QUANTITATIVE STUDY OF LOWER-SECONDARY SCHOOL STUDENTS' ACCEPTANCE OF EVOLUTION IN FRANCE

Keywords: Misconceptions, Quantitative methods, Secondary School

The present work aims to identify some factors that might influence lower secondary school students' acceptance of evolution in France, with a focus on religion. A closed questionnaire was designed based on previous research documenting students' conceptions of evolution, as well as existing concept inventories targeting older students. About 1600 students (aged 11 to 15) took part in the study. Quantitative analyses using multivariate analyses was conducted. Results highlight that more than a third of the students surveyed rejected the evolution of living species, regardless of the species considered in the question (humans, animals) and regardless of the class level (grade 6 to grade 9). Their declared religious beliefs strongly influenced their degree of acceptance, expressed in a school context in France.

INTRODUCTION

Evolution is a complex object of teaching and learning, with existing societal controversies [START_REF] Williams | Evolution Versus Creationism: A matter of acceptance versus belief[END_REF] standing as obstacles to its acceptance. Students already have ideas about evolution that might be distant or even explicitly rejecting scientific explanations of evolution. A number of studies identify difficulties related to students believes influenced by cultural or sociocultural factors (see for example [START_REF] Hanley | The inter-relationship of science and religion: a typology of engagement[END_REF]. In France, evolution is taught from primary school in a context where secularity is one of the key pillars of the educational system [START_REF]Programme d'enseignement de l'école élémentaire et du collège[END_REF]. However, Author (2011) has previously highlighted that French students can express non-evolutionist and fixist ideas at the end of primary school, predominantly for those receiving religious education at home (Author, 2011): children agree with a possible transformation of species but reject a common origin. In high school, the study of [START_REF] Fortin | L'évolution à l'école : créationnisme contre darwinisme[END_REF] shows that students acknowledge the existence of a past world (mammoths or dinosaurs) and possible extinctions. However, their ideas are ranging from pro-evolutionist ideas, where students express ideas in line with scientific knowledge, to creationist ideas where students reject the idea of evolution. High school students often hold an anthropo-centered vision of evolution that hinders their acceptance of evolution.

Taking into consideration that the expression of religious beliefs is kept out of French schools and that French teachers, compared to other countries, largely accept the theory of evolution [START_REF] Clément | Creationism, Science and Religion: A Survey of Teachers' Conceptions in 30 Countries[END_REF], the aim of this research is to identify to what extent French lower secondary school students (11-15 years old) are influenced by factors from their private sphere, and in particular the religion factor.

METHOD

A quantitative approach was chosen to study the acceptance and knowledge of lower secondary school students. Such choice was made on the bases of the qualitative studies already conducted in France that document various conceptions held by French students regarding the theory of evolution (for example: Author, 2011;[START_REF] Fortin | L'évolution à l'école : créationnisme contre darwinisme[END_REF]. From these conceptions, as well as existing conceptual inventories [START_REF] Anderson | Development and Evaluation of the Conceptual Inventory of Natural Selection[END_REF][START_REF] Rutledge | Reliability of the measure of acceptance of the theory of evolution (MATE) instrument with university students[END_REF][START_REF] Yates | A Study Identifying Biological Evolution-Related Misconceptions Held by Prebiology High School Students[END_REF], we developed a questionnaire that we called UnRESt (Understanding Randomness and Evolution for Students). UnRESt has a broader objective, to explore the link between how students understand evolution and how they understand randomness. The full questionnaire is composed of 64 closed questions and 3 sections: A) testing students' acceptance and understanding of evolution, B) testing students' understanding of randomness and C) personal questions. In this communication, we focus on the results from section A, crossed with the expression of students' religious belief (section C). The questions in section A are statements where students are asked to position their agreement/disagreement on a 4 points Likert scale. Different dimensions of the theory of evolution were tested by the items, such as the apparition, extinction, common origin of animals, etc (Author, 2018). Three items per dimension are present, with same wordings, but different examples for humans, living and extinct animals.

UnRESt was filled by 1,634 students aged 11 to 15 from 10 different lower secondary schools in France. The sample is composed of a heterogeneous public according to different school characteristics: its location (urban or rural), the socio-economic background of the school (low, middle, high) and the type of school (public, private). All students in a same class responded, during class hour, with their teacher (mostly biology teacher).

Various methods were used to analyse the data: descriptive statistics to expose general tendencies on the degree of acceptance of the 1,634 students, followed by several multivariable analyses. In particular, in order to highlight the possible difference between the groups (age, class, degree of religious believes, etc) and its significance, we carried out a between-class analysis along with Monte Carlo Randomisation tests.

RESULTS

The results of multivariate analyses show that the influence of religious beliefs (degrees of belief and practice) is greater than all the other variables tested in our study. The students who declare that they have religious beliefs and regular practice their religion are mostly accepting a divine origin of species and reject a common origin of species and the idea that living species evolve, and vice versa. In order to provide an insight of the analyses done, we present here the results of one between-class analyses focusing on the questions related to the context of human evolution (fig. 1). The D1 axis contains almost all (98%) of the information. The other axes (D2 and D3) form background noise because of their low variance (fig. 1a). Figure 1d represents the distribution of students according to their degree of belief. It highlights a clear difference between students on the D1 axis. The numbers, from 1 to 4, represent the four centres of gravities of the answers regrouping the students, 1 expressing stronger belief, 4 little or no religious belief.

Answers from students expressing stronger religious beliefs are at the highest of the positive values, and vice versa. The Monte Carlo randomization test indicates that the difference observed in figure 1d is strongly significant (p-value <0.001). The meaning of the D1 axis can be derived from the circle of correlations (fig. 1b). Three variables are more significant (according to the coordinates of these variables on D1) and are related to the statements expressing the degree of agreement/disagreement with a divine origin of humans (statement AH2) or common with other species (statement AH1) and expressing the possible evolution of human species (statement AH6). The other variables do not provide information that can be analysed. It appears that statement AH2 is negatively correlated to AH1 and AH6. Globally, when students from group 1 express agreement with a divine origin of humans (AH2), they reject the two other statements: common origin of humans (AH2) and evolution of humans (AH6), and vice versa. In particular, statement AH2 "Men were created by God" differentiates significantly students according to their religious belief (pvalue <2.2e-16, Chi2 test).

CONCLUSION

To conclude, more than a third of the students surveyed rejected the evolution of living species, regardless of the species considered (humans, animals) and regardless of the class level (grade 6 to grade 9). Their religious beliefs strongly influence their degree of acceptance, expressed in a school context in France. Such result was surprising considering the French context marked by a strict separation of religious practice and beliefs and formal school education. Also, previous research showed that France was part of countries with particularly few teachers (less than 2%) holding creationist conceptions [START_REF] Clément | Creationism, Science and Religion: A Survey of Teachers' Conceptions in 30 Countries[END_REF]. However, the cross-study in Belgium and Greece conducted by [START_REF] Wolfs | Sciences, religions et identités culturelles : quels enjeux pour l'éducation[END_REF] highlight results that, even in a secular school context, and with non-creationist teachers, the teaching of evolution at school does not allow students to access non-creationist ideas. Our results come in line with others, stressing that personal ideologies tend to take over knowledge learned in formal school teaching (Drummond & Fischhoff, 2017). Perspective for this work is to explore alternatives to teach evolution, targeting the concept of randomness, also controversial when it comes to personal beliefs, in a context of a board game.

Figure 1 .

 1 Figure 1. Between-class analyses of questions related to human evolution, depending on students declared degree of religious belief. (a) Histogram of eigenvalues of the axes D1, D2 and D3 (b) Correlation circles (c) Monte Carlo randomisation test (d) Distribution of the groups of students depending on their degree of religious belief (1 for strong belief, 4 for no or little belief declared)


Magali Coupaud
email: magalicoupaud@icloud.com

EDUCATIONAL GAME ABOUT RANDOMNESS & EVOLUTION FOR STUDENTS IN SCIENCE

3/ A STUDY TO EXPLORE THE LINK BETWEEN STUDENTS' CONCEPTIONS OF RANDOMNESS AND CONCEPTION OF EVOLUTION THROUGHOUT SECONDARY SCHOOL (UnRESt) 4/ DESIGNING A GAME TO ENHANCE THE JOINT UNDERSTANDING OF RANDOMNESS AND EVOLUTION

The specific design of the board game aims to enable students to develop experience with probabilistic thinking and evolutionary thinking. As a result, we propose several game mechanics, associated with artefacts for game prototypes in order to address the 3 ideas of randomness (Gayon, 2005) identified above: Chance: a deck of characteristic cards that players do not know in advance, can define the characteristics of a population for each player. Random probabilities : a deck of dices that players throw successively. They can change a constructed genetic pool associated to the variation of individuals in a population within the game. In the first prototype, a roll of the dice allows to select the characteristics from a generation to another one. -Agree with extinctions of species -Pro-evolutionist ideas (in line with scientific knowledge) to creationist ideas (reject the idea of evolution) -An anthropo-centered vision of evolution Fortin (2010)

Students' conceptions of randomness

Relation between students' conceptions of randomness and students' understanding of ToE

Evolution is a complex object of teaching and learning, with existing societal controversies (Williams, 2015) standing as obstacles to its acceptance.

Teachers largely accept the ToE compare to other countries (Clément, 2015). In France, evolution is taught in a context where secularity is one of the key pillars of the educational system. This secular context implies that no studies have been conducted to assess lower secondary school students acceptance of ToE with the possibility that students religious beliefs might influence their acceptance.

Mechanisms of biological evolution Sub-concept of randomness associated

Genomic variation Chance

Fortuitous event with no intentionality (not associated to any finality)

Genetic drift Random probabilities

Depending on the size of the biological population, and on probability laws. For a population to evolve, it is not necessarily linked to adaptation, it can simply reflect the effect of random probability at any stage of reproduction (Jacob, 1981).

Natural selection Contingency

Encounter of independent causal series: the presence of external factors and the variation internal to an organism.

Combines fortuitous events that are contingent in a historical perspective. The same type of analysis performed for 4 ideas of randomness emerges that the ideas of randomness 'probability' and randomness 'destiny' are linked to the pupils' answers to their understanding ToE.

Contingency : a deck of event cards (brings sudden changes in the environment tiles: "chaotic" mechanic) modeling a matching system between population and environment. With the students, it is important to underline, that this perturbing event is not predictable and not the result of players' luck or misfortune.

How is it … so far ? What's next?

Several games can be played in parallel, in the class contexts. The analyses of the history and outcomes of each game can come as interesting opportunities to underline the different path taken by players. Thus, the teachers are able to insist on the unpredictability characteristics of species, and connect it to the non-deterministic nature of biological evolution.

Fig

  Fig. Distribution of students' answers about randomness in everyday life questions Contingency: totally or rather agree Destiny: large number agree Students rarely recognize chance or ignorance as the random

Fig.

  Fig. Distribution of students' answers about their understanding of evolution An understanding of the ToE not in accordance with current theory.

Fig

  Fig. Between-class analyses of answers related to the understanding of human evolution, depending on student's answers about "probability". (a) Histogram of eigenvalues of the axes (b) Correlation circles (c) Monte Carlo randomisation test (d) Distribution of the groups of students depending on their answer about "probability" (4 for agreement with "probability" statements, 16 for disagreement)

  http://evolution.berkeley.edu/ evolibrary/article/evo_202 https://biologyboom.com/e volutionary-mechanisms/ https://creationscience4ki ds.com/can-naturalselection-make-anything/ Method Developmentand use of a questionnaire UnRESt (64 questions, 3 sections: A)students' acceptance and understanding of ToE (different dimensions with 3 items: examples for Humans, living and extinct animals) / B)students' understanding of randomness (sub-concepts of randomness related to 3 everyday situations) / C)personal questions) n=1634

  Fig. Photos of first prototype of game about randomness and biological evolution


Ying Liu

Mart Krupovic
email: mart.krupovic@pasteur.fr

Genome chromatinization in giant double-stranded DNA viruses

Keywords: viral genome packaging, icosahedral capsid, virus evolution, chromatin, family Marseilleviridae, phylum Nucleocytoviricota (NCLDV)

Giant viruses have extravagantly large double-stranded (ds)DNA genomes that are packaged into exceedingly complex virions. In two recent papers, Liu et al. and Valencia-Sánchez, Abini-Agbomson et al. show that some giant viruses encode unique histone doublets, which form nucleosomes remarkably similar to those found across the eukaryotic domain of life.

Virions (virus particles or capsids) represent metastable containers which protect the viral genetic information in hostile extracellular environments and facilitate its delivery into the host cell. However, the internal volume of spherical (typically icosahedral) capsids is limited and the viral genome would simply not fit inside without being compacted. Over billions of years, viruses have evolved multiple mechanisms of genome compaction and packaging. The smallest and simplest singlestranded RNA viruses knit their icosahedral capsids through protein-protein and protein-RNA interactions, compacting the genome in the process [START_REF] Twarock | RNA-Mediated Virus Assembly: Mechanisms and Consequences for Viral Evolution and Therapy[END_REF]. A very different strategy is used by most double-stranded (ds)DNA viruses, including tailed bacteriophages and herpesviruses, which use powerful ATP-driven motors, genome packaging ATPases, to pump the genomic DNA into preformed empty capsids, achieving near-crystalline packaging densities [START_REF] Rao | Mechanisms of DNA Packaging by Large Double-Stranded DNA Viruses[END_REF].

Another solution used by some viruses (and all cellular organisms) relies on chromatinization of the genome, i.e., the genome is condensed by chromatin proteins. Some viruses (e.g., adenoviruses) encode their own chromatin proteins unrelated to the cellular counterparts, whereas others appropriate the chromatin proteins of their hosts. For instance, the circular dsDNA genomes of papillomaviruses and polyomaviruses are complexed with hostderived histones [START_REF] Porter | Histone modifications in papillomavirus virion minichromosomes[END_REF], the major chromatin proteins in eukaryotes and many archaea, which act as spools around which DNA wraps to create structural units called nucleosomes. The eukaryotic nucleosome invariably includes two copies of each of the four histones, H2A, H2B, H3, and H4, with H2B-H2A and H4-H3 forming heterodimers that assemble into an octamer that wraps ~147 bp of dsDNA to form nucleosomes. Strikingly, some viruses with giant icosahedral capsids and dsDNA genomes, namely, members of the families Marseilleviridae and 'Medusaviridae', encode the entire complement of the core eukaryotic histones. Whereas in medusaviruses each histone homolog is encoded as a standalone protein [START_REF] Yoshikawa | Medusavirus, a novel large DNA virus discovered from hot spring water[END_REF] (just like in eukaryotes), in marselleviruses, the four histones are encoded by just two genes in the form of unique histone doublets, vH2B-vH2A and vH4-vH3 [START_REF] Thomas | Lausannevirus, a giant amoebal virus encoding histone doublets[END_REF][START_REF] Boyer | Giant Marseillevirus highlights the role of amoebae as a melting pot in emergence of chimeric microorganisms[END_REF]. Although the existence of viral histone genes was known for over a decade, their function remained speculative. Now, two recent studies simultaneously published by Liu et al [START_REF] Liu | Virus-encoded histone doublets are essential and form nucleosome-like structures[END_REF] and Valencia-Sánchez, Abini-Agbomson et al [START_REF] Valencia-Sánchez | The structure of a virus-encoded nucleosome[END_REF] illuminate the role of viral histones in condensation of the giant viral genomes.

Liu et al [START_REF] Liu | Virus-encoded histone doublets are essential and form nucleosome-like structures[END_REF] and Valencia-Sánchez, Abini-Agbomson et al [START_REF] Valencia-Sánchez | The structure of a virus-encoded nucleosome[END_REF] have determined the structures of nucleosomes formed by histone doublets of two different amoeba-infecting marseilleviruses, Melbournevirus and Marseillevirus, respectively. It turned out that the viral nucleosomes and the constituent histone doublets are remarkably similar to the canonical eukaryotic counterparts (Fig. 1A). Interestingly, however, the viral nucleosomes wrap less DNA compared to the eukaryotic ones (~120 bp versus ~147 bp, respectively), although the main contacts between the histones and DNA, including the basic amino acids defining the path for the DNA, are conserved between viral and eukaryotic histones. Furthermore, the viral nucleosomes are prone to dissociation and appear to be considerably less stable than the eukaryotic nucleosomes, a property attributed to reduced positive charge and distinct structural makeup of the viral histone subunits [START_REF] Liu | Virus-encoded histone doublets are essential and form nucleosome-like structures[END_REF]. In eukaryotes, chromatin condensation and accessibility to RNA polymerase are primarily regulated by post-translational modifications on extended, positively charged N-terminal histone tails, especially those of H4 and H3. The tails of the viral histones do not appear to have the same function and instead assume structural roles; in the case of vH4, the N-terminal tail, instead of extending over the DNA, takes the opposite direction to interact with the core domain of vH4 [START_REF] Liu | Virus-encoded histone doublets are essential and form nucleosome-like structures[END_REF][START_REF] Valencia-Sánchez | The structure of a virus-encoded nucleosome[END_REF]. These changes likely further contribute to the lability of the viral nucleosomes. It has been suggested that metastability is an intrinsic property of viral nucleosomes, presumably facilitating timely transcription of the early viral genes by the host RNA polymerase recruited to the viral factory from the nucleus, thereby alleviating the need for ATP-dependent chromatin remodelers used by eukaryotes [START_REF] Liu | Virus-encoded histone doublets are essential and form nucleosome-like structures[END_REF].

Viral histones have been detected in virus particles, suggesting that nucleosomes observed in vitro are also present within the virions [START_REF] Boyer | Giant Marseillevirus highlights the role of amoebae as a melting pot in emergence of chimeric microorganisms[END_REF][START_REF] Liu | Virus-encoded histone doublets are essential and form nucleosome-like structures[END_REF]. Importantly, Liu et al demonstrated that viral histones are important for viral infectivity, with knockout of either viral histone doublet gene being associated with a strong fitness cost to the virus and loss of the mutant viruses after 2 days of propagation [START_REF] Liu | Virus-encoded histone doublets are essential and form nucleosome-like structures[END_REF]. Expression of the GFP-tagged viral histones revealed their recruitment to the viral factories in infected cells, whereas in the absence of infection they were evenly distributed throughout the cell, suggesting that that chromatinization of the viral genome is a spatially orchestrated process. One of the outstanding questions is how marseilleviruses package their genomes into icosahedral capsids. Similar to other members of the realm Varidnaviria, marseilleviruses encode a putative genome packaging ATPase [START_REF] Boyer | Giant Marseillevirus highlights the role of amoebae as a melting pot in emergence of chimeric microorganisms[END_REF]. In the case of viruses for which the function of this protein has been investigated, it has been shown to play a key role during genome packaging into preformed capsids (e.g., in tectiviruses) or capsid intermediates (e.g., in poxviruses). However, this molecular motor is unlikely to promote the translocation of chromatinized substrates. One possibility is that nucleosomes are formed following the packaging of naked viral DNA into preformed histone-containing capsids. Indeed, empty marseillevirus particles have been observed in infected cells (e.g., [START_REF] Thomas | Lausannevirus, a giant amoebal virus encoding histone doublets[END_REF]).

Another intriguing question is the provenance of the viral histones. Phylogenetic analyses consistently place the four (after splitting the doublets) groups of viral histones either as sister groups to or at the base of the corresponding eukaryotic core histones, whereas archaeal histones are more divergent and occupy the basal position in the trees (Fig. 1B) [START_REF] Yoshikawa | Medusavirus, a novel large DNA virus discovered from hot spring water[END_REF][START_REF] Thomas | Lausannevirus, a giant amoebal virus encoding histone doublets[END_REF][START_REF] Valencia-Sánchez | The structure of a virus-encoded nucleosome[END_REF]. This topology suggests either viral origin of the eukaryotic histones or at least ancient divergence of the eukaryotic and viral histones, predating the last eukaryotic common ancestor. The idea that such key proteins as histones could have been acquired by eukaryal ancestor from viruses might appear heretic. However, it is known that in dinoflagelates, a group of singlecelled eukaryotes, histones have been replaced by a chromatin protein from giant dsDNA viruses of the Phycodnaviridae family, which are evolutionarily related to marseilleviruses [START_REF] Gornik | Loss of nucleosomal DNA condensation coincides with appearance of a novel nuclear protein in dinoflagellates[END_REF]. Furthermore, it has been suggested that at least one of the eukaryotic RNA polymerases has Based on [START_REF] Yoshikawa | Medusavirus, a novel large DNA virus discovered from hot spring water[END_REF][START_REF] Thomas | Lausannevirus, a giant amoebal virus encoding histone doublets[END_REF][START_REF] Valencia-Sánchez | The structure of a virus-encoded nucleosome[END_REF]. Branches corresponding to the viral histones are indicated with blue hexagons. The inset shows the alternative evolutionary scenarios whereby the histone genes (colored squares) are horizontally transferred between cells and viruses, possibly resembling contemporary medusaviruses (with the question marks indicating that the direction of transfer remains unclear). The viral histone genes are fused in one of the viral lineages to produce histone doublets found in marseilleviruses.

Abbreviations: a, archaeal; e, eukaryotic; v, viral; LECA, last eukaryotic common ancestor; MarV, marseillevirus; MedV, medusavirus.

Figure 1 .

 1 Figure 1. Genome chromatinization in giant viruses and their cellular hosts. A. Comparison of the vH2B-vH2A and vH4-vH3 histone doublets (top) and nucleosomes (middle and bottom) of Melbournevirus (left) with the corresponding eukaryotic counterparts (right). Each histone protein, depicted using ribbon representation, is colored differently. The shown histone structures have the following PDB accession numbers: 7n8n (Melbournevirus) and 7lz0 (Xenopus laevis). B. Schematic phylogeny showing the relationships between cellular and viral histones.Based on[START_REF] Yoshikawa | Medusavirus, a novel large DNA virus discovered from hot spring water[END_REF][START_REF] Thomas | Lausannevirus, a giant amoebal virus encoding histone doublets[END_REF][START_REF] Valencia-Sánchez | The structure of a virus-encoded nucleosome[END_REF]. Branches corresponding to the viral histones are indicated with blue hexagons. The inset shows the alternative evolutionary scenarios whereby the histone genes (colored squares) are horizontally transferred between cells and viruses, possibly resembling contemporary medusaviruses (with the question marks indicating that the direction of transfer remains unclear). The viral histone genes are fused in one of the viral lineages to produce histone doublets found in marseilleviruses.Abbreviations: a, archaeal; e, eukaryotic; v, viral; LECA, last eukaryotic common ancestor; MarV, marseillevirus; MedV, medusavirus.

been horizontally acquired from giant viruses [START_REF] Guglielmini | Diversification of giant and large eukaryotic dsDNA viruses predated the origin of modern eukaryotes[END_REF]. Thus, the viral origin of eukaryotic histones should not be dismissed lightly (Fig. 1B). Finally, the fact that most other giant viruses do not encode histones begs the question of how their genomes are condensed and packaged. Further exploration of virus diversity and evolution, coupled with structural and functional studies, such as those by Liu et al [START_REF] Liu | Virus-encoded histone doublets are essential and form nucleosome-like structures[END_REF] and Valencia-Sánchez, Abini-Agbomson et al [START_REF] Valencia-Sánchez | The structure of a virus-encoded nucleosome[END_REF], are bound to uncover more surprises and clarify the extent of the giant virus contribution to the origin and evolution of eukaryotes.


ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Baudrillard [START_REF] Baudrillard | La Société de consommation[END_REF] and McCracken [START_REF] Maccracken | Culture and consumption II. Markets, meaning, and brand management[END_REF] show that possessions have meaning beyond their desired functionalities: the cultural significance of consumption is projected from the world of cultural values and symbols to consumer goods. The object of consumption is thus also a social marker, which participates in social and cultural identities [START_REF] Sahlins | Stone Age Economics[END_REF] . So, it is possible to consider pink objects produced by gender marketing as a way for some women to signify their femininity through the consumption of these While it is common to find a product available in several shades, pink is specifically used in gender marketing to make products available in a version for women, allowing double profits for marketers [fig. 1]. Although it is not possible to control all the parameters that influence consumer persuasion, Kacha argues that colour can influence, or even change, consumer attitudes towards a product by acting on both the cognitive -congruence with the symbolism of a colour -and emotional -(dis)liking a colour -dimensions [START_REF] Kacha | La Couleur, variable d'action marketing[END_REF] .

Regarding pink, however, we are emotionally confronted with its rejection by many women [START_REF] Heller | Psychologie de la couleur. Effets et symboliques[END_REF] , and the growing criticism from feminist academics and associations about its use for gender marketing purposes, which they consider as reinforcing sexist gender stereotypes [3][4] .

automatisms", linked to the conditioning of consumers [START_REF] Derbaix | Persuasion : la théorie de l'irrationalité restreinte[END_REF] . Pink in marketing operate all these levers at once: it is a nearly worldwide recognised symbol of femininity; it spreads as such through tradition and fashion; girls are conditioned from childhood -via toys, media,… -to associate pink with femininity; and it is very difficult to associate it with anything other than females and femininity [START_REF] Bideaux | La Vie en rose. Petite histoire d'une couleur aux prises avec le genre[END_REF] . Female consumers are thus conditioned from birth to own pink objects [START_REF] Pennell | Babes in Toyland: learning an ideology of gender[END_REF] , making pink marketing a real tool of persuasion, playing on both the cognitive and emotional registers, and having repercussions on gender relations. Derbaix and Gregory identifiy four "gates of persuasion", conceptual levers usable by advertisers permitting to change consumers' attitudes and behaviour through persuasive communication: "gate of logic", corresponding to cognitive learning; "gate of imitation", referring to interpersonal relationships; "gate of feelings and emotions"; and "gate of objects, or more accurately, a way to signify their conformity to a model of femininity. Consuming "in pink" can then be seen as a way of expressing femininity and constructing a gendered identity [START_REF] Peril | Pink Think. Becoming a woman in many uneasy lessons[END_REF] . Thus, it does not matter whether women like pink or want to have pink objects, the important thing is that they buy these products, because to consume pink is to consume femininity. We can relate this to the concept of "extended self" developed by Belk: human being invest objects symbolically as an extension of oneself [START_REF] Belk | Possessions and the Extended Self[END_REF] . Possession would define not only what is "mine", but also what is "Me", implying a definition of identities through objects and their consumption. Pink objects are thus visible and measurable markers of femininity: to possess something pink is to be pink oneself, and to be what it symbolises -the feminine. Pink in gender marketing is therefore a paradox: it means femininity in order to respond to women's "natural" needs and, at the same time, it refers femininity to an artificial aesthetic process that is consumed.

Fig. 1 :

 1 Fig. 1: Various pink products from gender marketing, 2021 (brand names have been masked)


Élise Ricadat

Karl-Leo Schwering

Sophie Fradkin

Nicolas Boissel

Isabelle Aujoulat

Adolescents and young adults with cancer: how multidisciplinary healthcare teams adapt their practices to better meet their specific needs

Keywords: cancer, oncology, adolescents, young adults, nursing, dedicated units, qualitative methods cancer, oncology, adolescent, young adult, nursing, dedicated units, qualitative methods cancer, oncology, adolescent, young adult, nursing, dedicated units, qualitative methods

Objective: Dedicated adolescent and young adult (AYA) cancer units have emerged from the early 90s to address multiple challenges faced by AYA patients with cancer. Specific needs of AYA patients have been considered in an increasing number of studies. However, few describe how the healthcare professionals (HCPs) perceive their patients' needs and how they actually adjust their day-to-day practices to meet such needs. The purpose of this study is to identify and describe the practical methods of care and teamwork implemented by HCPs in response to what they perceive as essential to support psychosocial development of AYA patients. Methods: Qualitative research was conducted between 2012 and 2014 with 31 HCPs from a recently created hematology AYA unit in France. The transcripts of open-ended interviews were subject to inductive analysis using constant comparison as recommended by the Grounded Theory methods.

Results: Our results show how HCPs adapt their practices and care relationships to support three major developmental milestones related to identity construction in AYAs: selfdetermination and individuation from parents; gender and sexual identity; social life and connectedness to peers and adults (other than parents). Our results also show how HCPs adapt their practices and organizational methods to enhance the flexibility required to address their young patients', thus setting consistent and high standards for the whole team. Such adaptation is made possible through collaborative work and collective processes that facilitate selfreflection. Conclusions: Our findings shed light on some meaningful young patient-friendly practices of care and advocate for AYA dedicated units. Adolescence, as a transition from late childhood (12 years) to adulthood (the mid-20s up to 30), is a challenging period due to the intense physical and psychosocial changes that adolescents and young adults (AYAs) need to cope with, in order to build a valued and steady sense of self 1 . Cancer is a complex life-limiting condition which deeply interferes with the transition process inherent to adolescence. Having cancer is likely to hinder or delay the achievement of several important developmental milestones in adolescents: physical and psychological development, sexuality, education and vocation, family and peer relationships 2- 5 . As a growing number of AYA patients survive into adulthood [6][7][8] , there is higher awareness of the need to comprehensively address their psychosocial and developmental needs, and to help them cope successfully with the numerous interrelated medical and psychosocial challenges due to their condition. During the last three decades, while medical care to young cancer patients has considerably improved, psychosocial care has become a major issue, with the aim to enhance quality of life in adults who have survived paediatric cancer [9][10][11][12] .

Several studies have addressed how far the hospitalisation experience may adversely affect the adolescence process in cancer patients, and how HCPs may try to make it the least disruptive possible [13][14] . Arguing that AYA patients are seen as belonging to a "no-man's land" between paediatric and adult models of care 15 , the need for dedicated units to bridge this gap has emerged [16][17] . Although AYA units have been created since the early 90s in high-income countries, little is known about their practical organisation and what kind of adaptations are required from HCPs to best respond to their young patients' needs [18][19] .

The aim of our study was to investigate how the members of a multidisciplinary team adapt their caring practices and work organisation to meet what they perceive as essential needs for the psychosocial development of AYA patients.

METHODS

Interviews were conducted in an AYA haematology in-patient unit in Paris. This unit was founded in 2010 in line with the second governmental cancer action plan (2009-2013). It admits patients aged 15 to 25. A great majority of them is diagnosed with acute leukemia and highgrade lymphoma, both of which require long lasting treatments, including allogeneic stem cell transplant (HSCT). The unit is composed of 16 single bedrooms, including 4 that are equipped with high-efficiency particulate air filtration mostly used to perform HSCT. The average length of stay is about 11 days, ranging roughly from 3 days -for a short chemotherapy regimen -to 4-6 weeks for the induction phase for acute leukaemia or HSCT.

Procedures

The aim of our study was presented by the head of the AYA unit (4 th author) during a regular team meeting. All staff members were invited to participate in an in-depth interview during their working hours, including night shifts. Interviews were led by two external researchers (1 st and 3 rd author), both clinical psychologists and PhD students at the time of the research. In line with our two research objectives, open-ended questions were used to encourage participants to reflect on their own beliefs and experiences: "How would you define the AYA patients' psychosocial and developmental needs? How do you see your role and that of the team as a whole in supporting these specific needs?" Interviews were allowed to evolve as a natural discussion, following the path of every participant. The interviews lasted an average of 60 minutes [30-85], were audio-recorded with the consent of the participants and transcribed verbatim.

Participants

Thirty out of the 43 members of the staff agreed to participate (Table 1). All have been working in this unit since its creation 2 years before the study, some of them had a previous paediatric or adult oncology experience, others were at the beginning of their professional life.

Data analysis

We opted for an inductive and iterative approach for the analysis of the collected data. The initial coding of the transcripts involved the 1 st , 2 nd , 3 rd and 5 th authors, who set up a preliminary analysis grid based on an independent coding of the 4 first interviews. Referring to the Grounded Theory approach 19 , the rest of the transcripts were coded by the two main researchers (1 st & 3 rd author) in a process of constant comparison. Major emerging categories and subcategories were discussed and refined until the end of the process to reach a strong consensus. This process involved 2 group discussions around preliminary results with the healthcare team.

Results

Regarding our first research objective, i.e. the AYA patients' psychosocial and developmental needs as perceived by the multidisciplinary health care team, our analysis revealed a core category -namely that of supporting identity construction in AYAs -and 3 subcategories that may be seen as 3 different facets of the process of identity construction: (i) self-determination and individuation from parents, (ii) gender and sexual identity and (iii) social life and connectedness with peers and adults (other than parents). Regarding our second research objective, i.e. to reveal how the HCPs in this unit individually and collectively adapt their practices to meet what they perceive as essential psychosocial needs of their patients, flexibility emerged as a core category, which was made possible by collaborative work and a number of collective processes that facilitate self-reflection and build a solid team cohesion. Our results are presented according to these emerging categories with examples of concrete practices to illustrate the findings.

SUPPORTING IDENTITY CONSTRUCTION

The participants generally attested that AYAs go through an important process of identity construction, which involves major physical and psychological changes to be integrated. They acknowledged that the experience of cancer largely hampers this process and advocated for the provision of in-patient care that includes ways of addressing these specific needs. They argued that an AYA patient does not only have cancer, but is a person who must achieve some important developmental milestones that need to be taken into account in the care relationship: « They remain adolescents, no matter how ill they are. An AYA patient is not an ordinary patient » (nurse). To mitigate cancer and treatment effects, they identified 3 major challenges inherent to the identity process of any adolescent that may be particularly threatened by the experience of cancer and therefore require special attention from the healthcare team.

Supporting individuation from parents and self-determination. HCP insisted on the

importance of supporting the processes of self-determination and individuation as a way of compensating for the dependence created by in-patient care. Therefore, the team aims to deeply involve patients in decision-making processes during the whole duration of their hospitalisation. Parents are less systematically involved by the HCPs in their children's care, as compared to usual practices in paediatrics: « What changes, with regards to paediatrics, is that the cancer diagnosis is not given first to the parents but directly disclosed to the teenager » (doctor). HCPs assumed that the parents' presence has to be constantly discussed to support the separation process, which is even more complex in the context of cancer. According to HCPs, there is no one way of regulating the parents' presence, and individualised decisions need to be made. A concrete example is the management of extra beds for accompanying parents or relatives who ask to stay overnight. In this AYA unit, it is not a rule to have an extra bed in the room, as it is in paediatrics: « I think that nothing should be imposed but rather proposed at this age. This is more important than for the younger ones. » (doctor). Another example is how HCPs engage in trying to prevent parents from reverting to former relationships they would have had with their child at a younger age, induced by the status of being ill: « A mother washing her small child doesn't shock me. However, when this happens with an AYA, I find it difficult… F o r P e e r R e v i e w 7 I try to discuss the matter with the parents and that it's not up to them to help with everyday things. » (nurse aide). Regulating the distance between parents and AYAs has been acknowledged by the participants as being of significant benefit to AYAs' need for empowerment: « I am thinking of situations where the parents behave in an exemplary manner whilst being able to maintain the right distance. This has an extraordinarily beneficial effect on both the young patient and the parent. » (doctor).

Regarding the need to self-determine their goals and actions, the HCPs in our study acknowledged that this is basically undermined because of the cancer treatment, which is not negotiable. As a result of being aware of their young patients' need for self-determination, flexibility is introduced into the manner in which the treatment is administered, to suit the young patients' need to remain active decision makers, thus allowing them to develop a sense of control. Non-compulsory treatments are discussed and sometimes dismissed or postponed: « I try to respect their preferences. If they don't want to be disturbed too early in the morning for instance, I will accept it once but not a second time. Hence, I am not rushing them but still stand firm. » (nurse). The participants defined their care relationships and practices as being based on an implicit rule: "allowing for negotiation within a fixed framework" (nurse).

In order to allow for negotiations, there are no written internal procedures that would set the rules too rigidly and hinder the necessary flexibility. In agreement with doctors, maskwearing measures are usually relaxed. External home-prepared or commercial frozen meals, prohibited in other places due to infectious risks, may be permitted under certain conditions.

In their capacity as adults, HCPs saw themselves as playing a key role in supporting their young patients' identity-forging process by tolerating conflicts and differing opinions: « After all, we represent the adult world for them, and perhaps it is a good thing that they know they can't do whatever they want to do, even when they are sick » (nurse). They acknowledged negotiation and conflicts as making sense in the caring relationship: « Teenagers are looking for conflict. Yes, there are clashes, but these are natural things that happen because we are in facility that deals with adolescence. We need to remember the need for mutual respect all the time » (nurse).

Supporting gender and sexual identity. HCPs were aware that the challenges around sexuality and body image are crucial in the process of defining one's identity during adolescence. As treatments alter the pubescent body, they perceive the importance of enhancing the patient's emerging gendered identity, much more than when working with younger or older patients: « when I was working in paediatrics, I didn't ask myself those kinds of questions. But teenagers become conscious about their own bodies so I cannot take over it without asking them. They are a person, already an adult for some and for others still ''in progress'', but at the end of the day, they have their say in things! » (nurse). Consequently, HCPs are extremely respectful of their young patients' modesty and privacy. In practical terms, the AYA unit is organised with single rooms which are separated by opaque doors, thus precluding from the possibility of being observed from the outside. Moreover, for intimate aspects of care, such as hygiene-related issues or fertility preservation procedures, HCPs single out one member of their team of the same gender as the patient when they perceive that the patient feels too uncomfortable: « Our male colleagues are involved in matters of care that bother boys, for instance for explaining the semen collection procedure. Talking to a man about this is easier than to confide in a woman, even more so if she is a young caregiver. » (nurse).

Finally, the staff noticed that when special care was provided to enhance well-being in addition to physical treatment, it eased the suffering stemming from a painful and injured body.

Massages are offered to allow for positive experiences and to relieve anxiety and stress. HCPs were deeply convinced that attending to physical needs other than only those ones exclusively related to the treatment of cancer contributes to a better body image, self-esteem and therefore to positive identity construction. coordination nurse whenever the staff identifies that a patient might be suffering from social isolation, a community worker organises collective activities to encourage links between inward patients and coordinates the actions of several out-door organisations. One of these provides a teacher who lectures in the hospital and liaise with schools in order to facilitate the patients' pursuit of their studies. A social worker helps young adult patients already engaged in a professional activity to maintain it by liaising with their employers. This gives an indication of the numerous professions involved in the care to AYAs with cancer in this unit.

These concrete measures show a strong will to approach the AYA patient more holistically and the HCPs' conviction that caring means more than curing cancer: « After all, I do not look at them as ill people in the first place, but rather as people. » (nurse). Our participants conveyed that AYAs with cancer need not only efficient and evidence-based medical and technical treatment, but also strong links and genuine human connection, which they acknowledged as the core component of the care relationship: « If they need to talk, I don't leave, I give them time. Interpersonal relationships are very important in this unit. » (wardaide). Such involvement was recognised as giving sense to their work. On the other hand, they also acknowledged that it might make them more vulnerable: « In this unit, our caring

F o r P e e r R e v i e w 10
technique is based on relationships. It is not much more difficult than anything else, but it means that we are much more involved. » (nurse). Reflecting on their efforts to best address their young patients' needs, HCPs reported that they get personally involved beyond the boundaries of their traditional professional roles, thus exposing themselves to an increase risk of emotional burden. Reflective practices and strategies are used to process the constant adjustments that are required to maintain a collective cohesion and flexibility.

FLEXIBILITY, COLLECTIVE PROCESSES AND SELF-REFLEXION

HCPs were aware that being individually flexible was dependent on collective strategies aimed at protecting their professional roles and ensuring overall coherence of staff decisions: « I always try to give a consistent message, because otherwise AYA patients fall between the cracks. » (nutritionist). In practice, they reported that formal and informal teamwork practices had emerged, such as feeling free to ask for help from a colleague whenever they face emotional difficulties with a patient: « We must have empathy to be a good caregiver, but we also need to attend our own needs". When I feel emotionally fragile with a patient, I hand him/her over to a colleague. » (nurse). Working in pairs and mutual trust were cited as important team resources in which interpersonal relationships are central. Although such flexibility could be seen as carrying a risk of confusion, HCPs reported that sharing opinions ensures the team's cohesion: « I cannot work by myself because we all have our small contribution toward building this care project. » (social worker). Therefore, HCPs acknowledged the importance of the right motivation to work in such a ward: « We are all very motivated here because facing an adolescent requires a high sense of solidarity » (night nurse).

The weekly staff meetings aim to favour a multi-focal approach and individualisation of care procedures. Personalised decisions are more appropriate than decisions that would be taken by complying with predefined criteria according to a fixed medical protocol: « I remember a patient, in aplasia and feverish, who wanted to leave for the weekend. From my Every staff member feels responsible for passing on information while optimising his/her professional role: « This multidisciplinary exchange is very constructive: it invites us to share different views, thus revealing aspects of a patient's experience, that I would otherwise not necessarily be aware of. This experience enriches me. » (nutritionist).

Open-mindedness and reflexive practices were described as a strong resource that nurtures in return the HCP's own professional role, and their ability to better meet the demands imposed on them by AYA patients.

DISCUSSION

Identity work was identified by the HCPs as the core challenge that AYAs with cancer must face, along with the interconnected challenges of building one's autonomy and sexual and social identities. Whereas these issues have been well studied from the patients' perspective 21 , they have remained understudied with regard to opinions of HCPs'. Yet, HCPs are particularly challenged when it comes to support such needs in the patient-provider relationship. This study does not only report on individual and collective practices meant to support AYA patients' psychosocial needs but also on strategies and skills HCPs should aim to develop in order to meet this challenge.

First, HCPs contribute concretely to individuation and self-determination targets when involving patients in decision-making processes and playing a subtle role in negotiating their parents' presence. Recent research suggests that AYA health communication and collaborative decision-making is a sensitive issue, because the age of legal responsibility should not determine who (the parents or the young patient) has to be informed [22][23] . Assessing as comprehensively and as early as possible the patient's degree of autonomy and the quality of the parent-AYA relationship should contribute to a better balance of decision-making 12 responsibilities as far as the patient-parent dyad is concerned. This is consistently related to an important coping strategy to develop AYAs' sense of control 24 .

Secondly, our results highlight how HCPs pay attention to AYA patients' sexual development by being sensitive and responsive to individual patients' level of sexual maturity and physical development. There is some evidence that treatment-related side effects adversely affect AYAs' early puberty, sexual function and development [25][26][27][28] . Recent research suggests that impairments of body image seriously threaten the gendered identity if related to lower selfesteem. Self-esteem plays a key role in the development of the sense of self as a sexual being at that age 29 . Our study shows that HCPs support the body image with the onset of puberty by being highly respectful of modesty and privacy. They promote a better body image as they offer positive sensory experiences and feelings about physical impairments thanks to their careful handling of physical areas affected by illness or treatments by providing massages. As shown in other studies, such attitudes are likely to contribute to a better self-acceptance, thus fostering enhanced relationships with peers and intimate partners [30][31] . We believe that it paves the way for better communication regarding the emotional, romantic and sexual dimensions of their quality of life, all of which are key issues in this population of patients [32][33] .

Another major issue for HCPs was about maintaining a bond with peers by favouring outpatient hours, school attendance or the pursuit of work and projects as key elements in building one's identity at that age. They adapt hospital and ward rules to reduce the disruptive effects of hospitalisations. In doing so, they provide personalised adjustments which require that they improve their own tolerance to conflicts. The present study shows how they develop negotiation skills, patience, with mutual respect as a strategy to promote a genuine and nonauthoritative therapeutic bond. There is some evidence that a strong patient-oncologist alliance is associated with psychosocial wellbeing and therapeutic adherence in AYA cancer patients 34 . However, being empathic exposes HCPs to a "double-edged sword" 36 , with a clear benefit for patients potentially counterbalanced by a detrimental effect on professional stress levels, especially when patients are facing life-threatening condition [37][38][39][40] . It would deserve further investigation to assess how HCPs' empathy is a source of work exhaustion or distress. Our results suggest that a reflection about what it means to get personally involved in care should be introduced early in the curricula of medical and paramedical studies, and the importance of a trained and balanced workforce within the team (i.e. multidisciplinary and mixed-gendered).

Study limitations

The strength of our study lies in the high participation of a multidisciplinary health care team in an AYA dedicated unit, althought nurses are an over-represented professional category. Moreover, as this was a study conducted in a single centre, the sample of participants was inevitably small, and our results may not be appropriate for extrapolation. In addition, we opted for an iterative process of data collection and analysis. Yet, at this stage of our study, we are aware that we have not reached saturation of the data. Rather, as is typical in grounded theory, our initial research question has

Background

Adolescence, as a transition from late childhood (12 years) to adulthood (the mid-20s up to 30), is a challenging period due to the intense physical and psychosocial changes that adolescents and young adults (AYAs) need to cope with, in order to build a valued and steady sense of self 1 . Cancer is a complex life-limiting condition which deeply interferes with the transition process inherent to adolescence. Having cancer is likely to hinder or delay the achievement of several important developmental milestones in adolescents: physical and psychological development, sexuality, education and vocation, family and peer relationships 2- 5 . As a growing number of AYA patients survive into adulthood [6][7][8] , there is higher awareness of the need to comprehensively address their psychosocial and developmental needs, and to help them cope successfully with the numerous interrelated medical and psychosocial challenges due to their condition. During the last three decades, while medical care to young cancer patients has considerably improved, psychosocial care has become a major issue, with the aim to enhance quality of life in adults who have survived paediatric cancer [9][10][11][12] .

Several studies have addressed how far the hospitalisation experience may adversely affect the adolescence process in cancer patients, and how HCPs may try to make it the least disruptive possible [13][14] . Arguing that AYA patients are seen as belonging to a "no-man's land" between paediatric and adult models of care 15 , the need for dedicated units to bridge this gap has emerged [16][17] . Although AYA units have been created since the early 90s in high-income countries, little is known about their practical organisation and what kind of adaptations are required from HCPs to best respond to their young patients' needs [18][19] .

The aim of our study was to investigate how the members of a multidisciplinary team

Procedures

The aim of our study was presented by the head of the AYA unit (4 th author) during a regular team meeting. All staff members were invited to participate in an in-depth interview during their working hours, including night shifts. Interviews were led by two external researchers (1 st and 3 rd author), both clinical psychologists and PhD students at the time of the research. In line with our two research objectives, open-ended questions were used to encourage participants to reflect on their own beliefs and experiences: "How would you define the AYA patients' psychosocial and developmental needs? How do you see your role and that of the team as a whole in supporting these specific needs?" Interviews were allowed to evolve as a natural discussion, following the path of every participant. The interviews lasted an average of 60 minutes [30-85], were audio-recorded with the consent of the participants and transcribed verbatim.

Participants

Thirty out of the 43 members of the staff agreed to participate (Table 1). All have been working in this unit since its creation 2 years before the study, some of them had a previous paediatric or adult oncology experience, others were at the beginning of their professional life.

Data analysis

We opted for an inductive and iterative approach for the analysis of the collected data. The initial coding of the transcripts involved the 1 st , 2 nd , 3 rd and 5 th authors, who set up a preliminary analysis grid based on an independent coding of the 4 first interviews. Referring to the Grounded Theory approach 19 , the rest of the transcripts were coded by the two main researchers (1 st & 3 rd author) in a process of constant comparison. Major emerging categories and subcategories were discussed and refined until the end of the process to reach a strong consensus. This process involved 2 group discussions around preliminary results with the healthcare team.

Results

Regarding our first research objective, i.e. the AYA patients' psychosocial and developmental needs as perceived by the multidisciplinary health care team, our analysis revealed a core category -namely that of supporting identity construction in AYAs -and 3 subcategories that may be seen as 3 different facets of the process of identity construction: (i) self-determination and individuation from parents, (ii) gender and sexual identity and (iii) social life and connectedness with peers and adults (other than parents). Regarding our second research objective, i.e. to reveal how the HCPs in this unit individually and collectively adapt their practices to meet what they perceive as essential psychosocial needs of their patients, flexibility emerged as a core category, which was made possible by collaborative work and a number of collective processes that facilitate self-reflection and build a solid team cohesion. Our results are presented according to these emerging categories with examples of concrete practices to illustrate the findings.

SUPPORTING IDENTITY CONSTRUCTION

The participants generally attested that AYAs go through an important process of identity construction, which involves major physical and psychological changes to be integrated. They acknowledged that the experience of cancer largely hampers this process and advocated for the provision of in-patient care that includes ways of addressing these specific needs. They argued that an AYA patient does not only have cancer, but is a person who must achieve some important developmental milestones that need to be taken into account in the care relationship: « They remain adolescents, no matter how ill they are. An AYA patient is not an ordinary patient » (nurse). To mitigate cancer and treatment effects, they identified 3 major challenges inherent to the identity process of any adolescent that may be particularly threatened by the experience of cancer and therefore require special attention from the healthcare team.

Supporting individuation from parents and self-determination. HCP insisted on the

importance of supporting the processes of self-determination and individuation as a way of compensating for the dependence created by in-patient care. Therefore, the team aims to deeply involve patients in decision-making processes during the whole duration of their hospitalisation. Parents are less systematically involved by the HCPs in their children's care, as compared to usual practices in paediatrics: « What changes, with regards to paediatrics, is that the cancer diagnosis is not given first to the parents but directly disclosed to the teenager » (doctor). HCPs assumed that the parents' presence has to be constantly discussed to support the separation process, which is even more complex in the context of cancer. According to HCPs, there is no one way of regulating the parents' presence, and individualised decisions need to be made. A concrete example is the management of extra beds for accompanying parents or relatives who ask to stay overnight. In this AYA unit, it is not a rule to have an extra bed in the room, as it is in paediatrics: « I think that nothing should be imposed but rather proposed at this age. This is more important than for the younger ones. » (doctor). Another example is how HCPs engage in trying to prevent parents from reverting to former relationships they would have had with their child at a younger age, induced by the status of being ill: « A mother washing her small child doesn't shock me. However, when this happens with an AYA, I find it difficult… F o r P e e r R e v i e w 7 I try to discuss the matter with the parents and that it's not up to them to help with everyday things. » (nurse aide). Regulating the distance between parents and AYAs has been acknowledged by the participants as being of significant benefit to AYAs' need for empowerment: « I am thinking of situations where the parents behave in an exemplary manner whilst being able to maintain the right distance. This has an extraordinarily beneficial effect on both the young patient and the parent. » (doctor).

Regarding the need to self-determine their goals and actions, the HCPs in our study acknowledged that this is basically undermined because of the cancer treatment, which is not negotiable. As a result of being aware of their young patients' need for self-determination, flexibility is introduced into the manner in which the treatment is administered, to suit the young patients' need to remain active decision makers, thus allowing them to develop a sense of control. Non-compulsory treatments are discussed and sometimes dismissed or postponed: « I try to respect their preferences. If they don't want to be disturbed too early in the morning for instance, I will accept it once but not a second time. Hence, I am not rushing them but still stand firm. » (nurse). The participants defined their care relationships and practices as being based on an implicit rule: "allowing for negotiation within a fixed framework" (nurse).

In order to allow for negotiations, there are no written internal procedures that would set the rules too rigidly and hinder the necessary flexibility. In agreement with doctors, maskwearing measures are usually relaxed. External home-prepared or commercial frozen meals, prohibited in other places due to infectious risks, may be permitted under certain conditions.

In their capacity as adults, HCPs saw themselves as playing a key role in supporting their young patients' identity-forging process by tolerating conflicts and differing opinions: « After all, we represent the adult world for them, and perhaps it is a good thing that they know they can't do whatever they want to do, even when they are sick » (nurse). They acknowledged negotiation and conflicts as making sense in the caring relationship: « Teenagers are looking for conflict. Yes, there are clashes, but these are natural things that happen because we are in facility that deals with adolescence. We need to remember the need for mutual respect all the time » (nurse).

Supporting gender and sexual identity. HCPs were aware that the challenges around sexuality and body image are crucial in the process of defining one's identity during adolescence. As treatments alter the pubescent body, they perceive the importance of enhancing the patient's emerging gendered identity, much more than when working with younger or older patients: « when I was working in paediatrics, I didn't ask myself those kinds of questions. But teenagers become conscious about their own bodies so I cannot take over it without asking them. They are a person, already an adult for some and for others still ''in progress'', but at the end of the day, they have their say in things! » (nurse). Consequently, HCPs are extremely respectful of their young patients' modesty and privacy. In practical terms, the AYA unit is organised with single rooms which are separated by opaque doors, thus precluding from the possibility of being observed from the outside. Moreover, for intimate aspects of care, such as hygiene-related issues or fertility preservation procedures, HCPs single out one member of their team of the same gender as the patient when they perceive that the patient feels too uncomfortable: « Our male colleagues are involved in matters of care that bother boys, for instance for explaining the semen collection procedure. Talking to a man about this is easier than to confide in a woman, even more so if she is a young caregiver. » (nurse).

Finally, the staff noticed that when special care was provided to enhance well-being in addition to physical treatment, it eased the suffering stemming from a painful and injured body.

Massages are offered to allow for positive experiences and to relieve anxiety and stress. HCPs were deeply convinced that attending to physical needs other than only those ones exclusively related to the treatment of cancer contributes to a better body image, self-esteem and therefore to positive identity construction. coordination nurse whenever the staff identifies that a patient might be suffering from social isolation, a community worker organises collective activities to encourage links between inward patients and coordinates the actions of several out-door organisations. One of these provides a teacher who lectures in the hospital and liaise with schools in order to facilitate the patients' pursuit of their studies. A social worker helps young adult patients already engaged in a professional activity to maintain it by liaising with their employers. This gives an indication of the numerous professions involved in the care to AYAs with cancer in this unit.

These concrete measures show a strong will to approach the AYA patient more holistically and the HCPs' conviction that caring means more than curing cancer: « After all, I do not look at them as ill people in the first place, but rather as people. » (nurse). Our participants conveyed that AYAs with cancer need not only efficient and evidence-based medical and technical treatment, but also strong links and genuine human connection, which they acknowledged as the core component of the care relationship: « If they need to talk, I don't leave, I give them time. Interpersonal relationships are very important in this unit. » (wardaide). Such involvement was recognised as giving sense to their work. On the other hand, they also acknowledged that it might make them more vulnerable: « In this unit, our caring technique is based on relationships. It is not much more difficult than anything else, but it means that we are much more involved. » (nurse). Reflecting on their efforts to best address their young patients' needs, HCPs reported that they get personally involved beyond the boundaries of their traditional professional roles, thus exposing themselves to an increase risk of emotional burden. Reflective practices and strategies are used to process the constant adjustments that are required to maintain a collective cohesion and flexibility.

FLEXIBILITY, COLLECTIVE PROCESSES AND SELF-REFLEXION

HCPs were aware that being individually flexible was dependent on collective strategies aimed at protecting their professional roles and ensuring overall coherence of staff decisions: « I always try to give a consistent message, because otherwise AYA patients fall between the cracks. » (nutritionist). In practice, they reported that formal and informal teamwork practices had emerged, such as feeling free to ask for help from a colleague whenever they face emotional difficulties with a patient: « We must have empathy to be a good caregiver, but we also need to attend our own needs". When I feel emotionally fragile with a patient, I hand him/her over to a colleague. » (nurse). Working in pairs and mutual trust were cited as important team resources in which interpersonal relationships are central. Although such flexibility could be seen as carrying a risk of confusion, HCPs reported that sharing opinions ensures the team's cohesion: « I cannot work by myself because we all have our small contribution toward building this care project. » (social worker). Therefore, HCPs acknowledged the importance of the right motivation to work in such a ward: « We are all very motivated here because facing an adolescent requires a high sense of solidarity » (night nurse).

The weekly staff meetings aim to favour a multi-focal approach and individualisation of care procedures. Personalised decisions are more appropriate than decisions that would be taken by complying with predefined criteria according to a fixed medical protocol: « I remember a patient, in aplasia and feverish, who wanted to leave for the weekend. From my Every staff member feels responsible for passing on information while optimising his/her professional role: « This multidisciplinary exchange is very constructive: it invites us to share different views, thus revealing aspects of a patient's experience, that I would otherwise not necessarily be aware of. This experience enriches me. » (nutritionist).

Open-mindedness and reflexive practices were described as a strong resource that nurtures in return the HCP's own professional role, and their ability to better meet the demands imposed on them by AYA patients.

DISCUSSION

Identity work was identified by the HCPs as the core challenge that AYAs with cancer must face, along with the interconnected challenges of building one's autonomy and sexual and social identities. Whereas these issues have been well studied from the patients' perspective 21 , they have remained understudied with regard to opinions of HCPs'. Yet, HCPs are particularly challenged when it comes to support such needs in the patient-provider relationship. This study does not only report on individual and collective practices meant to support AYA patients' psychosocial needs but also on strategies and skills HCPs should aim to develop in order to meet this challenge.

First, HCPs contribute concretely to individuation and self-determination targets when involving patients in decision-making processes and playing a subtle role in negotiating their parents' presence. Recent research suggests that AYA health communication and collaborative decision-making is a sensitive issue, because the age of legal responsibility should not determine who (the parents or the young patient) has to be informed [22][23] . Assessing as comprehensively and as early as possible the patient's degree of autonomy and the quality of the parent-AYA relationship should contribute to a better balance of decision-making 12 responsibilities as far as the patient-parent dyad is concerned. This is consistently related to an important coping strategy to develop AYAs' sense of control 24 .

Secondly, our results highlight how HCPs pay attention to AYA patients' sexual development by being sensitive and responsive to individual patients' level of sexual maturity and physical development. There is some evidence that treatment-related side effects adversely affect AYAs' early puberty, sexual function and development [25][26][27][28] . Recent research suggests that impairments of body image seriously threaten the gendered identity if related to lower selfesteem. Self-esteem plays a key role in the development of the sense of self as a sexual being at that age 29 . Our study shows that HCPs support the body image with the onset of puberty by being highly respectful of modesty and privacy. They promote a better body image as they offer positive sensory experiences and feelings about physical impairments thanks to their careful handling of physical areas affected by illness or treatments by providing massages. As shown in other studies, such attitudes are likely to contribute to a better self-acceptance, thus fostering enhanced relationships with peers and intimate partners [30][31] . We believe that it paves the way for better communication regarding the emotional, romantic and sexual dimensions of their quality of life, all of which are key issues in this population of patients [32][33] .

Another major issue for HCPs was about maintaining a bond with peers by favouring outpatient hours, school attendance or the pursuit of work and projects as key elements in building one's identity at that age. They adapt hospital and ward rules to reduce the disruptive effects of hospitalisations. In doing so, they provide personalised adjustments which require that they improve their own tolerance to conflicts. The present study shows how they develop negotiation skills, patience, with mutual respect as a strategy to promote a genuine and nonauthoritative therapeutic bond. There is some evidence that a strong patient-oncologist alliance is associated with psychosocial wellbeing and therapeutic adherence in AYA cancer patients 34 . However, being empathic exposes HCPs to a "double-edged sword" 36 , with a clear benefit for patients potentially counterbalanced by a detrimental effect on professional stress levels, especially when patients are facing life-threatening condition [37][38][39][40] . It would deserve further investigation to assess how HCPs' empathy is a source of work exhaustion or distress. Our results suggest that a reflection about what it means to get personally involved in care should be introduced early in the curricula of medical and paramedical studies, and the importance of a trained and balanced workforce within the team (i.e. multidisciplinary and mixed-gendered).

Study limitations

The strength of our study lies in the high participation of a multidisciplinary health care team in an AYA dedicated unit, althought nurses are an over-represented professional category. Moreover, as this was a study conducted in a single centre, the sample of participants was inevitably small, and our results may not be appropriate for extrapolation. In addition, we opted for an iterative process of data collection and analysis. Yet, at this stage of our study, we are aware that we have not reached saturation of the data. Rather, as is typical in grounded theory, our initial research question has broadened and there are still many issues that need to be explored to improve the AYA's psychosocial care.

  Encouraging social life and connectedness. HCPs acknowledged that the process of identity construction in AYAs involves developing more intense relationships with peers and maintaining their professional and social projects. They observed the disruptive effects of diagnosis and prolonged in-patient stays on AYAs' social dynamics. Despite the isolation measures mandatory in haematology, the AYA unit has been designed with the aim of opening up the boundaries of the hospital: some open living spaces encourage AYAs' social relationships and informal meetings. Various practical adaptations have been set up to reduce their feelings of isolation despite the usual hospital rules: visiting hours were extended to respect the more nocturnal hours favored by AYAs, hospital discharges are facilitated by a

  perspective, letting her out was out of the question… But after discussing it with the team, I let her go out. This enables us to do work on a case by case basis » (doctor).

  findings highlight that a genuine personal relationship based on openmindedness and strong motivation are to be considered subjective abilities HCPs must develop to support such an alliance. The HCPs' skills are strongly linked with the understudied concept of empathy in the patient-caregiver relationship. A recent review concludes that HCPs' empathy is associated with better psychosocial adjustment and less psychological distress in the HCPs35 , although there is a lack of nursing-focused research in this field. Various sections of the transcripts obtained show deep emotional and subjective commitment as core human qualities developed by the HCPs to favour empathy: it can be seen as a main contribution to this topic.

2 Results:

 2 there are still many issues that need to be explored to complete the complexity of the AYA's psychosocial care.Clinical implicationsHCPs have delivered useful recommendations to support AYA's psychosocial development such as providing patients personalised adjustments in their caring practices and implementing strategies to that end. As such, these can be transferable to other similar care situations and may initiate a reflection on practical guidelines for young patient-friendly models of care in dedicated units. Our results show how HCPs adapt their practices and care relationships to support three major developmental milestones related to identity construction in AYAs: selfdetermination and individuation from parents; gender and sexual identity; social life and connectedness to peers and adults (other than parents). Our results also show how HCPs adapt their practices and organizational methods to enhance the flexibility required to address their young patients', thus setting consistent and high standards for the whole team. Such adaptation is made possible through collaborative work and collective processes that facilitate selfreflection. Conclusions: Our findings shed light on some meaningful young patient-friendly practices of care and advocate for AYA dedicated units.

  adapt their caring practices and work organisation to meet what they perceive as essential needs for the psychosocial development of AYA patients.

  in an AYA haematology in-patient unit in Paris. This unit was founded in 2010 in line with the second governmental cancer action plan(2009-2013). It admits patients aged 15 to 25. A great majority of them is diagnosed with acute leukemia and highgrade lymphoma, both of which require long lasting treatments, including allogeneic stem cell transplant (HSCT). The unit is composed of 16 single bedrooms, including 4 that are equipped with high-efficiency particulate air filtration mostly used to perform HSCT. The average length of stay is about 11 days, ranging roughly from 3 days -for a short chemotherapy regimen -to 4-6 weeks for the induction phase for acute leukaemia or HSCT.

  Encouraging social life and connectedness. HCPs acknowledged that the process of identity construction in AYAs involves developing more intense relationships with peers and maintaining their professional and social projects. They observed the disruptive effects of diagnosis and prolonged in-patient stays on AYAs' social dynamics. Despite the isolation measures mandatory in haematology, the AYA unit has been designed with the aim of opening up the boundaries of the hospital: some open living spaces encourage AYAs' social relationships and informal meetings. Various practical adaptations have been set up to reduce their feelings of isolation despite the usual hospital rules: visiting hours were extended to respect the more nocturnal hours favored by AYAs, hospital discharges are facilitated by a

  perspective, letting her out was out of the question… But after discussing it with the team, I let her go out. This enables us to do work on a case by case basis » (doctor).

  findings highlight that a genuine personal relationship based on openmindedness and strong motivation are to be considered subjective abilities HCPs must develop to support such an alliance. The HCPs' skills are strongly linked with the understudied concept of empathy in the patient-caregiver relationship. A recent review concludes that HCPs' empathy is associated with better psychosocial adjustment and less psychological distress in the HCPs35 , although there is a lack of nursing-focused research in this field. Various sections of the transcripts obtained show deep emotional and subjective commitment as core human qualities developed by the HCPs to favour empathy: it can be seen as a main contribution to this topic.

Table 1 -Sample of the HCPs interviewed at the time of the study

 1

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	9 day nurses	10 night nurses	1 coordination nurse	2 ward-aides
	1 social worker	1 kinesiologist	1 nutritionist	1 community worker
	2 doctors	1 junior doctor
	1 senior health
	manager

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Psycho-Oncology

Acknowledgements

We are grateful to all the participants who agreed to share their experience with us. We are most grateful to INCA (Institut National du Cancer) for doctoral fellowship, and to Novartis for their administrative support (basically interviews' transcripts). We also thank the following colleagues for their editorial help at various stages of the writing process: Giulietta Von Salis and Lydia Stephens.

Acknowledgements

We are grateful to all the participants who agreed to share their experience with us. We are most grateful to INCA (Institut National du Cancer) for doctoral fellowship, and to Novartis for their administrative support (basically interviews' transcripts). We also thank the following colleagues for their editorial help at various stages of the writing process: Giulietta Von Salis and Lydia Stephens.

Clinical implications

HCPs have delivered useful recommendations to support AYA's psychosocial development such as providing patients personalised adjustments in their caring practices and implementing strategies to that end. As such, these can be transferable to other similar care situations and may initiate a reflection on practical guidelines for young patient-friendly models of care in dedicated units.

Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.