Prior to the Covid-19 pandemic, heart failure (HF) disease management programmes were predominantly delivered in-person, with telemedicine being uncommon. Covid-19 resulted in a rapid shift to “remote-by-default” clinic appointments in many organisations. We evaluated clinician and patient experiences of teleconsultations for HF.From 16th March 2020, all HF appointments at a specialist centre in the UK were telemedicine-by-default through a mixture of telephone and video consultations, with rare in-person appointments. HF clinicians and patients with HF were invited to participate in semi-structured interviews about their experiences. A purposive sampling technique was used. Interviews were conducted using Microsoft Teams®, recorded and transcribed verbatim. Narrative data were explored by thematic analysis. Clinicians and patients were interviewed until themes saturated.Eight clinicians and eight patients with HF were interviewed before themes saturated. Five overarching themes emerged: 1) Time utilisation – telemedicine consultations saved patients time travelling to and waiting for appointments. Clinicians perceived them to be more efficient, but more administrative time was involved. 2) Clinical assessment – without physical examination, clinicians relied more on history, observations and test results; video calls were perceived as superior to telephone calls for remote assessment. Patients confident in self-monitoring tended to be more comfortable with telemedicine. 3) Communication and rapport – clinicians experienced difficulty establishing rapport with new patients by telephone, though video was better. Patients generally did not perceive that remote consultation affected their rapport with clinicians. 4) Technology – connection issues occasionally disrupted video consultations, but overall patients and clinicians found the technology easy to use. 5) Choice and flexibility – both patients and clinicians believed that the choice of modality should be situation-dependent.Telemedicine HF consultations were more convenient for patients, saved them time, and were generally acceptable to clinicians, but changed workflows, consultation dynamics, and how clinical assessment was performed. Telemedicine should be used alongside in-person appointments in a “hybrid” model tailored to individual patients and settings. Heart failure (HF) management programmes, including regular clinical review, are recommended by European guidelines to reduce morbidity and mortality . In 2020Prior to the Covid-19 pandemic restrictions, the use of telemedicine consultations was rare in secondary care; a report by the Organisation for Economic Co-operation and Development (OECD) found that telemedicine consultations were less than 0.2% of in-person consultations in surveyed countries, including Australia, Canada and Portugal . ConsequAs Covid-19 becomes endemic, healthcare services must plan for “the new normal” where universal face-to-face clinic reviews are likely replaced by a “blended” model of care. A qualitative evaluation of telemedicine consultations, from both the patient and healthcare professional perspective is likely to inform discussion around the optimal delivery of future outpatient care.th March 2020, just prior to the first national “lockdown”, with face-to-face appointments only in exceptional circumstances. We aimed to evaluate the experiences of clinicians and patients who had participated in telemedicine consultations, contrasting that with their experience of the traditional “face-to-face” model of care.The Royal Brompton Hospital provides specialist HF care to patients from across the South of England. Prior to Covid-19, most patients with HF were seen 6-monthly with face-to-face appointments, weights, and blood pressure measurements, in line with national guidance . It shifMethods.The Royal Brompton Hospital runs a specialist HF service led by five consultants and three clinical nurse specialists. All scheduled HF clinic appointments for new patients and for routine follow-up were initially converted to telephone appointments, and from July 2020 onwards the option of video consultation was made available. Video consultations were conducted using the AttendAnywhere® web-based video consultation platform – an NHS recommended platform not requiring additional software to be installed by either the patient or healthcare professional. The platform uses a virtual “waiting area” where clinicians can see which patients have logged on and are waiting, with clinicians then triggering patient access into the virtual clinic room.Study design.We used a qualitative study design, following the Standards for Reporting Qualitative Research . CliniciPlease describe your experience of telemedicine consultations.How did you find the technology?What was your experience of the clinical interaction?How could the experience of consultations be improved?How would you like future consultations to be conducted, and why?Five prompt questions guided the interview. Questions were chosen to be open-ended but ensuring key areas of interest were covered:Data collection.A purposive sampling technique was used for clinician and patient recruitment. Members of the HF clinical team (except for the investigators) were invited to take part in the study by e-mail and selected to ensure a good mixture of doctor and nurse responses with a range of levels of clinical experience and familiarity with technology. By the point at which interviews saturated, however, all permanent members of staff (excluding the investigators) had been interviewed, and so limited demographic data are provided to avoid identification of responses. Patients who had a scheduled appointment in either a consultant or nurse-led HF clinic between 1st January 2021 and 28th April 2021 were sent a text message link to a survey in which they were invited to participate in interviews. Patients were screened to confirm a diagnosis of HF and recent clinic attendance. Purposive sampling criteria for patients were chosen to ensure patients were representative of the wider cohort in age, sex and ethnicity, whilst also including a range of respondents. In the Royal Brompton Hospital, the median age of patients under follow-up with HF is 68 (with most aged between 45 and 85), a majority of patients are male, and the largest ethnic group is white-British. Patients were also sampled to explore emerging hypotheses; we included patients with both recent and long-term diagnoses, and a mixture of those who had video and telephone follow-up. Participants were selected and interviewed sequentially until data were “saturated” (see below).th February 2021 and 17th March 2021, and interviews with patients were conducted between 9th April 2021 and 19th May 2021. All interviews lasted no more than 40 min.All interviews were conducted by AS following training by JPR. Interviews were conducted and recorded using Microsoft Teams®, and then transcribed verbatim. Interviews with clinicians were conducted between 24Interview transcripts were pseudo-anonymised and narrative data were analysed by thematic analysis , 11. BriEthics.The study was registered as the “VIDEO-HF” study with the UK Integrated Research Application System (IRAS number 284625) and received ethical approval from South West—Frenchay Research Ethics Committee (20/SW/0096).th March 2020 and 15th March 2021 there were 2797 HF clinic appointments, of which 2761 (98.7%) were by telemedicine. Most telemedicine consultations were by telephone rather than video call, but it was not possible to gather an accurate breakdown as consultations were not coded separately in hospital IT systems.Between 16Four consultant cardiologists in the HF service, three specialist nurses that were part of the multi-professional team, and one rotational training-grade doctor were interviewed. Half of interviewees were male and half were female. Clinician recruitment was terminated following these eight interviews as themes were deemed to have saturated.1296 patients were sent a text message link to the survey, and 128 patients (9.9%) completed the survey. 63 respondents (49%) reported that their most recent clinical interaction was by telephone, 40 (31%) by video call, and 25 (20%) face-to-face. Using purposive sampling, we selected patients based on their clinical and social characteristics described in the methods  owing to the lack of interoperability between GP and hospital health records. Others perceived that more preparation was required for clinics as patients needed to be pre-allocated to clinicians to call them.“That's the big benefit for me, I think, just the saving in time and expense of travel. It takes me 2, 2 1/2 hours to get there from home, so it saves me a good half day, plus the train fare. So yeah, I can see very real benefits.”– P03, 70MMost patients perceived that a key advantage of telemedicine consultations was that they saved them time, effort and expense of travelling to hospital:For patients who previously drove to their appointments, there was also the added benefit of not having to “burn up a load of fossil fuels, [and] get frustrated in the traffic…. it’s saving the environment”. Most patients preferred waiting at home for the video consultation rather than waiting in a hospital waiting room, as they found it more comfortable, and were able to do other things whilst they waited.Patients did not perceive that telemedicine consultations were shorter, brief or rushed, but some patients thought that it would be more efficient for clinicians.Theme 2: Clinical assessment.Telemedicine consultations meant that different methods of information gathering were required to assess patients and make clinical decisions.“The examination can often pick up something and I don't find it very satisfactory to have someone sort of use the camera to go ‘here are my legs look at my oedema’ or not.”– S05, HF ConsultantThe lack of physical examination was deemed by most clinicians to be a significant downside of telemedicine consultations:“At least you can, you know, turn the camera around so you can have a look and see what- what that person's legs look like, so it's a bit of a halfway house in that sense in terms of your clinical assessment.”– S03, Training grade doctorExamination of oedema was possible by video but perceived to be less reliable than a physical examination:Clinicians stated that patient self-monitoring data, such as weight, blood pressure and heart rate measurements assisted clinical assessment. Some patients were able to also get blood tests from the community. Without physical examination and when patients did not have easy access to monitoring equipment, clinicians became more reliant on the patient history.Patients also found that the clinical assessment in telemedicine consultations differed from in-person consultations. Physical examination was not possible by telemedicine, but most patients did not perceive this to be a problem for them.“Where it is a straightforward review of the medication, how am I, checking on blood pressure, checking those sorts of things that can be done at arm’s length, then [video consultation] is perfect.”– P08, 72MMost patients thought that physical examination was not a vital part of the heart failure consultation, particularly if they were symptomatically stable:One patient did find routine physical examination and regular in-person clinical assessment more reassuring, and this was her primary reason for preferring face-to-face consultations.“Perhaps there might be a mismatch between them saying ‘I'm absolutely fine, absolutely fine’ and you may think you don't look perhaps, you know- don't look as well, perhaps, as you're saying.”– P01, 57MPatients stated that telephone consultations were particularly reliant on self-described clinical status, and therefore open to a possible “mismatch” between the patient’s and clinician’s perceptions of their clinical status, whereas video allowed a visual assessment which may be able to detect this mismatch:“I think that sometimes that you- you could miss something yourself that- that they wouldn’t.”– P04, 56FMost patients were confident that they were able to notice any deterioration in their cardiac status and could therefore alert the clinician. Those that described being less confident in their ability to self-assess preferred in-person reviews by clinicians for routine heart failure monitoring. For example, a 56-year-old diagnosed with heart failure two years before the pandemic stated:Some patients found getting blood tests at GP surgeries more convenient than in hospital as it was a quicker process with shorter travel times.Theme 3: Communication and rapport.“There is a chemistry you have when there's another person next to you, another person in any room … the intimacy and the confidence of being in the close presence of some- someone else is all part of how they come to trust you and listen to you.”– S01, HF ConsultantClinicians stated that there was a difference in “chemistry” between in-person and remote consultations that altered the clinician-patient relationship:Clinicians almost unanimously agreed that new patients were better seen face-to-face to develop a “connection” which was felt to be important for patients to trust clinicians and thus speak freely, but also for clinicians to best interpret the significance of patient histories. The personal aspect of face-to-face consultation was thought to be particularly important when having a difficult conversation around a sensitive topic; breaking bad news or advanced care planning was thought to be inappropriate by telemedicine.“I think just being face-to-face and closer to someone you pick up more on certain nuances with communications, and body language, that sort of thing. And it's all part of communication, isn't it? And, being in a room, you see all that.” – P02, 65MLike clinicians, patients found that telemedicine consultations changed how they communicated, affecting rapport and consultation dynamics. Patients also emphasised the importance of non-verbal communication:“It's pretty much the same, again it's all to do with seeing someone. I think the operative word there is seeing.”– P02, 65MMany patients described communication in video consultations to be similar to in-person consultations, as it was still possible to make use of visual cues through a screen:For telephone, some patients perceived that the lack of these key visual cues impaired communication and detracted from the experience of telephone consultations. Others, however, judged that consultation modality had minimal impact on rapport.“I think if it was like you've got six months to live, I’d probably rather do that face-to-face than over a Zoom call. I think that would be quite hard to hear that when you're on your own in the house, you know, and there's no support.”– P05, 63FUnlike clinicians, however, patients did not express a specific preference for first appointments to be face to face, and most respondents thought that meeting someone for the first time by telemedicine was similar to in-person appointments. Most patients stated that sensitive topics such as breaking bad news were best discussed in-person so that patients could have adequate support:Theme 4: Technology.“And when it crashes, oh my goodness, that's a disaster. You know, when you can't use it, that's quite stressful.” – S06, HF NurseOccasionally, technical disruptions would occur on the video platform, often due to internet connection issues, which could have a significant impact on the timing of the clinic. Clinicians described how they would then revert to telephone. Most clinicians had experienced some technical difficulties during a telemedicine consultation:Video consultations required access to a computer with a webcam, personal headset and high-speed internet, ideally in a private space; such spaces were sometimes difficult to find, and computers were not always set up properly.“When you speak, it's clear that there's a one, you know, fraction to one second delay, and there’s the risk of speaking over each other.”– S05, HF ConsultantA disadvantage of video consultation was that occasionally latency issues  resulted in disrupted and staggered conversational flow:Some clinicians believed that telemedicine posed privacy challenges; patients and clinicians may not want others to see their home environment, and unlike in a consultation room, it was not always clear who was able to see or hear the consultation.Most patients interviewed had prior experience of video calling outside of healthcare, often using platforms such as Zoom™ to connect with family and friends, particularly during the pandemic, and some patients had also used video platforms for work. Patients did not report technical disruptions during their video consultations, though one patient reported signal disruption in a telephone consultation.“It was absolutely fine. Worked- worked first time, no delays getting in and I didn't have to download anything. So that was- it was part- perfectly fine, yeah.”– P01, 57MSome patients were apprehensive before their first appointment using video technology as they were unfamiliar with the platform and concerned about potential difficulties in accessing it. Despite this, most patients found video consultations intuitive and easy-to-use:Theme 5: Choice and flexibility.“I think it's really important to give patients the choice, 'cause we are tech savvy and happy with either, but they, I think, fall into different groups…”– S05, HF ConsultantClinicians deemed that the choice of modality was very much dependent on the patient and on the situation. Patient choice was essential, as some patients may not be comfortable with using telemedicine or have the necessary equipment for video consultations:Clinicians also had preferences based on the purpose of the consultation and needs of the patient. Where patients described worsening symptoms, the clinician stated a preference for in-person appointments to make a full assessment including physical examination. On the other hand, more “routine” appointments such as periodic assessment and conveying test results could be done by telemedicine.“So, I think the good news is it's here to stay. How do we deliver it and make sure that … all the stakeholders … get the best of this, I think we're still learning, aren't we?”– S05, HF ConsultantClinicians perceived that patients and healthcare systems were more receptive to the idea of telemedicine consultations owing to the Covid-19 pandemic. Clinicians deemed that clinics were unlikely to return to how they were before Covid-19, and that a mix of in-person and telemedicine consultations would likely be the future model of care:“The health service has got a great tradition of making up its mind as to what the patient thinks, and then giving it back to them…”– S01, HF ConsultantSome clinicians, however, expressed fears of top-down diktats for future delivery of care, with rigid policies such as quotas for telemedicine patients, restricting flexibility for how clinicians choose to run their own clinic, or not allowing patients to choose their mode of appointment:Similarly, patients stated that the choice of consultation modality depended on the situation. Most patients thought that a combination of in-person and telemedicine clinics would be ideal for future care. Communicating test results, for example, was generally perceived to be best done by telemedicine, whereas, as reported above, patients tended to prefer in-person appointments when their symptoms deteriorated, and would also prefer in-person appointments if they were receiving bad news.“Well, if there's no need for, uh, contact, physical contact, then obviously you don't really need to travel.” – P02, 65MSome patients thought that telemedicine should be the default modality for them, and in-person appointments should be reserved for when physical assessment was required:“Well, I'd rath- I would rather come in and see the consultant myself.… I- personally I don’t mind travelling to go there.” – P04, 56FSome patients believed that in-person appointments should be reserved for when specialist investigation was required, but otherwise telemedicine was preferable. Others, however, preferred in-person assessment as the default as the reassurance of routine physical assessment outweighed the benefits of saving a journey:“Obviously, there are issues about sort of connectivity and people who don't have access to digital communication… I think it's that balance of if it's more efficient for everybody, uh, then… encouraging people towards the most efficient way is- is better.”– P01, 57MOne patient, however, believed that the efficiency of telemedicine needed to be balanced against access to services, and he emphasised the importance of improving access:We identified five main themes in patients’ and clinicians’ perceptions of telemedicine consultations for HF: time utilisation, clinical assessment, communication and rapport, technology, and choice and flexibility.Comparison of clinician and patient perceptions.Whereas clinicians had mixed opinions on whether telemedicine saved time, patients were unequivocal that telemedicine consultations saved a significant amount of journey time and were more convenient. Both patients and clinicians emphasised the importance of non-verbal communication and visual cues for clinical assessment, however clinicians placed more emphasis on the effect this had on rapport; some patients even reported that telemedicine consultation did not change rapport at all. Clinicians unanimously thought that it was best to meet patients for the first time in-person rather than by telemedicine, but patients interviewed did not express a preference for this. Patients and clinicians agreed that breaking bad news was best done in person. Most clinicians raised the issue of lack of physical examination being a limitation to telemedicine, whereas patients had mixed opinions; some patients did not perceive physical examination to be an important part of clinical assessment. Most clinicians interviewed experienced technical difficulties during video consultations and some perceived that patients would find video consultations technically challenging. Patients, on the other hand, tended to have good experiences with video consultation and did not encounter technical issues; this may simply reflect the fact that clinicians had performed a far higher number of consultations. Both patients and clinicians stated that telemedicine consultations may be more efficient.Benefits and challenges of telemedicine.Patients and clinicians in our study identified several benefits and challenges  [. in a hermeneutic review of the literature of HF and telehealth [Patients in our study reported significant time benefits of telemedicine consultation. This is consistent with interviews of primary care patients in the USA , New Zeaywhere™) . In theiywhere™) , and strywhere™) , Challenlehealth ,The VOCAL study evaluated telemedicine consultations for diabetes and cancer surgery at an acute hospital in the UK using mixed methods , ImplemeDiscussion of methodology and limitations.Study design.Semi-structured interviews are the most common form of interview used in qualitative healthcare research . NonetheInterviewee perceptions of the interviewer, and the relationship of the interviewer to the study group may influence responses . PatientThematic analysis, as with all qualitative research, is subjective and subject to different interpretations of data. Two independent investigators agreed the emerging themes accurately reflected narrative data, one of whom (JPR) is an experienced researcher in qualitative methodology.A total of 16 participants (8 clinicians and 8 patients) were interviewed before themes saturated. Although the sample size may appear small, meta-research of qualitative studies suggests this is in-fact a reasonable sample size, and that the majority of key themes emerge within the first 6 interviews –26.Study population.The Royal Brompton Hospital is a tertiary centre reviewing patients from a wide geographical area across Southern England, and patients’ and clinicians’ experiences may not be representative of those in district general hospitals, or from other countries.Patients were recruited by a text-message link to a survey. The response rate was just under 10%, and it is likely that respondents may have been more motivated or interested in research and more positive about technology than those who did not agree to take part in the study. A strength of our study, however, is that unlike other telemedicine research pre-Covid-19 , 27, neaSignificance and implications.Whilst the rapid transition to telemedicine consultations was “catalysed” by Covid-19 related social restrictions and “lockdowns”, healthcare systems have recommended expanding telemedicine in order to help service over-burdened hospital outpatient departments , 30. TheFurther research should focus on safety and outcomes, and cost–benefit analyses of telemedicine consultation for HF care for telemedicine strategies. Other areas of potential research include whether telemedicine may allow more flexible working to help address staff retention and shortages. Additionally, clinicians reported increased reliance on local blood tests and imaging. It is therefore important to assess the impact of this on primary care resources and demand for specialist imaging.Telemedicine consultations change clinician workflows and consultation dynamics but are likely to play an important ongoing role in outpatient HF care as they are more convenient for patients and save them time; they are particularly suitable for patients who are clinically stable. For patients reporting a deterioration in symptoms or for those less confident in self-monitoring, clinical assessment is more challenging via telemedicine and so the option for in-person assessment remains necessary. Choice and flexibility are key to a positive experience, and patients and staff should be supported to ensure they are able to get the best experience from their consultation . A hybri


In various countries, it is assumed this use of biodiversity leads to the depletion of the species involved. However, other important aspects must be considered, including the role of the people who produce and sell these ramos, the associated symbolism that has been overlooked, as well as commercial aspects that have barely been documented. This ethnobotanical study evaluates the regional-scale cultural, biological and socioeconomic aspects associated with Domingo de Ramos in central Mexico from an emic perspective.Domingo de Ramos, or Palm Sunday, is a traditional Christian religious event where devotees use ramos sellers in 28 municipalities in the state of Hidalgo, Mexico. We specifically sought sociodemographic data regarding the interviewees, as well as information pertaining to the ramos themselves and the palms. These aspects were explored with all of the sellers. The free list method was used to describe the uses and key elements associated with the ramos.Ethnographic and commercial information was obtained through interviews with ramos are used for religious purposes, they have eight different uses in the daily life of the sellers, the main one being “protection.” They serve to protect families, crops and animals, as well as against several diseases. Likewise, they are considered valuable for diminishing strong storms. This belief in the protection conferred by the ramos preserves pre-Hispanic concepts and is combined with their use in blessing corresponding to Western beliefs. Ramos are made from 35 introduced and native plant species and comprise a base , a “reliquia”  and natural or artificial flowers. The ramos sellers are mostly adult women of indigenous origin and heads of family.Although the ramos palm and in the species used, as well as socioeconomic aspects that had not previously been identified in the study area and reflect the occurrence of complex relationships in non-timber forest products that remain little addressed.This study of Domingo de Ramos, carried out at a regional scale, highlights a syncretism that is reflected in both the symbolic importance of The online version contains supplementary material available at 10.1186/s13002-023-00587-3. Domingo de Ramos  is a religious tradition that marks the beginning of the Christian Holy Week. Research into this celebration has focused on the characterization of the biological species utilized [ramos (Spanish for bouquet) on that day, and the associated symbolism has been overlooked. From an etic perspective, which is the researchers’ interpretation of different phenomena [ramos fulfill an ornamental function and that their only use pertains to Catholic celebrations. From an emic perspective, that is to say, the symbolism that the ramos could represent for those who use and trade them, the practice remains little understood. The present study, conducted in the central region of Mexico, focuses on the composition and symbolic meanings of the ramos from the sellers’ perspective, as well as characterizing their economic status and assessing the financial revenue generated by the trade in these ramos.The practice of various religious festivals and ceremonies has been an aspect crucial to the preservation of the intangible value of nature, representing a millenary connection between biological and cultural diversity that conveys a vast biocultural abundance , 2. Domiutilized , 4, pursutilized , 6, descutilized , 8, and utilized . Howeverhenomena , it is uDomingo de Ramos is celebrated by the main Christian denominations . The devotees hold liturgy, in which they use palms (or olive branches) to commemorate the arrival of Jesus Christ to Jerusalem. Since the time of the ancient Greeks, palms have represented fertility and victory, and the Christian faith has adapted and associated them with sacred symbols; the palm represents heaven and its image has been linked to Christ and Mary , 12. MexRamos are currently elaborated in various countries using leaves from palm trees and some other elements. They are then blessed and taken to homes, where they remain for a year until the cycle restarts. These rituals create a clear demand for palms, which in many countries come from species inhabiting natural ecosystems; e.g., Ceroxylon echinulatum in Ecuador [Ceroxylon pityrophyllum in Bolivia [Attalea cohune in Central America [Attalea phalerata in Peru [Acrocomia aculeata in Honduras [ Ecuador , 17, Cer Bolivia , Attalea America , Attalea in Peru , and AcrHonduras . On otheHonduras .C. echinulatum [This ceremony generates 500,000 USD per year in Ecuador, with the commerce of palm leaves of inulatum . These ainulatum , 7. On tinulatum . Short cProsthechea karwinskii), Mexican laurel (Litsea glaucescens), bromeliads  and cycads which are placed on the facades of churches and used to weave ramos [Chamaedorea spp. [, Sabal mexicana [Brahea dulcis [In Mexico, these commercial aspects have barely been documented, even though there is a considerable demand for orchids  to document the sales volume of palms and their productive chain, as well as to characterize the socioeconomic status of the people conducting their commerce. The goal is to provide a panorama that integrates not only biological aspects, but also socioeconomic and cultural features regarding Domingo de Ramos, at a regional scale. Based on the previous aims, our hypotheses are: (1) since Domingo de Ramos is a Catholic tradition, it is expected that the symbolism behind the ramos will be associated with this particular religion; (2) considering the numerous natural palms distributed in the study area [The present ethnobotanical study evaluates the regional-scale biological, socioeconomic and cultural aspects associated with Domingo de Ramos in central Mexico. The objectives of the study were: (1) to elucidate, from an udy area –36, it iTwenty-eight municipalities were studied in central Mexico in the state of Hidalgo Fig. . HidalgoThree physiographic provinces converge in Hidalgo: the Transversal Volcanic System, Sierra Madre Oriental mountain chain and Gulf of Mexico Coastal Plain . The warHidalgo is inhabited by about 3 million people. The most populated studied municipalities are the state capital of Pachuca de Soto , Mineral de la Reforma , and Tulancingo de Bravo  . The staramos are made. The second type of interview was used to obtain descriptions of the vegetal elements contained in the ramos, their symbolism and the palm commercialization processes. To direct the sampling effort, only the municipal capitals were considered, since the most important churches and the main markets where the ramos are sold are located in these places.Twenty-eight municipalities were selected, which cover eight out of ten geo-cultural regions, to get a broad overview of the diversity of plants required and their symbolic uses while allowing the documentation of their exclusive or non-common uses. In these areas, two types of semi-structured interviews were carried out. The first type of interview was applied to identify the gathering sites of the palm from which the ramos are sold during the days before Domingo de Ramos.Two semi-structured types of interviews were designed and applied following the recommendations of Bernard . The firramos. When all the sellers were located, all the legal age ones that were in the place were interviewed, considering only one person per family group. In some cases, when the number of sellers was low, more than one adult person per family was interviewed. The second type of interview ; and (3) the palms . These aspects were applied to all sellers of ramos. Furthermore, if the person was identified as a collector and/or weaver of leaves, specific questions relevant to these particular activities were asked. For palm collectors, the interview focused on the location of the sites gathered and the quantity of leaves gathered. Weavers were asked about what aspects make them feel proud of their work, what materials can be used as a substitute for palm, whether there is any governmental support for the handcrafter, among others.The second type of interview was done on Domingo de Ramos . A total of 149 interviews were done in 28 municipalities. The number of interviews applied depends on the total number of vendors in each municipality  was taken. Seventy-seven ramos were purchased, which made it possible to determine a posteriori the botanical identity of the plants used. They were obtained in 20 municipalities from different sellers in order to have a sample of each design. All the ramos bought were chosen by their diversity of weaving style, materials and plants used. We sought to purchase the ramos with each of the individuals that were interviewed as long as the designs were not repeated.For both types of interviews, all interviewed sellers gave their prior consent to participate . They were each given an introductory letter explaining the objectives and providing our contact number. Each interview lasted from 30 min to 1 h. Photographic evidence of the sales sites, churches, ramo: a code to identify each seller, the place where the ramo was purchased, its sale price, among others /L))/N, where L is the length of the list, Rj is the average rank of each item j in the list and N is the number of lists [The items obtained in the free list were reclassified in order to group the responses considered related. This free list was analyzed using the Smith Index with the ANTHROPAC 4.0 program . The Smiof lists . The impramos. Since the palm is obtained from natural populations, the production chain of these non-timber forest products (NTFP) can best be understood as an obtaining chain. By palm obtaining chain, we refer to the agents and steps required to transform palm leaves cut from natural populations into a ramo for use in the Domingo de Ramos celebration.The production chain refers to the set of agents (“economic agents”) -or their activities- involved in acquiring a final product. The chain involves everything from obtaining the resource , to its transformation and final generation of the product for purchase by the final consumer . On the ramos is always handmade. Identification of agents (step 2) was conducted through observations and informal semi-structured interviews in markets and churches prior to Domingo de Ramos, following Bockel and Tallec [For this, we followed the steps outlined by Bockel and Tallec : (1) ided Tallec , with spFor each type of seller, it was determined from which type of agent the palm was obtained . This was achieved by collecting information from the total number of interviewees in the 28 municipalities. The obtaining chain was represented in a graph. Trade agreements were tabulated and graphed. Prices were registered in Mexican currency (MXN) and US Dollars (USD) according to the Banxico exchange rate for March 23, 2023.Finally, we traced where the palm leaves were brought to each municipality. This information was used to produce a map of the localities, tracing the origin of the palm leaves sold in those 28 municipalities and including their passage through wholesale and retail markets.ramo represent?” The most common answer was its religious meaning (63.5%), but also protection, tradition, or some people simply “do not know” , crops, and animals, as well as against several diseases . However, above all, they are considered valuable for diminishing strong storms. In contrast, their religious use refers to “la entrada triunfal de Jesús a Jerusalén”  and “el Miércoles de Ceniza” (“Ash Wednesday”). Their use for blessing purposes refers to the fact that the palms are taken to the church to be sprinkled with holy water.Considering the question, “what does the ow” Fig. . In contow” Fig. . The proramo are used as a spice or for medicinal purposes, while the “unblessed palms” are utilized as fodder for animals or they can be unwoven. The ramo can be boiled and dried and then used to make “petates” (mat), “aventadores” (winnowers), hats, kitchen brushes, and brooms, thus beginning a new useful life as a daily use item. The use of the ramo as decoration was assigned in this category since people commented that they used them as “adorno en la casa, después de la misa”  . “Family tradition,” refers to the ramo, representing the activity of weaving every year, which is passed down between generations: “simboliza herencia familiar, nuestro trabajo” (“Our work symbolizes family inheritance”) , “sé hacerlo desde niña, mi papá se dedicó a esto siempre y yo después aprendí”  .The least mentioned uses correspond to the categories “everything is used,” followed by decoration, family tradition, burials and sale. “Everything is used” reflects an ecological importance that must be highlighted. Some plants and flowers of the ramo of blessed palms placed around the deceased. At the end of Domingo de Ramos, any ramos that are not sold are given to different family members and friends, donated to the church, or, as described above, reused to make other palm objects.Interestingly, the use that presented the least importance for sellers was that of sale. At burials, the palm is used for the ceremony called “Levanta Cruz” (Raising the Holy Cross), in which the cross , placed during burial prayers held around the deceased, is collected with the blessed palm. Furthermore, 33 crosses are made with the ramos, they are significant to the sellers. This asseveration was clear when asking the following question: “what makes you proud of your work with the palm?” The responses evidence that this activity is significant to the sellers because of the family heritage it represents and because palm weaving is a skill not possessed by everyone. One of the sellers interviewed reported, “es un orgullo saber tejer mientras que otros no saben cómo trabajar las palmas, yo creo que es un don que Dios nos ha dado”  . Another interviewee said, “lo que más orgullosa me hace sentir es que conservo la tradición familiar, religiosa y al mismo tiempo es mi trabajo”  . Although the work carried out by the sellers is significant for them, the activity is little appreciated by those who demand the ramos for sale: “lo hago con cariño (el tejido de ramos), pero la gente lo regatea mucho y hace menos mi trabajo”  . However, despite these facts, many sellers enjoy this activity year after year: “nada me molesta, me siento feliz con mi trabajo y con lo que me enseñaron”  .In addition to the utility of Ramos are made from 35 plant species, where the majority (24) are introduced species and, to a lesser extent (11) native species , a “reliquia” (“relic”), and, in some cases, flowers  are not part of the “reliquia.” For some people today, and especially in the past, a ramo is a green palm or sotol leaf with no weaving or other plants. Typically, ramos are woven into forms representing Jesus Christ or the Virgin Mary, accompanied by glitter, ribbons, and images of saints  is listed as an “endangered species (P)” according to NOM-059 [majority 4 are intmajority 4 are int NOM-059 .Table 2Pramo must include rosemary (Smith index of 0.628), chamomile (0.471), palm (0.403), natural flowers (0.338) and Mexican laurel (0.31) (Table cannot be missing from the ramo are rosemary (0.444), palm (0.279) and chamomile (0.231)  of sellers replied that palm could not be replaced, while 19 believed it could be substituted with wheat, and 11 with another similar palm. The rest of the sellers considered it could be substituted with other elements , followed by working at home (20.8%), others (17.4%), farming (14.8%), and handcraft sales (11.4%)  “Strategy 2 ”: same as above and additionally purchase palm leaves; (3) “Strategy 3 ”: only sell ramos; (4) “Strategy 4 ”: purchase palm leaves, weave and sell ramos . A fourth stage, dubbed “marketing,” may occur when some people are intermediaries and only attach the “reliquia” and flowers. The final stage is that of the sale, which takes place outside or close to the churches where the ramos reach the final consumer  “Strategy 1 ”: gather and weave the palm and sell the mos Fig. . The firmer Fig. . Among tmer Fig. .Fig. 7 Pramos represents the secondary economic activity for 29.5% of the sellers interviewed  or it can be purchased in bulk: 100 leaves commonly cost from 150 to 300 MXN (8.09–16.18 USD) in Hidalgo, and from 350 to 500 MXN (18.88–26.86 USD) in markets in Mexico City. Ramos vary in price from 10 to 40 MXN (0.54–2.16 USD), but they can usually be purchased for 25 MXN (USD 1.35). It was also shown that ramos (without other plants) can be purchased by the dozen, and their cost in this form ranged from 70 to 90 MXN (3.76–4.83 USD). All of the prices given above can vary depending on the particular commercial agreements , Tulancingo (East), and Ixmiquilpan (Center); however, there are other places from which palm leaves can be sourced. Actopan and Atotonilco el Grande are considered the leading sites for obtaining leaves. For the northern zone of Hidalgo, the palm comes predominantly from natural populations within the same localities as their final use, but also from San Luis Potosí and Veracruz. In the eastern part of the state, the palm can be acquired in markets and from the natural populations of Puebla and Tlaxcala. Toward the south, the palm leaves are obtained from large wholesale markets  in Mexico City and Puebla. In these cases, the original source of the palm is almost certainly unknown. However, the sellers who move directly to the supply centers and have always procured goods from the same place, report that the palm comes from Oaxaca, Morelos, and Puebla Fig. .Fig. 10Cramos are a mixture of native Mexican species and others introduced from Europe. On the other hand, the use of ramos has protective and medicinal elements and is not only used for what is referred to as Catholic ritual. This dialectical interaction between the two beliefs has been documented in certain religious festivities [Domingo de Ramos, in central Mexico, is a syncretism between pre-Hispanic beliefs and Catholic religion, reflected both in the species used and in the associated symbolism. On the one hand, the plants used to make tivities , 24, 51 ramos, in the daily life of the sellers they have other uses. Their main use is as “protection,” a use in which pre-Hispanic beliefs are still preserved. For this reason, we kept “protection” and “blessing” as two distinct categories in the study. This belief in the protection conferred by the ramos preserves pre-Hispanic concepts and rituals, while their use in blessing corresponds to Western beliefs. The emic interpretation goes beyond the Catholic conception, thus rejecting our first working hypothesis.While the interviewees recognized the Catholic significance of the rozchodnik or goldmoss stonecrop (Sedum acre L.) concerns protection from thunder; these beliefs concerning the powers of this plant are common throughout Europe and can be traced to Roman times [Some research about the use of plants for religious festivities and their symbolic importance are also reported in Poland for Assumption Day (August 15). People make bouquets mainly of medicinal herbs on this festivity, which also have a protective and apotropaic use against evil influences. The bouquets are hung on walls, inside one’s house or on farming premises and are still used for smudging in protective magic against storms and thunder or may be laid under a deceased person’s head. In this research, an times .We could consider many species of plants as living examples of history that continues until our days because they retain symbolic, ritual and medicinal uses that are very difficult to separate from each other. They have probably overlapped on many occasions since antiquity .ramo as a protector of people or crops have been described as paganism. Thus, maintenance of these beliefs has been seen as an illegitimate form of faith: “lo verdaderamente importante es participar en la procesión y no simplemente procurarse una palma o ramo de olivo; que estos no se conserven como si fueran amuletos, con un fin curativo o para mantener alejados a los malos espíritus y evitar así, en las casas y los campos, los daños que causan, lo cual podría ser una forma de superstición”  [ramos have been interpreted as a link between popular religiosity, magic, and nature and have been described as “profane remedies” [Uses of the tition”) , 55. Simemedies” .ramo, referring to the rosemary, chamomile, laurel, and palm. These are used as spices or medicinal herbs. At the same time, in the study area, Guerrero [The term “reliquia” (“relic”) merits a special mention. Some interviewees recognize the “reliquia” as part of the Guerrero  reports Guerrero .Brahea dulcis palm, considered a “reliquia,” has a very important protective use. On the one hand, in funerary contexts, the deceased are protected with huaraches , crowns and crosses made of palm so that they can safely reach the afterlife. This is practiced among the Hñähñu, Nahuas and Ixcatecos in Hidalgo, Guerrero and Oaxaca [emic approximations, which result from the syncretic process, merit further study.d Oaxaca , 59–61. d Oaxaca ) and is d Oaxaca , 63. Theramo” are of European origin: chamomile (Chamaemelum nobile), rosemary , rue (Ruta graveolens) and olive (Olea europaea). The latter three have been documented in Spain in relation to Domingo de Ramos, where rosemary is venerated for its relationship with the story of the Virgin, rue is considered protective due to its powerful smell and the olive tree symbolizes peace [Brahea dulcis palm and the Mexican laurel (Litsea glaucescens)  is a symbol of victory and eternal life accordance to [The species identified as essential to make a “good es peace . These idance to , which rBrzoza or birch (Betula verrucosa Ehrh.), is believed to have healing and magical powers and is considered a lucky tree. Cis or yew (Taxus baccata L.), despite being a toxic plant, is used in ramos; likewise, sick cattle are incensed with it and it also protects persons from witches, misfortunes and all evil. Leszczyna or hazelnut (Corylus avellana L.) is considered magical and protective usages against lightning; crosses made with this plant are hung over doors and windows to prevent the access of an evil spirit. Jałowiec or juniper (Juniperus communis L.) is used in houses and livestock against witchcraft. Jemioła or mistletoe  once blessed, is believed to have power and strength against curses. Jodła or silver fir , although considered unlucky tree and not planted next to houses, is added to the blessed palm on Palm Sunday. Kłokoczka or bladdernut (Staphylea pinnata L.) is used to make ramos; local people also attributed great magical power to it. Kocanki or sandy everlasting (Helichrysum arenarium L.) is tied in ramos which protect against lightning when hung on the walls. Also, in Ukraine, other studies reported that Tagetes patula L. has a ritual use that is blessed on Assumption Day and Palm Sunday [Salix spp.) on Palm Sunday; it protects against evil and aids in beating out the devil [In Europe, many plants are used during Palm Sunday, which are blessed and have an apotropaic use. In Poland, Kujawska et al.  carried m Sunday , and brahe devil .Ramos were originally made with natural plant elements that can be returned to the soil and can easily be degraded. Since the price of natural flowers increases the purchase costs, cheaper artificial flowers are being used to replace them. This substitution leads to changes in significance, since each element of the ramo has a very deep symbolism, although some interviewees included artificial flowers as elements that cannot be missing in a “good ramo.” The use of plastic elements occurs in different religious festivals, where some authors state that this practice detracts from the purity and cultural value of the celebrations [brations , 68.ramos over time. In some European countries, it has been observed that one of the most important reasons for those changes on ramos for Assumption Day is the transformations of the vegetation and lifestyle in rural areas [ramo in central Mexico must be considered.An interesting aspect that needs to be addressed in future research is the changes in the composition and symbolism of the al areas . This kiramos and the economic income that this festivity provides for thousands of people, which is part of the biocultural heritage of these localities. The case of the Mesoamerican palm B. dulcis has played a particularly key role in religious celebrations, as exemplified by the ramos made with this species in Nahua communities of Guerrero [Palm leaves gathered from plantations are considered “eco-friendly” . In contGuerrero , 77, HñäGuerrero –36 and PGuerrero .ramos requires a new leaf with a non-extended (unopened) blade; this leaf is gathered without damaging the trunk or apical meristem of the plant [B. dulcis has the highest leaf production rate of the palms studied in America [Braheadulcis has a great potential for sustainable use because of the gathering strategy employed, and the high productivity and wide distribution of the species [The elaboration of he plant . One or  America  and the  species . Its rol species , 77.ramos represents an important monetary income for thousands of people. For all of the stated reasons, the use of natural populations of B. dulcis should be considered even more “eco-friendly” than that of palm leaves obtained from plantations.Similarly, the sale of Chamaedorea leaves in Mexico and Guatemala for exportation to the USA, generating fairer profits. This initiative has achieved a market of 300 million leaves/year [B. dulcis, which has a high potential for sustainable use, as described above.The University of Minnesota has a program called “Eco-palms,” directed toward the sustainable gathering of ves/year . It is iThis initiative involves the direct use of natural ecosystems, which is relevant to Latin America, where there is a lack of incentives that could be used to demonstrate the true value of nature and invite reflection, rethinking the manner in which conservation has been conceived to date. While observing landscapes that have been plundered and eroded by large-scale mining, agricultural and forestry industries, one cannot continue to conceive that the best form of sustainable use is not to use nature , or thatSabal and B. dulcis requires the development of a management plan. According to the interviewees, the reason for regulating use is unknown, since it is not a terminal use, or many people are actually unaware of the need for permits for its use.However, Mexican laurel is a threatened species according to NOM-059-SEMARNAT-2010 , and thuB. dulcis and S. mexicana in our study area, some of the interviewees chose to buy the palm in big markets, mainly in Mexico City, either because they are unaware that there is palm in Hidalgo or because they mistakenly believe that it can be obtained at a better price.According to the productive chain and gathering plots for the celebration of Domingo de Ramos, our second hypothesis is rejected. Despite the fact that there are natural populations of ramos sellers buying the leaves and weaving them. The second most frequent strategy is gatherers weaving and selling the ramos. In contrast, in Bolivia, Miguez et al. [ramos.The obtaining chain of the palm is long and includes intermediaries. The most frequent method includes the z et al.  found thramo palms is an occasional and often an annual activity, so the commercial processes can be flexible. For B. dulcis, the leaf demand volumes are three orders of magnitude higher for the hat industry in Guerrero than for ramos in Hidalgo , the lack of space to talk or even self-doubt, due to which they believed that the questions would be difficult to answer. Given this situation, there is the possibility that the most compromising questions, such as those related to economic income, could have been underestimated. Furthermore, one of the limitations was the number of individuals interviewed for the municipalities studied . Another limitation is that the regional scale might not produce sufficient qualitative information on the emic perspective of ramos. However, the Free List method seems to be a suitable tool for a first approximation since, with the Smith Index, the most frequently cited uses, and those mentioned first, tend to indicate what is uppermost in people's minds and most significant in their lives [ramos and thus allow this tradition to continue to the present day. However, additional efforts and future studies are needed to document the knowledge of the ramos in more states or countries. For example: comparative studies with historical data that allow an approximation on the modification of traditional knowledge on the use of ramos’ plants; investigations that deeply address the symbolism of plant use, which let us to understand the role plants play not only in religious life but also in shaping identity; commercial aspects for NTFP that rarely addressed in research. These efforts could elucidate a more comprehensive understanding of the biological, social and economic elements, from a comparative perspective.In this study, the ir lives . In thisramos and its elements on a regional scale. While the ramos represent religious meaning, the principal current uses given to the ramos are protection followed by religious. However, it also has uses related to pre-Hispanic beliefs, such as the protection and the usage of some of its elements as medicine. In the same way, the ramos elaboration represents a family tradition and a source of extra income for sellers; the main use of the ramos is still protection and religious, but contemporary economic, social and cultural aspects are now also part of their value.This research highlights, from an emic perspective, the contemporary complexity of the cultural significance of the Other festivities, overlooked because of their regularity, may in fact have a considerable cultural, biological and economic importance that should also be addressed at different spatial and temporal scales.Additional file 1. The initial interview which was conducted during the week prior to Domingo de Ramos. The interview has 27 questions and was structured 1) for data on the origin and costs of the palms; and 2) if the person collected the palm leaves, detailed questions were asked about the gathering and whether palm weaving is a tradition or if it is practiced solely as a means of generating income.Additional file 2. Interview format which was conducted on Domingo de Ramos. The interview has 65 questions and was structured around: 1) the sociodemographic data of the interviewees; 2) the ramos themselves; and 3) the palms.Additional file 3. Database with information for each ramo: name of the handcrafter, place where the ramo was purchased, its sale price, among others.Additional file 4. Ethnobotanical Collection of ramos, Laboratory of Ethnobiology on Universidad Autónoma del Estado de Hidalgo.


Fracture-related infection is a devastating complication confronting the patient with several challenges. To improve the management and to enhance the patients’ wellbeing the focus of this study was to understand the emotional impact and patients’ experiences during the process to identify challenges, difficulties, and resources. For this, a qualitative content analysis of semi-structured interviews according to Graneheim and Lundman was performed.n = 20 patients of a German university orthopedic trauma centre specialized in bone and joint infections were recruited using a purposive sampling strategy. The patients were treated at the hospital between 2019 and 2021 and underwent at least one surgery. Individual in-person interviews were performed by one researcher based on a semi-structured guide, which was previously conceptualized. Content analysis according to Graneheim and Lundman was performed on the transcripts by two of the researchers independently.In total The following major themes emerged: (i) the emotional and mental aspects highlighting the fact that FRI patients faced severe restrictions in their day-to-day life, which resulted in dependency on others and frustration, as well as future concerns showing that patients could not overcome a state of anxiety and fear even after successful treatment, (ii) socioeconomic consequences confronting patients with consequences on the job and in finances where they often feel helpless, and (iii) resources emphasizing the role of spirituality as a coping strategy and yoga exercises for keeping the positivity.This study emphasized the challenge of fracture-related infection management and associated consequences from the patients’ perspective. Not being well informed about possible negative outcomes or restrictions makes it harder for patients to accept the situation and patients expressed a need for better information and certainty. Also, patients developed constant anxiety and other psychological disturbances, highlighting the potential benefit of psychological support and patient-peer support to exchange experiences. In trauma surgery, reduction and internal fixation are applied to restore skeletal integrity. The use of an intramedullary ivory peg for the treatment of complicated fractures to restore skeletal integrity was reported as early as 1886 . Since tIn light of increasing numbers of fractures, especially in older adults incidence of fracture-related infections (FRI) can be expected to rise as well . The manHowever, success in the treatment of FRIs is mainly determined by infection eradication and there are very few data in the literature focusing on patient-reported outcomes. Some studies provided insights in the detrimental effect on patients’ quality of life . For insHowever, hitherto the experience of undergoing management for an FRI has not been elucidated yet from the patients’ perspective. Therefore, to improve the management and to enhance the patients’ wellbeing the focus of this study was to understand the emotional impact and patients’ experiences during the process to identify challenges, difficulties, and resources. For this, a qualitative content analysis of semi-structured interviews according to Graneheim and Lundman was performed.The study population was identified using a purposive sampling strategy . Patientn = 31 patients were approached, whereby = 7 were not reachable and n = 4 declined their participation. Informed consent was obtained from all participants prior to the interviews. The study was approved by the institutional ethics committee of the University Hospital Regensburg according to the Helsinki Convention (file number 21–2464-101).Participants were approached by telephone and asked for their study participation after explaining the background and the purpose of the interviews. In total A semi-structured interview guide was conceptualized by the authors and pilot tested. In-depth qualitative research interviews were conducted in person between March 2021 and October 2021 by an independent female researcher with a background in psychosomatic medicine in an undisturbed office room. The interviewer was occupied at the same clinic, however, no relationship with the participant was established prior to the study commencement. Interviews lasted between 28:56 and 46:22 min. No repeat interviews were carried out and no field notes were made during the interview. The following areas were covered in the interviews: experiences of the time in the hospital, challenges, and resources during FRI management as well as emotional impact and socioeconomic consequences. No participant dropped out.In total, 20 patients were willing to participate, at which point data saturation was reached based on data replication or recurrence in the content . All intData were analyzed with content analysis. During the process, “Meaning units” were extracted from the transcripts, and condensed, i.e., shortening the text while preserving the essential part. Next, an abstraction was performed, meaning that the condensed units were labeled with a code by two of the researchers independently. After grouping the codes, data were categorized in themes as described previously . FinallyIn total 20 participants were interviewed .As an overarching category “the burden of FRI” was identified with the subthemes describing the challenges of the treatment in detail differentiated into „the emotional, mental and social aspects,” “socioeconomic consequences” and “resources” . PatientThe interviewed FRI patients still expressed anxiety and fears even after a successful surgery. „I have been afraid of every surgery” -P1. “So yes, I was afraid at the beginning that it would no longer close and that I would need such a skin transplant” -P2. The fear sometimes manifested although healing was adequate and there was no need for a renewed hospital visit. “I do not have blood drawn and I do not have an injection in my right arm. There is already something in the back of my head” -P1. This constant fear turned out to be very emotionally draining for patients. “Honestly, I felt very weak and somehow broken” -P2. While challenged by fear patients also reported physical pain during and after recovery. “I have had a lot of pain for a long time. Until the first of February, I had to take oxycodone, but it was not that I think about suicide”-P4. “There is always a dull pain, even if I do not move. Sometimes the two fractures rub against each other, and it goes clack clack and there is pain for seconds and it goes through the whole body. I feel it exactly at the fracture site when it will rain, and I also try to avoid painkillers.”- P15. In this stance, also side effects of antibiotic therapy were mentioned as a factor contributing to the suffering. In total, 18 out of 20 patients (90%) reported that they have struggled with massive intestinal problems. “I had severe pain. I took penicillin for 6 weeks, which I do not tolerate by nature, it was insane, the itching no one can imagine. The pain was terrible, my life was no longer worth living.”-P9. “What particularly affected me were the antibiotics. I was constantly nauseous and that has burdened me additionally. I had intense intestinal problems, six weeks of diarrhea and I could not eat anything”- P15. Many patients also mentioned having problems sleeping which added to the mental burden. “At the beginning I could not sleep so well because I was afraid that there was something there again or something like that”- P2. “Already extreme pain, I should try it, if possible, without opiates, because I have lost so much blood. I tried only with ibuprofen, but sleep was almost impossible, only half an hour, so hardly any sleep.”- P20.Due to prolonged recovery, daily activities were restricted, and patients had to become dependent. “It was challenging when you can no longer do anything for yourself. Eating, washing, toileting, was terrible at first, but you grow into the situation, not overnight and you are grateful that someone is there for you and try to do as much as you can yourself.”- P14. This dependency was not easy to accept for most of the patients. “You feel like a 2nd class human being that you are no longer a full-fledged person.”-P15. “This has pulled me down brutally in the first moment because I had to start again from the beginning.”- P19. They had to accept that this situation does not only affect them but also their families and caregivers. “My family was hit very hard, because I could not do anything more”- P9. “A lot has changed for my daughter. My daughter had to drive me to every doctor’s appointment, she had to do the shopping and the cooking.”- P7. “I have a girlfriend and a child, and you want to do your job well and sometimes feel useless; already a burden to cope with it. I already reached the point where I no longer could handle it. At night-time I had so much pain that the next day was unbearable, it affected my mental state.”- P20. Additionally, almost all the patients interviewed expressed concerns for their future no matter how good or bad their recovery went. Main concern was the reappearance of an infection. “Yes, you often think that something could come again”- P7. “But the problem was still predominant and at times I just again had that fear. Hopefully there will not be any germs again”- P19. Also concerns about how life will change from now on were expressed. “Mentally I just once had a sag where it was said that they do not know if they can maintain my shoulder”-P5. “Psychologically, I was only burdened by the fact that I did not know how my career would continue.”- P20.Further, during the interview some patients had a bigger loss of their formal social lives than others, but there were big changes throughout. “I lost my job. My husband is gone. Family life is destroyed. My children are now with my former husband.”- P19. A main change for patients was the current job situation. “So I was suspended and then I was unemployed. Since then, I had problems with finding a job. Let us put it this way because I still have these restrictions.”-P2. “Work was not so good and had to change the job because of it. It is now also not quite optimal and hope for another job with the same employer”- P20. While having a long recovery or restrictions maintaining a job is not easy and thus, financial problems many patients faced also create a negative impact on them. “But otherwise, financially it had a certain effect, because the salary is simply not as high as if I were working full time. I would say 20 percent less”-P3. Many patients also had to rely on social services or family members for finances which also had a negative effect on their mental health. “They have given me disability from the agricultural pension. I am entitled to 375 Euros, because I have not yet paid more. But they deduct 300 Euros monthly contributions. If this continues, I will not financially recover from it starting in June.”-P4.While interviewing patients and hearing about the difficulties the patients experienced it became clear that for some spirituality and religion were a positive coping strategy and resource. “Certain trust in God really helped me”-P1. “But in the meantime, it is definitely a hard situation and I think to myself that he still has something planned for me, the good Lord.”- P19. “I am catholic, but I am not into that, but still I prayed before the operation” -P15. “I have been doing yoga since I was 20 years old, this helped me a lot; meditation and positive thoughts” -P10. “I tried to keep my mental health positive, my physiotherapist helped me, I did some yoga to calm myself.” -P17.In this study, FRI patients’ personal experiences and challenges were identified using a qualitative approach. Similar studies were carried out showing the negative impact on patients with a PJI . This stDue to not being able to know for certain if there is going to be a relapse of the infection patients expressed anxiety and fear. Restrictions in their mobility affected them physically and psychologically. Having to rely on family members also made changes in their social dynamics. With all these challenges patients got frustrated with many having depressive thoughts. Such mental health sequela are not uncommon after injuries and complications, which are associated with a high level of psychological distress . For insDue to the frustration, some patients seemed to show insufficient compliance regarding the treatment. Also, in the field of PJI it was reported that non-compliance often resulted from the fact that patients were not aware of the severity of the infectious complication and thus, did not expect a long-time course of treatment . To addrp < 0.001)  . This as< 0.001) .Some patients reported that spirituality was a positive resource on their way to recovery. Spiritual beliefs are an essential factor for enhancing mental health, easing up depression and anxiety, as well as providing meaning and purpose, especially during times of suffering . It has A limitation of this study is that only the experiences of FRI patients in one clinic, specialized in bone and joint infection were captured. Thus, the generalizability of the results may be limited, and findings may slightly differ when transferred to centres with less expertise in the management of FRI as well as to the healthcare in other countries. In addition, the time of the interviews was relatively short (30 to 46 min). However, at the end each participant was asked whether there is anything else they would to add, or anything they wish to talk about that we have not covered already, which was denied by all participants.The findings of this study highlight the patients’ need for psychological support and advocate for integrating psychological interventions into clinical practice. Here, a wide range of interventions is possible including for instance relaxation, cognitive behavioral therapy, hypnosis, guided imagery, or emotional counseling. However, it has to be noticed, that such an approach is still in its infancy and a gap in the literature exists, also when it comes to primary arthroplasty without the development of an infection . TherefoIn conclusion, this study underlines the negative impact of FRI on the emotional and mental levels experienced from the patients’ perspective highlighting their personal challenges as well as resources during the recovery process. Not being well informed about possible negative outcomes or restrictions makes it harder for patients to accept the situation and patients expressed a need for better information and certainty. Acknowledging these aspects could improve clinician-patient communication and multiple understanding. Further, patients developed constant anxiety and other psychological disturbances. This finding indicates the potential of integrating psychological services as well as adjunct mind–body therapies in the treatment of FRI. Whereas multidisciplinary approaches are warranted and recommended in the literature, opportunities to enhance not only patients’ somatic but also their mental state are still underestimated.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the institutional ethics committee of the University Hospital Regensburg (file number 21-2464-101). The patients/participants provided their written informed consent to participate in this study.BW, MR, VA, and NW conceptualized the work. BW and NW acquired the data. NW, BW, and MR analysed the data. BW, MR, VA, and NW interpreted the data. BW and NW drafted the manuscript. BW, MR, VA, and NW revised it critically for important intellectual content and approved the version to be published. All authors contributed to the article and approved the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


After the outbreak of the COVID-19 pandemic, employees in Europe increasingly worked from home. In the German public sector, many employees experienced working from home for the first time. Concurrently, employees could use job crafting activities to alter job demands and resources while working from home. This exploratory case study aims to shed light on how public service employees craft their job demands and job resources, and how they perceive job satisfaction and productivity while working from home during the COVID-19 pandemic. A novel theoretical approach is applied to explore crafting activities that target specific job demands and resources when working from home, using a combined framework of resource-based job crafting based on the Job Demands–Resources model and time-spatial job crafting.Qualitative telephone interviews were conducted with employees from different public sectors in Germany between December 2021 and February 2022. According to the COREQ guidelines, the 12 semi-structured interviews were audio-recorded, transcribed verbatim, and content-analyzed using MAXQDA.The results suggest that employees, who were new to working from home, developed personal crafting strategies for their flexible work environment. These strategies supported them in coping with hindering job demands  by optimizing their working conditions. Additionally, employees used strategies to increase their social resources  and structural resources . The use of given job resources and optimization of job demands are closely linked to the time-spatial demands fit. Thereby, the time-spatial demands fit is used to combine workplaces, work hours, or work tasks with the provided resources and demands to achieve an optimal work environment, which also facilitates employees' productivity and satisfaction.The results enrich the resource-based and time-spatial demand job crafting research by adding specific job crafting strategies utilized by public service employees. Furthermore, the results highlight job crafting strategies for enhancing job satisfaction and productivity when working from home in the post-pandemic world, thus offering valuable insights for researchers and practitioners. The COVID-19 pandemic has accelerated the transformation of work processes to a working-from-home environment in Europe  conducted qualitative interviews with the participants. All of them possessed a master's degree and had experience with qualitative data collection. Since all of the public service employees had participated in two online surveys before the qualitative data collection, they already knew about the study and showed an ongoing commitment. The three researchers communicated with the participants via email regarding the details of the scheduled interview. The telephone interview was the first interactional contact between the interviewees and the research team. In accordance with German data protection laws, written consent was obtained from each participant before the telephone call. The participants provided their signed consent forms via email. Due to COVID-19-related social restrictions, interviews were carried out over the telephone from December 2021 to February 2022. Before the telephone interview started, the interviewer briefly introduced herself and the aims of the study and its confidentiality. Participants were asked if they had any remaining questions and still wanted to participate in the interviews. After they repeated their consent, the audio recording started. During the interview, only the research team was present. The semi-structured guideline was handled as a flexible framework, where the interview questions ensured that the main research topics were included in the discourse and guaranteed a certain comparability between the 12 interviews Patton, . NeverthA total of 12 employees in the public service sector from different agencies in Germany were interviewed, with a mean age of 54.3 years (range: 29–62 years) and 33% of them being women. Their work experience in the current agency varied from 1 to 36 years, with a mean of 14.8 years. Before the COVID-19 pandemic, only a minority of participants (33.3%) had experience working from home. On average, they worked from home for 2.25 days during the time of data collection, whereas five participants worked from home every workday. It is worth noting that all participants reported having a designated workspace when working from home. Seven (58.3%) of the 12 participants held leadership positions. The audio-taped files were transcribed verbatim following the rules by Dresing and Pehl  and pseuAn overview of the categories and sub-categories is provided in For the category “increasing challenging job demands”, the results suggested job enrichment of facility managers. These results were interesting because due to the COVID-19 pandemic, this group stayed on-site and received more responsibility and an upgrading of their job. Nevertheless, we excluded these results from the study, since it was not an active job crafting strategy implemented by the employees. Rather, this was imposed on them by the circumstances of the pandemic.Concerning the demands that were reported by employees, there were no employees who strived to increase challenging job demands. Employees' experiences rather pointed in the opposite direction. Thus, the sub-category was rephrased to “no wish for increasing challenging job demands”. One employee stated:I am already working to capacity. So, I don't have to look for work or something like that.” (interview 2)“put up with that” (interview 5). Regarding interruptions by others, one of the employees suggested, when being interrupted at work:On the contrary, many categories explain how employees decreased hindering job demands such as decreasing time pressuring work load (interview 6) and decreasing distractions at the office . There were also employees, who saw no need for decreasing distractions  and were willing to “It would be better to say, ‘Please make an appointment', but (laughs), yes, and that means I'm much more disturbed in my work processes.” (interview 3)“The above suggestion is closely linked to decreasing the work-related availability which can be seen as a job demand. The participant also achieved to optimize this demand by scheduling video conferences (interview 3). Another crafting strategy targeting work-related availability entailed withdrawing from communication channels from time to time:So, yes, there are different strategies, well um, if you're constantly online and constantly responding to your e-mails, you don't really get to work. You just have to find ways for yourself, maybe to structure it a bit.” (interview 1)“One interviewee reported that he consciously selected time slots on the weekend for tending to his tasks because at this time point, hindering technical demands were lower:That also happened to me once or twice—I don't want to say happened. That was a conscious decision, because it was simply easier for me to watch an import on Saturday, because if it had broken off, I would have had a lot more work on Monday than if I had intervened at the moment when it happened. In principle, I made it easier for myself at the beginning by switching on briefly. But that rarely happens.” (interview 6)“From the employees' perspective, there was an emphasis on the increase of social job resources by enhancing the opportunities for social exchange, e.g., by increasing communication channels (interview 12) and initiating social exchange at the office or digital social exchange from home.At the office, an open door can invite people to knock and come in (interview 3) and social interaction can be initiated by seeking out gathering places:There you just go to the coffee room, or you go to your colleagues, who you now unfortunately only get into the house by phone or e-mail or chat or video conference, you used to very often say ‘I'll just go to my colleagues around the corner or one floor higher'.” (interview 6)“we quickly came back to the office voluntarily for certain things, simply to see the colleagues.” (interview 8).This is why one interviewee stated “much harder than walking the three steps” (interview 8) to the next office. Additionally, employees initiated digital coffee breaks, where everybody was invited to participate voluntarily and private talks could take place (interview 11).When working from home, other measures have to be taken to start a social exchange, and making a phone call was perceived “According to one interviewee, while working from home, they implemented a practice of seeking assistance from colleagues on-site, who could forward documents via email (interview 8). Another strategy was to actively seek a conversation with the supervisor to negotiate their interests. One employee stated:That's what I've learned over the course of time: Formulating my interests and then putting them forward, and then it works out well, yes.” (interview 1)“There were also strategies reported that employees used to increase structural resources. These entailed the planning of office or working-from-home days, while, e.g., taking work documents home (interview 8) or deciding to go to the office to use the printer:So, when I see that there are larger documents that I just don't want to work on, then I go to the office and then I stay there and then I print them out, among other things, and then I also stay in the office for the day.” (interview 5)“Increasing structural resources also meant getting the right work equipment  or a separate room for working from home (interview 11).Employees were able to increase their resources through self-initiated skill development, e.g., by learning the software applications needed for extensive remote work (interview 7), using literature for guidance (interview 11), and learning to structure a working-from-home day:I used to say, 'I'm not the kind of person who can do that, I need an orderly framework, I need the way to work so that I can say, 'Now I'm here, now I'm working, and when I close up here, I'll be gone again.' In this respect, it was a learning process for me to actually be able to structure myself.” (interview 8)“Concerning the reflection of employees regarding their choice of workplace, working hours, and work tasks, the category “reflection” comprised the following sub-categories: “More scheduled meetings when WFH” (working from home), “different day structure when WFH”, “different relationships at the office”, “productivity/concentration when WFH”, “preparation/daily schedule”, “barriers to leadership tasks when WFH”, and “advantages WFH”.First, scheduling appointments in the digital work environment seemed easier but more time-consuming (interview 9). Second, working from home allows for a different day structure. Thus, one employee stated:I have a bit of a stomachache when I think about the possibility of having to work four days a week on site again, because that would mean a complete restructuring of everyday life for us or for me as an employee. And that goes hand in hand with a different work-life balance.” (interview 9)“Additionally, employees reflected on the different relationships with colleagues at the office:Of course, it's not the same as when I come into the office in the morning and greet my colleagues in person and you may run into each other and use this opportunity to talk about something on the fly.” (interview 10)“Social exchange and interaction were different when they were able to meet in person. There was more engagement in small talk (interview 9) and more information passed on (interview 3). Simultaneously, the decreased chance for conversation led to fewer disruptions and a higher productivity or concentration on tasks , especially, leading to distance imposed challenges as one of the supervisors recalled, when two employees bullied each other:If I had been on the spot, I could have intervened and said ‘Stop, that's not your job'. (...) Since I was not there, I did not know what they were doing.” (interview 2)“From the employees' perspective, the advantages of working from home were contemplated, when choosing one work form over the other:And what I really like about working from home actually now, especially in winter, in the gray season, is the flexibility, that commuting is eliminated or at least partially eliminated. Thus, I can react more flexibly at the point. If it rains, I don't have to get on my bike and go to the office, but I can work from home.” (interview 8)“because it was always something on the way to work, that you could concentrate a bit on the work already, so that you have mentally processed or prepared for it a little bit” (interview 2). Instead, she used the time walking the dog in the morning for her mental preparation for work. Other aspects that were reflected were environmental factors (interview 7), money-saving (interview 1), and others such as the freedom of clothing (interview 5). The closeness to the familiar environment also played a role:The omission of commuting (interview 5) and saving commute time (interview 11) were considered reasons for working from home, whereas one of the employees missed this time “I experienced a great personal advantage, since during this Corona period I was able to watch my grandson grow up close to me. (...) We saw each other almost every day.” (interview 1)“When it comes to the selection process of employees, they needed to decide on the tasks that were to be done and selected either tasks done working from home or tasks done in the office:There are a few tasks that you can only do in the office. For example, signing off on invoices and the like, which we don't do electronically yet.” (interview 5)“use an app to book a workstation for the days” (interview 4) on which he wants to work from the office because alternating workstations were implemented. The selection of the specific work location also depended on the right equipment:One employee reported that he has to “And for me personally, I used the working from home option only very sporadically at the beginning, on one or two days a week, because it was simply a matter of using a private computer at home, sitting at the kitchen table, and all the problems that I'm sure you're familiar with and that a lot of people encountered, until the technical equipment was ready. That was the crucial point, does the equipment fit.” (interview 8)“logged off for an hour, then at 4 o'clock (..) simply resumed duty for an hour or an hour and a half” (interview 1).Employees enjoyed the flexibility of selecting working hours (interview 10). They may have “In terms of adaption, most interruptions of prior planned working processes were named:I'm much more disturbed when I work at the office, right? I also make my daily schedule, but then I can't keep to it in part because I'm disturbed.” (interview 3)“Additionally, getting used to continuous work–life blurring was mentioned as a form of adaption (interview 1).In this section, the experiences of employees regarding the possible outcomes of working from home will be presented. As employees might have decided to work from home as part of the selection process and applied job crafting strategies, these are possible outcomes related to those choices. We already discussed potential health effects related to job demands and job resources  and joy regarding work tasks or field of work (interview 1) as reasons. Especially, the experienced advantages of working from home were reported as factors for satisfaction. One supervisor mentioned the reaction of his employees as working from home was allowed:They're happy, they're so fully motivated, and those are also the cases, for example, where the work results, productivity and also the motivation have naturally shot through the roof.” (interview 7)“The work autonomy linked to working from home is also reported by employees:So, the flexibility is fantastic for me.” (interview 11)“This relatively high degree of autonomy, I like that. And, um, I think that's also the most important point that I would say contributes to my satisfaction.” (interview 1)“Factors regarding their dissatisfaction can be tied to the causes of the social distancing measures during the COVID-19 pandemic. Mostly, the lack of social exchange was reported:Yes, one thing that I like about my work, but which is actually very limited now due to the pandemic, is the personal contact with colleagues in the various federal states. Or even internationally, because all of these face-to-face meetings have actually all been virtual conferences in the last two years. That is something that really makes up a large part of the attractiveness of the work, which has been lost as a result. That has to be said quite clearly, yes.” (interview 10)“Another aspect that derived from the situation during COVID-19 measures was the change or omission of work tasks. Thus, employees were dissatisfied that certain components of their tasks such as traveling could not take place:And on top of that, I also have to take care of certain administrative tasks in our team in connection with certain IT issues, and I'm not particularly happy about that. But that only has a limited connection with working from home. It's simply a shift of work tasks due to Corona, yes, where you then have no reason to postpone such things, because you don't have to go on an important business trip as an alternative, do you?” (interview 5)“Finally, the lack of appreciation by supervisors was reported as a dissatisfying factor (interview 8).Employees reported that they were more productive from their point of view when they worked from home. This perception was due to various reasons. First, they could better focus on tasks and concentrate on their work (interview 11). This was due to eliminated interruptions or distractions by colleagues (interview 9), as one employee stated:I might have fewer disruptions there than in the office, especially when the office is busy again, and I can actually follow my own rhythm then.” (interview 10)“Following their own rhythm led to better energy management. Therefore, one interviewee said:Because I simply do some exercise at lunchtime and I somehow have the feeling that after lunch or after a lunch break, my brain switches off automatically, which is a bit of an exaggeration, but when I work from home I really start somehow fresher into the second half of the work day after lunch break.” (interview 9)“converted into office work” and more tasks. Hence, he asked himself if he “was always necessarily more effective” (interview 8).Another aspect was that some work tasks were simply eliminated because of the digital work environment. Thus, employees saved travel time or preparation time for meetings, where the room previously needed to be prepared or coffee needed to be made for colleagues (interview 6). One of the interviewees also stated that he has worked more since the saved commute time was “The digital communication also allowed for more increased communication on interim results, which may have prevented working for nothing, because errors in work processes could have been detected earlier:Then we might have another meeting in the middle of the day or at the end of the day, where we say ‘This is the work progress now. Does this fit into the management concept?' and if it doesn't fit or if it fits, then it's good, then (...) efficiency increases and if it doesn't fit, efficiency also increases, because the misguided development hasn't continued over 14 days.” (interview 12)“This study contributes to the growing body of literature about the effects of working from home in Europe. First, the results provide insights into actual job crafting strategies that public service employees used 1 year and a half after the breakout of the COVID-19 pandemic. Second, it discusses how employees combine job crafting strategies to cope with job demands and increase resources. Third, our study attempted an integrative view of resource-based job crafting, optimizing demands, and time-spatial demands fit, and the theoretical relations will be discussed. Finally, possible impacts of crafting strategies and working-from-home conditions are reported from employees' point of view. In the following, the research questions are answered.1. How do public service employees craft their job demands and job resources when working from home?The results indicate that public service employees craft their job demands and job resources when working from home corresponding to the resource-based job crafting theory by Tims and Bakker  and TimsThe fact that employees shied away from seeking challenging demands could also be explained by the uncertainty of the work situation during the COVID-19 pandemic and the increased job demands placed on employees, e.g., through the extensive use of technology and digital communication channels  for the publication of any potentially identifiable images or data included in this article.LS and KS contributed to the conception and design of the study and performed the content analysis. LS, KS, and JN administered the project and carried out the investigation. LS wrote the first draft of the manuscript and prepared the visualization. HP supervised the project. All authors contributed to the manuscript revision, read, and approved the submitted version.