compared the primary psychotherapies of naturalistic design, which represents real-life situations.Objective: The objectives of this study were to evaluate three modalities of evidence-based psychotherapy for clinical, psychosocial, and biological outcomes and to identify the mediators and confounders of this process. Our primary hypothesis is that all psychotherapies will improve clinical and psychosocial outcomes and will increase BDNF levels.Methods:Design: longitudinal, naturalistic. Participants: One hundred twenty-six patients who underwent one of three evidence-based modalities of individual psychotherapy  were included. Measure: Primary outcomes are divided into three domains of variables: clinical , biological (serum BDNF levels), and psychosocial . Confounding/mediator variables included clinical , psychosocial , and other (religiosity) factors. Procedure: The follow-up period will be baseline and 6 months and 1 year after entering the study. The study will include 42 controls for biological variables only. Sample size calculation considered a significance level of 5% and a power of 80% to detect a difference of 0.22 with a standard deviation of 0.43, assuming losses of 20–30% of patients. The comparison between the modalities of psychotherapy will be by generalized estimating equations (GEE) model, the analysis of mediators by the Hayes method, and confounders by multivariate logistic regression.Discussion: The findings of this study are intended to demonstrate the outcomes of evidence-based psychotherapies for clinical, psychosocial, and biological parameters and to understand the mediators and confounders of this process in a real-life setting for patients with severe mental illness, thus contributing to the establishment of evidence-based public health policies in the field of psychological interventions. Psychotherapies are effective interventions for most mental disorders –4. A sysComparisons between different types of psychotherapy have long been a source of controversy , even wiAlthough there have been many randomized clinical trials (RCTs) evaluating the outcomes of psychotherapies, this is the first protocol of a study to evaluate main available evidence-based psychotherapies using a naturalistic longitudinal design and including patients referred from primary and secondary centers with complex and severe disorders. This design has the advantage of evaluating clinical outcomes in a real-world situation. Clinical trials, on the other hand, have the standardization of interventions, but can suffer from a lack of rigorous control related to the criteria for inclusion of patients; also, longitudinal studies have a level of evidence lower than that of randomized clinical trials and meta-analyses . To our Reviewing the longitudinal studies in psychoanalytical psychotherapy published on PubMed, PsychInfo, and Embase databases within the last 5 years, we found seven studies –16, all The question of how to evaluate outcomes in psychotherapy is quite complicated and has been the subject of numerous studies . The mosPsychotherapies can function by environmental epigenetic mechanisms, altering gene expression through methylation of the DNA of the serotonin transporter gene (5HTT) and altering imaging exams. However, this subject has been rarely studied . The seaChanges in BDNF have already been investigated in different psychotherapies  in cliniPatients with borderline personality disorder who underwent behavioral dialectical psychotherapy had a change of methylation of the BDNF gene at the end of the treatment that was associated with change scores in depression, hopelessness, and impulsivity . PatientDespite the extensive literature of comparative studies of psychotherapies, there are still issues related to the effects of moderators and mediators in the psychotherapeutic process, especially considering a view of protective factors, biological factors, and outcomes that encompass factors of positive psychiatry such as quality of life and resilience. In addition, further studies are needed in naturalistic and severe patient contexts that assess psychotherapy in practice, seeking external validity.Our primary aim is to evaluate the outcomes associated with different forms of individual psychotherapy  in a public outpatient clinic for mental disorders. Our primary outcomes are divided into three domains of variables: clinical , biological (serum BDNF levels), and psychosocial .Our secondary aim is to evaluate potential confounders/mediators/moderators for the main outcomes: personality traits, type of psychotherapy, number of sessions, the therapist’s duration of training, concomitant use of pharmacological treatment, history of previous psychotherapeutic treatment, medical and psychiatric comorbidities, psychiatric diagnosis, therapeutic alliance, and defense mechanisms.Our main hypothesis is that all three modalities of therapy will produce reduction of symptoms in the clinical domain and improvement in the psychosocial domain. All psychotherapies will increase BDNF at 6 months of follow-up. As secondary hypotheses, the mechanisms of improvement will be mediated by the therapeutic alliance, motivational status, and defense mechanisms (for PDT). The confounders of this therapeutic improvement will be number of sessions, comorbidities, and medication use. The moderating factors will be gender, age, personality traits, religiosity, and defense mechanisms (for CBT).The Longitudinal Investigation of Psychotherapy Outcome (LIPO) study will compare three modalities of psychotherapy  in a longitudinal course, in a naturalistic setting. The choice of the three modalities of psychotherapy is evidence-based and listed in guidelines for indication of first-line treatment for depression , 31.The evaluations will take place in three moments: in the baseline (until the fourth session of psychotherapy) and 6 and 12 months after entering the study. The invited participants will be the patients who are undergoing any psychotherapy in the outpatient clinic of the Hospital de Clínicas of Porto Alegre (HCPA).All patients included at the HCPA psychotherapy clinic will be evaluated by a fourth-year psychiatry resident with training in psychotherapy. Patients will be referred from the outpatient clinic of clinical psychiatry, pain medicine, or preoperative bariatric surgery. Each patient who agrees will undergo up to five evaluation interviews and engage in discussions with a supervisor. They will be next referred, based on clinical judgment, to the most suitable modality of psychotherapy. The clinic offers three methods of individual psychotherapy: PDP, IPT, and CBT.The psychotherapy modality will be indicated by general criteria , considePsychotherapeutic care will be provided by psychiatry residents in their second, third, and fourth years of residency in psychiatry under weekly supervision of dialogued interviews. The residents have weekly theoretical seminars related to each of the psychotherapeutic techniques offered throughout the period of residence. They also engage in weekly clinical seminars in which patients are interviewed by teachers to prompt discussions about the clinical aspects related to cases. When there is doubt about patient management, the patient is interviewed by the supervisor.For the purposes of this study, outcomes were divided into clinical, psychosocial, and biological domains to make the study as comprehensive as possible in understanding the complex processes of change that may occur in psychotherapies (Table 1). The clinical domain refers to the more traditional measures of symptoms used to mediate the effectiveness of psychotherapy , 14. TheThe Symptom Checklist-90-Revised (SCL-90-R) is a self-administered scale consisting of 90 items distributed over nine dimensions: somatization, depression, interpersonal, obsessive–compulsive sensitivity, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. The scales of answers range from 0  to 4 (an extreme degree of injury). Over the 6 months after discharge from the clinical follow-up, only paranoid ideation and the psychosis domains are considered. This situation results in a total of 16 items. The next follow-ups are conducted face to face, which allows for the application of the entire checklist .These self-report rating inventories, developed by Beck, aim to measure symptoms of depression and suicidal ideation [Beck Depression Inventory (BDI)] and anxiety [Beck Anxiety Inventory (BAI)] .Blood Collection Serum samples will be obtained by venipuncture, and the blood will be immediately centrifuged at 3,000 × g for 5 min. The samples will be stored at −80°C until biochemical analysis.®, Houston, TX, USA), according to the manufacturer’s instructions, with techniques standardized by our group. The total quantity of proteins was measured according to the Lowry method.The levels of neurotrophins (BDNF) will be measured using a sandwich ELISA kit .The World Health Organization Quality of Life—BREF (WHOQOL-BREF) is an abbreviated quality of life instrument developed by the World Health Organization. It consists of 26 items that are answered in response scales ranging from 1 to 5, and it is based on a four-domain structure  , 36.The Connor–Davidson Resilience Scale (CD-RISC) is a widely used self-report consisting of a 25-item questionnaire for evaluating individual resilience. It is divided into four domains: tenacity, adaptability–tolerance, reliance on support from the outside, and intuition , 38.The Medical Outcomes Study (MOS) Social Support Survey consists of 20 self-reported items .The SF-6D was adapted to Brazilian Portuguese–Brazil (version 2002). This self-administered instrument produces a unique score, which ranges from 0 to 1. The score represents the strength of an individual’s preference for a given health condition; 0 corresponds to the worst health status and 1 corresponds to the best health status .The mediating factors will be therapeutic alliance, motivation, and defense mechanisms (for PDT only). The moderating factors will be gender, age, religiosity, stressors, social support, personality traits, and defense mechanisms (for CBT and IPT). The confounding factors considered will be diagnosis, medication use, number of sessions, and comorbidities.The psychodynamic diagnosis was based on Operationalized Psychodynamic Diagnosis (OPD II), a multiaxial diagnostic system for psychodynamicaly oriented therapists and psychiatrists , 42.The Personality Inventory for DSM-5  (PID-5)—Adult . A set oThe Life Events Questionnaire (LEQ) evaluates the occurrence of 14 stressful life events over the last 12 months and the impact of these events on the subject’s life. The LEQ also focuses on the stressors’ association with the onset of current psychiatric problems .The California Psychotherapy Alliance Scale (CALPAS) is a 24-item self-applicable questionnaire .The Defense Style Questionnaire (DSQ-40) is a 40-item self-applicable questionnaire that aims to identify derivatives of defense mechanisms .The University of Rhode Island Change Assessment (URICA) assesses motivation for change by providing scores on four stages of change: precontemplation, contemplation, action, and maintenance .meaning of life) located in the psychological domain of the WHOQOL-BREF (The Duke University Religion Index (DUREL) is a five-item measure of religious involvement. It was developed for use in large cross-sectional and longitudinal observational studies , 49. TheQOL-BREF , 50.Our sample size calculation relied on the study of Schaf  using BDThe study will include a subsample of healthy controls for control of blood samples that were recruited from the HCPA blood bank. The exclusion criteria for the control group included conditions (current or past) that precluded participation in the study , immune disorders, use of immunosuppressants, anti-inflammatory drugs used for fewer than 3 weeks, smoking, abuse and/or drug addiction, and infectious diseases for fewer than 3 weeks.t tests will be performed. To determine differences between categorical variables, the chi-squared test will be used. For nonparametric distributions, we will use the Wilcoxon test and Mann–Whitney U test to compare nonrelated and related means, respectively. A generalized estimating equations (GEE) model will be used to investigate multivariate repeated measurements. The Hayes method will be used to analyze the mediators . The statistical analyses will be performed using the SPSS version 20.0 software package .The data will be expressed as mean ± standard deviation (SD), and a The study will be disseminated through the presentation of its protocol in meetings with the outpatient services of the HCPA that refer patients to the psychiatry service, such as the internal medicine, pain, and bariatric surgery outpatient clinic.The researchers will not participate in the indication of treatment of patients or in their assistance. Patients will be sought weekly in the HCPA outpatient medical records and through contact with resident physicians screening new patients. Those who fall into the eligibility criteria will be contacted by phone by the research assistant and invited to participate. It will be explained that refusal to participate will not entail any loss to the treatment. If they agree to participate, they will be asked to attend the HCPA Clinical Research Center (CPC-HCPA), where they will receive the informed consent form, sociodemographic interview, OPD interview, BDNF blood collection, and protocol with self-administered questionnaires. The consent form and OPD will be applied by the researchers. Patients will be contacted by telephone for the follow-up of 6 and 12 months .This study will be conducted in the city of Porto Alegre in the state of Rio Grande do Sul in far-southern Brazil. This region has Portuguese, Italian, German, and African influence. It has a population of 1.4 million, and it is the 10th most populous city in Brazil. Its ethnic distribution is as follows: White (79.2%), Black (10.2%), and Pardo  people (10.6%). Its religious distribution is as follows: Catholic (83%), Protestant (9%), and others and atheists (8%). Brazil is a country with a high level of religiosity, and it is common for people to associate improvements in their health as being due to their faith . The rolThe only naturalistic longitudinal study that we found concluded that there was no significant difference in outcomes between therapies, as well as among therapists. However, these results need to be viewed with caution given some limitations related to loss, incomplete data, and the lack of long-term follow-up. Our study used direct contact with patients, which increased the number of variables and collection of BDNF as a possible biomarker in response to psychotherapy intervention.Historically, studies in psychotherapy have been difficult to perform because they involve multiple factors and variables that are interrelated. Many variables may act as only associated factors, and others  may have varying effect sizes. We had difficulty defining some variables as mediators or confounders because the mechanism by which psychotherapies work is a matter of debate . We are Regarding the biological factors, studies of biomarkers such as BDNF may provide insights into the possible mechanisms of illness and recovery from serious disorders such as depression, bipolar disorder, and schizophrenia . A few sConsidering the severity profile of patients referred to a tertiary medical center and the level of experience of resident physicians, the magnitude of improvement is lower than in other more favorable clinical settings. This improvement should be more pronounced in the 12-month follow-up considering the long-term effects of psychotherapies. The level of therapeutic alliance may possibly mediate this improvement. We believe that it will also reflect patients’ psychosocial factors and increase BDNF.Limitations of this study include the heterogeneity of the training and experience of the resident psychiatrists and the absence of evaluation from their point of view in the psychotherapeutic process. As a study is naturalistic, there is no way to control the impact of the researchers’ interviews. We will collect a series of demographic data, use of medications, and number of sessions to control possible confounders, but we know that because it is an open study, there is no way to control all differences between groups. Also, psychotherapy studies often have large amounts of losses . To contStudies such as this one seek to contribute to the foundations of public health policies and investments for the treatment of patients with severe mental illnesses who are at risk of hospitalization and suicide. These types of investigations also seek to promote mental health, rehabilitation, and social reintegration. Understanding the mediating and biological mechanisms of the psychotherapeutic process can help to optimize these interventions and facilitate their indication according to the psychopathological profile and the severity of the patients.This project was approved by the Ethics Committee of Hospital de Clínicas de Porto Alegre (GPPG–HCPA no 97-2015), and it is recognized by the CONEP Conselho Nacional de Ética em Pesquisa—National Council of Ethics in Research.LG and NR codeveloped the project. NR coordinated the project in HCPA. LG, GB, and CR were responsible for implementing, conducting, and collecting project data.This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior–Brasil (CAPES)—Finance Code 001 and by Hospital de Clínicas de Porto Alegre Research Incentive Fund (FIPE).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Demand side barriers to vaccination among rural and hard-to-reach populations in Chad are not yet well understood. Although innovative approaches such as linking human and animal vaccination increase vaccination uptake among mobile pastoralist communities, vaccination coverage in these communities is still lower than for rural settled populations. We hypothesize that mobile pastoralists’ communities in Chad face specific demand side barriers to access vaccination services. Understanding the factors that caregivers in these communities consider, explicitly or implicitly, in order to decide whether or not to vaccinate a child, in addition to understanding the provider’s perspectives, are essential elements to tailor vaccination programmes towards increasing vaccination acceptance and uptake.We conducted a qualitative study in a rural health district in southern Chad in April 2016 with 12 key informant in-depth interviews and four focus group discussions (FGDs) including 35 male and female participants. Participants in the study included caregivers, traditional chiefs, local and religious leaders from mobile pastoralist communities, and health officials and staff. We conducted a content analysis using a pre-defined set of categories for vaccine hesitancy covering issues on harmful effects of vaccination, mistrust with vaccination programmes/services, issues with the health system and other issues.n = 94), followed by health system issues , and concerns related to potential harm of vaccines . Concerns identified by caregivers, health professionals and community leaders followed a similar pattern with issues on programme mistrust being most frequently reported and issues with harm least frequently reported. None of the health professionals reported concerns about vaccinations being potentially harmful.The groups of demand side barriers reported most frequently in focus group discussions were mistrust on the expanded programme on immunization (EPI) and polio vaccination outreach services (53%, Mobile pastoralist communities face specific demand side barriers to vaccination. Understanding these barriers is essential to reduce vaccine hesitancy and increase vaccination uptake. Local health systems must plan for the periodic presence of pastoralist communities in their zones of responsibility and create more mutual trust. Vaccination is one of the most successful and cost-effective interventions in public health . In 2015Although increasing access to vaccination has been the main strategy employed to improve vaccination coverage during the last three decades, policy makers and international institutions have more recently focused on “vaccine hesitancy” (demand side barriers to vaccination) . VaccineIn Chad, a sub-Saharan African country with about 14 million inhabitants , polio vThe Sustainable Development Goals (SDGs) target reduction of inequities in an interdisciplinary manner with universal policies considering the needs of disadvantaged and marginalized populations . AlthougDemand side barriers to vaccination among rural and hard-to-reach populations in Chad are not yet well understood. Based on anecdotal and non-structured analysis of people’s beliefs and attitudes towards vaccination, managers of the Expanded Programme on Immunization (EPI) focused their efforts on providing information on the benefits of vaccines as a means to increase vaccination uptake. However, evidence from other West and Central African countries suggests that there can be other relevant factors that prevent caregivers from vaccinating their children, for instance, concerns about the potential harm of vaccines in Benin , fear ofThis study uses a qualitative approach to identify demand side barriers which hinder access to vaccination services among mobile pastoralist communities in Chad. Qualitative methods allow exploring the underlying issues underlying issues of vaccination hesitancy beyond the observed low utilization rates of vaccination services among mobile pastoralist communities. We hypothesized that Chadian mobile pastoralist communities face specific demand side barriers to access vaccination services. Understanding factors which caregivers in these communities might consider, explicitly or implicitly, in order to decide whether or not to vaccinate a child is an essential element to tailor vaccination programmes to increase vaccination acceptance and uptake. To our knowledge, the present study is the first to investigate factors that prevent mobile pastoralists from accessing vaccination services in Chad, providing an important opportunity to advance the understanding of why caregivers in hard to reach communities might decide not to vaccinate their children. The findings of this study will also inform the design and implementation of interventions to increase vaccination outcomes among mobile pastoralist communities. In this paper, the term “nomadic communities” is used interchangeably when referring to the same communities despite the fact that not all mobile pastoralists are necessarily nomads.Data was obtained from 12 individual semi-structured interviews and four focus group discussions (FGDs).Selection of participants was based on a convenience sampling approach designed to maximize demographic and functional diversity of the sample around the topic of vaccination. Interview participants were recruited based on their availability and included primary caregivers (mothers with at least one child under 5 years old), heads of families who were decision makers and resource controllers, local health authorities and civil and religious leaders Table . ParticiFirst drafts of the interview and FGD guidelines were based on literature review and discussions with health experts in the Chadian context. The draft was field tested and further refined in a participatory process involving local health experts and representatives from the nomadic communities to compare and contrast views and opinions. Each FGD took approximately one hour and was facilitated by at least two people of the same sex as the participants. Individual interviews took between 40 and 60 minutes. Data from male participants was obtained in mobile pastoralists’ camps, in a quit and private place away from distractions. To ensure confidentiality and a favorable atmosphere for discussions, interviews and FGDs with nomadic women were conducted in a protected environment, most often in a woman’s home. Data collectors were trained anthropologists and sociologists from the University of N’Djaména holding at least a Master’s degree. No relationship existed between researchers and study participants prior to study commencement.Face-to-face interviews and FGDs were audio recorded, transcribed and translated from Chadian Arabic into French. Data evaluation was done manually following a deductive approach. More specifically, the analysis of the transcripts was based on content analysis using a directed approach , 29 baseFirst, transcripts were carefully reviewed to highlight all text that appeared to describe vaccination concerns. Then, all highlighted text was coded using the pre-defined categories. Text that did not fit into one of the categories was assigned as “other issues”. Study findings were reported based on the incidence of codes that represent the pre-defined categories by comparing the overall rank order of the codes and the corresponding percentages within and between the population groups . EvidencEthical clearance was given by the National Bioethics Committee in Chad “Comité National de Bioéthique du Tchad (CNBT)” and the WHO Research Ethics Committee Review (WHO ERC) .The study participants were given detailed information about the purpose of the study, the background of the data collectors and the extent of their involvement. Informed consent was obtained from all study participants before starting any interviews or FGDs. It was explained that participation was voluntary, without compensation, individuals could withdraw from the study at any time, statements would be anonymised so that attribution to individuals would not be possible, and participation was without negative consequences for them, their family or their community. All participants were adults and either signed or fingerprinted the consent form.A total of 94 coded quotes that reported concerns about hesitancy or barriers to access vaccination in Danamadji were extracted from the transcripts based on 12 individual interviews and four FGDs. In total, 35 men and women participated in the four FGDs. There were no refusals to participate in the study.The quotes were retrieved as follows: 73 from interviews, 15 from FGDs with male participants and 12 from FGDs with female participants. Most quotes were from caregivers, followed by health staff and community leaders. We present the results using the pre-defined categories to describe the results  issues wn = 94), followed by health system issues , and concerns related to potential harm of vaccines . The sub-categories with the five most frequently demand side barriers to vaccination are shown in Table The most frequently reported demand side barriers were related to issues with programme mistrust 53%, %, n = 94Concerns related to the potential harmful effects of vaccines or their side effects were the least reported category of demand side barriers to vaccination among mobile pastoralist communities in Danamadji. Among other concerns, participants reported the risk of sterility, fever, diarrhoea, inflammation of the throat and even death.In general, diseases are part of human daily life. It is not all the time that when a child is sick, then we should go immediately to a hospital. Diseases for children are somehow a necessary bad thing. By falling ill, they become immune. So we do not go to the hospital or health centre immediately for a given disease of the child” .“For some individuals, the prevention of certain diseases by vaccines was not a desired outcome because diseases were opportunities for the body to get stronger and, since vaccines prevented them, they subsequently weakened the child’s (immune) system. One father pointed out:Certainly the disease is a very bad thing, especially malaria and colds in children. In general, we do not want the children to get sick. (…) But when the child is still in good health, there is fear the day it falls ill. I have in all 7 children, 2 of them died. One died unexpectedly because he was always healthy. One day he fell ill and the third day of his illness, he could not conquer the disease and died. Therefore, diseases in children are a sign of longevity. Do not regret too much that children fall ill” .“Some extreme views were reported by caregivers who believed that one of the reasons why children die unexpectedly was because they were consistently healthy: We cannot comment on the pros and cons of a thing until you know the thing. In the case of vaccination, we cannot say, because no one came to us to tell us against which disease the vaccination is. So we cannot know whether vaccination is a solution as described by the State or a problem as the rumours say” .“The most frequently reported demand side barrier to vaccination were that caregivers did not have enough information to understand the benefits of vaccination and to know the process for getting their children vaccinated or they did not trust health workers coming to the camps during polio outreach vaccination days. It was widely acknowledged by most participants that nomadic communities received too little information about vaccines and their benefits: Yes we heard about the vaccination about polio. But also for this vaccination issue, we have not seen drugs that can cure or protect our children” .“There was some confusion about the difference between vaccination days for polio vaccination and routine vaccination. Several participants referred only to polio vaccination when raising their arguments. They usually talked about “drops” when they referred to vaccination in general. Benefits of vaccination were not clear, and there was some reluctance to believe that vaccines are effective: Vaccination, I heard about it in street talks from people who do not know more than me. So nobody really told me what it is” .“Even the most basic information about vaccinations did not reach some nomadic communities: “There are no communication channels between nomads and health professionals. In our camp here as elsewhere, we do not have a person who acts as an intermediary to convey information between us and the immunization services. There is a total lack of dialogue between us and the health services. They do not even have the phone number of the camp chief to call and deliver information” .No communication channel was reported that brings pro-vaccination messages to nomadic communities. Some caregivers complained that instead of receiving more information they were intimidated by health authorities forcing them to vaccinate their children. A camp leader reported: Here we do not know that when a child is healthy, we can get him to the hospital to take the vaccine which protects him against a number of diseases that are disturbing and even killing our children” .“Mobile pastoralist communities were usually reached less often with information than other communities, and they did not have regular contact with health facilities or authorities. There were only few opportunities when individuals had regular contact with conventional health services , and they only made use of health services during illness or in emergencies. A participant in a FGD was surprised that health services could be used preventively:  “What we deplore is that when the vaccinators come here, they do not explain what they came to do. They only call the children and put the drops in their mouths. They are always in a hurry.” .Even when health workers from the district health system moved to camps to provide health services, they did not use the opportunity to reduce the information gap with either local leaders or caregivers. A mother complained:It’s true that I am the imam (religious leader) having a great influence on the community, but no one came to explain to me what the vaccination is about so that I may have the possibility to widely inform my congregation during the Friday prayer and when people meet. General health services and those related to vaccination in particular lack a method to inform or convey their message. For example in the case of polio, instead of explaining us the merits and inform us of the arrival of the team of vaccinators in our camps, we suddenly see them arriving and catching children within their reach and administering the drops of vaccines. We parents only accept this method against our will. Some prefer to hide their children and sometimes colour their fingers to show that the children were already vaccinated so that they would not swallow anything. All of this is the lack of information about polio” (Religious leader).“Some participants pointed out that it is understandable that parents do not have trust in something they do not know or have not been informed about. The way in which polio outreach vaccination days are organised, with teams moving from camp to camp during one day to vaccinate children, was inadequate to provide sufficient information and convince caregivers to vaccinate their children, specifically for routine immunization. A religious leader reported: a plan of God to train the child for the difficult moments” , and they should not fight them. For others, diseases had a religious/divine origin, and they must be handled by traditional healers such as the Marabout. The services provided by traditional healers were considered to be more affordable, despite the fact that vaccination is offered free of charge in Chad. They were also considered more effective as compared with western medicine (including vaccination): When the children here become sick, I intervene in the first place to use religious incantations. And it is only when the disease persists that the child is brought to the hospital. There are also cases where the child is sent home from the hospital without being cured, and at this level too I am the last resort to pray for God to cure the sick child. I intervene, I use incantations for all kinds of diseases” .“Religious and cultural beliefs also played a role in the decision making process of whether to vaccinate infants living in nomadic camps. Some communities believed that diseases are “(…) When we go to the health centre to seek care for our sick children, we are very poorly received. In some situations, we are expelled by health workers. Hoping that a child would never be ill so that one would not have to wait at the hospital saying that we want to have medication, imagine what treatments can be reserved for us? We pastoralists, don’t we have rights? Health workers consider us like our animals” .“Concerns about vaccination providers in health facilities being unpleasant were widely reported by participants in interviews and FGDs. Some participants considered health workers to be authoritarian and bad tempered. One informant pointed out: You see filthy agents who come to do this work. Some of them are drunkards, which we know. This does not inspire confidence. You end up saying this vaccination business is a way to get work for some, to make money for others and all this at the expense of the health of our children. Finally, I have a negative perception of the entire vaccination operation”, .“Nomadic communities had a very poor opinion of health care workers in the district which was a major barrier to vaccination. Even acknowledging that vaccination is free of charge and could have some benefits for children, parents decided not to vaccinate because they did not trust the system that provides them: some participants believed that vaccination was not effective and vaccination campaigns were only conducted in the interest of district officials and health workers who receive per diem payments for the vaccination days: For me, polio is an organised business from the high hierarchy to the last vaccinators who administers the drops. Everyone finds his interest and that’s it. This practice makes me doubt about the efficacy of poliomyelitis vaccine” .“In line with this idea, They send us the dirty young people from the neighbourhood to come and vaccinate our children against poliomyelitis. They are young people who only seek money without further concerns. They do not know anything about health (…..) People treat us like our animals and have no consideration for us. We have never seen a trained health worker or a doctor coming to vaccinate our children” .“It was frequently reported that health professionals working in vaccination campaigns were not trained doctors or nurses, which raised concerns about their capacity to deliver vaccination activities. Some interviewees even saw this situation as a form of disrespect to nomadic communities: We want people to send us staff who know the health field. We prefer people close to our realities, who know our problems and who can transmit them to higher authorities to react. We want reliable people, who can educate us on vaccination” .“The fact that the messages about vaccination  or the interventions themselves were not provided by staff who were considered as peers in terms of religious and cultural background prevented some parents from vaccinating their children. In addition to the language barrier between health professionals and nomadic communities, health workers seemed to ignore the basic cultural and religious norms in the camps, and there were few Muslim health workers. One camp chief criticised: The reality is that the vaccinators cannot make the trip to the camps at any time, when the head of household is absent following his herds, for example. This is a serious cultural breach in pastoral communities as a wife has to seek permission of her husband to decide on certain issues; such as exposing a child to strangers. This is also valid for the vaccination of children” .“Other examples of health system issues were the lack of cultural appropriateness of vaccination services and the timing of teams from the health centre for visiting the camps. The timing for the visits significantly interfered with daily activities and obligations for both men and women in the camps. As one of the administrative authorities in Danamadji recognised, We identified demand side barriers to vaccination among nomadic communities in Danamadji District in Chad. We conducted a study using qualitative research to identify factors or beliefs that prevent caregivers from vaccinating their children. Contrary to expectations, this study found that issues related to the health system itself, such as health staff being unpleasant or vaccination campaigns being poorly organised, were widely reported by nomadic communities. In comparison to previous studies on vaccine hesitancy in low and middle income countries (LMIC) , it is sThere is a significant body of literature on barriers to vaccination services which shows that concerns about the harmful effects of vaccination and lack of information are the most important (frequently reported) demand side barriers to vaccination , 15, 17.A limitation is that most participants referred primarily to the polio vaccination outreach days in their answers although the questions were designed to capture the perception of routine and outreach vaccination services. Issues related to lack of trust in the vaccination outreach days against polio and health system issues were the most frequently reported. Nomadic communities were reluctant to vaccinate their children because they did not have enough information about the benefit of vaccines or the location of vaccination services in their district. A substantial number of participants in our study complained that health staff were unpleasant or that they felt neglected or humiliated because they were nomads. They raised concerns about the qualification of vaccinators and their cultural distance from the nomadic community as one of the most important disincentives to get their children vaccinated. They sought interlocutors with knowledge on the daily life and culture between them and the health services.Communication channels between nomadic communities and the local health system does not seem to exist. It is well known that communication and social mobilisation is associated with high vaccination coverage and allows for reaching “sparsely covered groups” when included as a key component of immunisation programmes, e.g. polio , 30. AltThe health system in Danamadji fails to provide vaccination services to nomadic communities, which translates into substantial immunisation inequities when compared to rural settled populations in the same district. To reduce health inequities in light of the SDGs, modern health system interventions must ensure that all population strata benefit from new policies. Barriers to existing vaccination services among mobile communities in Danamadji could be substantially reduced by improving the information exchanges between the provider  and the population. It has been previously shown that outreach campaigns combining veterinary and human health services are a promising and feasible strategy for increasing vaccination uptake among mobile communities . These cIn the past, we have made good experience with trans-disciplinary stakeholder meetings  between A limitation of this study is that during transcription interviews were translated from Chadian Arabic to French. Even though the translation was done by native Chadian Arabic speakers, there was still potential for lost meaning during the process.Nomadic pastoralist communities face specific demand side barriers to vaccination. Understanding these barriers is essential to reduce vaccine hesitancy and increase vaccination uptake. Local health systems must be sensitive to and act upon these specific needs, particularly the mistrust based on bad experiences of mobile pastoralist communities.