The COVID-19 pandemic continues to cause a collapse in the health systems and econo-mies of many countries around the world, after 2 years of struggle and with the number of cases still growing exponentially. Health communication has become as essential and necessary for control of the pandemic as epidemiology. This bibliometric analysis identifies existing contributions, jointly studying health communication and the pandemic in scientific journals indexed. A systematic search of the Web of Science was performed, using keywords related to COVID-19 and health communication. Data extracted included the type of study, journal, number of citations, number of authors, country of publication, and study content. As the number of scientific investigations has grown, it is necessary to delve into the areas in which the most impactful publications have been generated. The results show that the scientific community has been quick to react by generating an extraordinary volume of publications. This review provides a comprehensive mapping of contributions to date, showing how research approaches have evolved in parallel with the pandemic. In 2020, concepts related to mental health, mass communication, misinformation and communication risk were more used. In 2021, vaccination, infodemic, risk perception, social distancing and telemedicine were the most prevalent keywords. By highlighting the main topics, authors, manuscripts and journals since the origin of COVID-19, the authors hope to disseminate information that can help researchers to identify subsisting knowledge gaps and a number of future research opportunities. Almost 2 years after the onset of the COVID-19 pandemic, the whole world is experiencing uncertainty. The current crisis caused by COVID-19 is taking place in a context that is unprecedented for society. In this globalised world, the transit of people between countries, the development and use of Information and Communication Technologies (ICT) ,4,5 and Thus, the World Health Organisation (WHO)  has highHealth communication is a field of research that emerged in the 1980s and focuses on the influence of communication on health-related aspects of a given population ,12. Its Effective communication in times of pandemic means that all messages should be shared with stakeholders in an open and transparent communication process. The main objective of this process is to rectify possible divergences between the information generated by those who create the information and those who receive it. In this way, public behaviour can be adjusted to proactively address risk ,15. But Health communication plays an important role in the society . The abiAccording to Newman , the anaAlthough there are many recognised databases, currently the two main databases of bibliographic references and citations of academic publications in the world are WoS and Scopus. The former is owned by Clarivate Analytics and the latter by Elsevier. The publications collected in both databases are of scientific content relevant to research in universities, hospitals and health research services, public and private research organisations, technology centres, science parks, etc.This research focuses on the analysis of the scientific production of all the publications indexed in the categories outlined above and centred on the keywords ‘coronavirus’, ‘COVID-19’ and ‘health communication’.To find out the volume of articles published on COVID-19 and health communication indexed in the WOS database during the pandemic.To identify the main countries, universities, authors and scientific journals publishing research on health communication during this period.To detect the most relevant approaches, methods and lines of research on COVID-19 and health communication.To visually represent the degree of international scientific collaboration and thus serve as a starting point for future research in the area.This study pursues the following objectives:For the bibliometric study, the Web of Science (WoS) database was used as a first source of information, from which scientific articles were selected in journals indexed in the categories of Social Sciences Citation Index (SSCI) and Science Citation Index Expanded (SCI-Expanded) that in the period 2020–2021 have dealt with the subject related to: COVID-19 or coronavirus and ‘health communication’. We also obtained manuscripts that referred to the terms COVID-19 or coronavirus and also to COVID-19 or coronavirus by adding the term ‘health’. These two searches have often served to focus the study.The inclusion and selection criteria, as well as the indices that were applied in the process of searching for publications in WoS, are summarised in The methodological design as well as the resources employed are based on the systematic review of the scientific literature on bibliometric analysis, as well as the scientometric and visual tools and indicators developed by Chen . In turn(1)Unit of analysis: Authors, Academic Journals, Organizations, Countries/Regions;(2)Type of network: Citation analysis;(3)Cluster network design: Network visualization and density visualization.Based on the results obtained in WoS, VOSviewer and CitNetExplorer software were used for the analysis of scientific production. The first tool was used to study bibliometric performance indicators and identify citation patterns . Configuration of the VOSviewer analysis  was as fTherefore, bibliometric networks are analysed to extract information about co-authorship, co-citation, citation networks and keyword co-occurrence in scientific publications ,30. CitNAccording to the scientific cartography obtained and the scientometric indicators calculated with the computational analysis of the data, the results shown in this section are obtained.After the first search , more thOn the citation report under study , a totalAs a starting point, the main journals that have published manuscripts on the subject of coronavirus and health were analysed. The International Journal of Environmental Research and Public Health ranks first with 4.84% of the total .Researchers from all over the world in the field of health have chosen these journals which, as can be seen in This ranking of the journals with the highest number of published articles has as common characteristics in that they are open access and dedicated to publishing high-quality research in the areas of science or social sciences. Moreover, they are online publications, which means that their papers can be published, read and analysed quickly by the scientific community.At this time of pandemic where the coronavirus has required the efforts of all researchers in the world to understand its implications in record time in order to safeguard the health of the world’s citizens, it is essential to have journals that are rigorous in their peer reviews but also very agile in their publication.In the case of the search on COVID-19 and health communication, the ranking of the 20 journals with the highest number of contributions on this topic is as shown in The inclusion of communication aspects shows that many of the journals, especially the Journal of Health Communication and Health Communication, are indexed in JCR Social Science . RelatedThe analysis of authors made it possible to identify the most prolific publications in terms of scientific diffusion. Based on the volume of publications in which the concept of ‘Health Communication’ accompanies the concept of COVID-19 or coronavirus, the authors listed in In the studies by country, the USA stands out, doubling its publications with respect to the rest of the countries and regions of the world, followed by China.In this analysis, a study has been carried out for each of the variables. Thus, firstly, the ranking of the 25 countries that have published the most on COVID-19 is shown . The USAIt can be seen that countries with a strong pressure of coronavirus in their territories, researchers have carried out a very important scientific production.The European Union has been one of the most affected by the different waves of contagion and has defined some common strategies to face the pandemic, such as vaccines or the COVID-19 passport. Although it is understood that the best way to see scientific production is broken down, if all the scientific production of the European Union were to be combined, the number of publications would amount to 10,081 manuscripts, placing it in first place. It should be noted that since Brexit, the United Kingdom is no longer counted within the European Union. In the case of the United Kingdom, WoS breaks down the data into England with 3270 and Scotland with 444 papers.Focusing again on the object of study for COVID-19 and Health Commnication, The Top 10 entities that have financially supported the most research for the publication of articles have been, in order from the highest number of funded registrations to the lowest: National Institutes of Health Nih USA; United States Department of Health Human Services; European Commission; National Science Foundation Nsf; Google Incorporated; Grants in Aid for Scientific Research Kakenhi; Japan Society for the Promotion of Science; Ministry of Education, Culture, Sports, Science and Technology Japan Mext; National Natural Science Foundation of China Nsfc; Swiss National Science Foundation Snsf.From the five general thematic areas in which the different manuscripts registered in WoS are classified , other thematic subcategories are derived.The main areas of research are reflected in In the articles selected after searching for articles in which ‘Health Communication’ appeared next to the concept COVID-19 or Coronavirus’, the 10 research areas in which the highest number is assigned are: ‘Public Environmental Occupational Health’ ; ‘Communication’ (28.57%); ‘Health Policy Services’ (15.41%); ‘Health Care Sciences Services’ (13.91%); ‘Information Science Library Science’ (12.78%); ‘Environmental Sciences’ (8.65%); ‘Medical Informatics’ (7.90%); ‘Medicine General Internal’ (4.14%); ‘Psychology Multidisciplinary’ (3.76%); ‘Multidisciplinary Sciences (3.39%) .Comparing the data of the two cartographic maps  and  , it can The most frequently repeated words in the analysed articles are represented visually. The graphs displayed after the analysis carried out with the VOSViewer tool also provide information on the terms that form fields or clusters of words that appear related in the same publication.With a minimum number of occurrences of a keyword of one, following the same methodological process, from the most general to the most specific analysis, the map of co-words has been determined after searching in WoS for the terms COVID-19 or coronavirus. Thus, Cluster 1, with the word ‘covid’ heading this group, which shares a core with terms such as ‘pandemic’, ‘telemedicine’, ‘social distancy’ or ‘resilience’;Cluster 8, with the term ‘sars coronavirus’ as predominant, together with ‘diagnostic’, ‘rt-pcr’ ‘antibody’ or ‘serology’;Cluster 6, in which the term ‘coronavirus’ is followed by ‘receptor’, ‘hydroxy chloroquine’, ‘molecular docking’ or ‘spike protein’.Of these three clusters, the strength of the relationship they maintain with other clusters and these clusters with each other stands out, such as:Cluster 3, with related terms: ‘mental health’, ‘anxiety’, ‘depression’, ‘lockdown’, ‘stress’, ‘quarantine’, ‘psychological impact’ or ‘healthcare workers’;Cluster 2, related to symptomatology: ‘mortality’, ‘pneumonia’, ‘inflammation’, ‘risk factor’, ‘pneumonia’, ‘prognosis’, ‘diabetes’, ‘pregnancy’, ‘infection’.Cluster 4 is noteworthy for dealing specifically with aspects related to the field of study in question. In this cluster, ‘public health’ stands out above the terms of the group in which it is related, followed by the words ‘social media’, ‘vaccine’ and ‘vaccination’, ‘china’, ‘prevention’, ‘knowledge’, ‘attitude’, ‘survey’, ‘risk communication’, ‘misinformation’, ‘disinformation’ and ‘conspiracy theories’, ‘network analysis’, ‘infodemiology’ or ‘fake news’.In terms of content, when analysing the keyword analysis by year with VOSviewer in those articles dealing with COVID-19 and Health Communication, there are similarities and differences in the predominant subject matter in one year or another, both in terms of the number of publications and the citations they have received.The most recurrent terms are those repeated in the articles published in 2020 and 2021, especially those related to the names with which the pathology is designated and directly related: pandemic, coronavirus, COVID-19, SARS or Public Health. What has been also found in both years are those referring to preventive measures: Behavior and Planned Behavior. Others, such as Health Communication or Mass Communication, change from one year to another in the order of prevalence. Thus, in the year 2020, articles on the media were more widely disseminated than those on health communication, although health communication gained prominence in scientific publications on the subject under study.Terms disappeared from the selected publications and others emerged over the months. In 2020, concepts related to Mental Health were more common: Anxiety, Awareness, Fatalism. In 2021, these were Vaccination, Risk Perception, Social Distancing, Health Promotion, or Telemedicine, which were not among the most prevalent keywords in the articles selected in 2020. From the terms Misinformation, Communication Crisis or Communication Risk in 2020, they changed in 2021 to the concepts of Infodemic, Conspiracy or Risk Perception, which denotes a difference in how information is received by society, depending on the time period .The cluster analysis for the two years, jointly, is performed on 877 keywords highlighted by the authors. Thus, 44 different clusters are distinguished  Figure .In this case, the main words at the top of the clusters that encompass terms with the highest prevalence in the published articles and that have a closer relationship with other terms are:Cluster 4: ‘coronavirus’ is followed by ‘vaccination’, ‘internet’, ‘SARS-cov-2’, ‘epidemiology’, ‘hesitancy’, ‘health literacy’, ‘health information’;Cluster 5: next to ‘health communication’ are ‘public health’, ‘crisis communication’, ‘infodemic’, ‘health education’, ‘readability’;Cluster 20: ‘social media’, ‘information’, ‘fake news’, ‘beliefs’, ‘preventive behavior’, ‘behavior change’, ‘awareness’, ‘intervention’;Cluster 9: ‘communication’, ‘misinformation’, ‘Twitter’, ‘COVID-19 vaccination’, ‘public opinion’, ‘conspiracy’, ‘conspiracy theories’, ‘sentiment’;Cluster 32: ‘pandemic’, ‘ambulatory care’, ‘primary health care’, ‘social media influencer’;Cluster 1: ‘health’, ‘outbreak’, ‘mass media’, ‘acute respiratory syndrome’, ‘lockdown’, ‘behavior’, ‘knowledge’;Cluster 3: ‘social distance’, ‘news’, ‘uncertainty’.The main clusters cited are closely related to each other and to other groups of terms, among whose most prominent keywords are: ‘fear appeal’, ‘risk perception’, ‘perception’, ‘behavior’, ‘attitudes’, ‘self-efficacy’, ‘risk perception’, ‘perception’, ‘behavior’, ‘attitudes’, ‘self-efficacy’, ‘self-efficacy’ and ‘knowledge’.The analysis of the 25 most cited articles on coronavirus and health communication provides information on the topics that have had the greatest influence on the scientific community .The article entitled: ‘‘Considering emotion in COVID-19 vaccine communication: addressing vaccine hesitancy and fostering vaccine confidence’’  is the o-‘‘The effects of social media use on preventive behaviors during infectious disease outbreak: the mediating role of self-relevant emotions and public risk perception’’ . The rel-‘Health communication through news media during the early stage of the COVID-19 outbreak in China: digital topic modeling approach’ . With ChTwo other articles have more than 50 citations during the years analysed:In the word cloud, This research presents the current status and trends of COVID-19 research and health communication. Although the scientific community has shown an unprecedented effort in generating a large number of studies to solve the problem, there is a need for a global characterisation in the different areas, given the existing multidisciplinarity .Although there are several bibliometric studies on COVID-19 and Health ,80, sociThe results of the bibliometric analysis also indicate that there is a relative concentration of the most influential papers among a certain number of researchers, in contrast to the study in the field of health by ElHawary et al. . In agreThe analysis of the geographical dispersion of the publications showed that the USA and China are the countries that contribute the highest number of papers, coinciding with other studies . The resCOVID-19 has caused possibly the largest concentration of scientific resources, without precedent. Despite the existence of a multitude of resources, such as repositories and their important contribution, journals are the core of scientific production.One of the debates at the beginning of this research was the use of the WoS or Scopus databases of bibliographic references and citations of periodicals. Both include prestigious journals and rigorous peer review, although it is true that normally the journals that are in WoS in its Social Sciences Citation Index (SSCI) and Science Citation Index Expanded (SCI-Expanded) databases are included in Scopus. Other WoS databases, such as Emerging Sources Citation Index, were not studied in the search for top-level references. For this reason, it was decided to use only the main scientific database, WoS.On the other hand, the search term and the use of the field tag with the topic TS= ‘health communication’ should also be noted. Although other terms such as information, social media or public relations would have provided more results, the main health journals specialised in communication choose this denomination even for the title of their publication. This is the case of Health Communication or Journal of Health Communication, both of which are indexed in Journal Citation Reports (JCR) in Q2. Moreover, other health journals such as the International Journal of Environmental Research and Public Health are indexed in JCR in Q1  with a section called health communication. Hence, given that the main health journals determine the term ‘health communication’ as their main topic, this was chosen as the main topic for the selection of articles.It was decided to carry out this research at a time when vaccines were already giving results and infections were at level 0, according to the European classification. However, it is true that a new variant of SARS-CoV-2, called Omicron, detected in November 2021, is causing a new wave of infections at the time of writing. The effects of the pandemic, according to the scientific director of Pfizer, Mikael Dolsten, will last until 2024 . TherefoFinally, it should be noted that the results obtained also suggest future lines of research. It has been found that research on the impact of the crisis has focused mainly on the areas of ‘Public Environmental Occupational Health’, ‘Communication’ and ‘Health Policy Services’. Therefore, it would be interesting to address new areas of study to expand on the results obtained. For example, the impact of health communication in growing economies and in different target groups remains to be studied. The current analysis shows a concentration of contributions in a certain number of countries, so it would be necessary to broaden it and offer a global point of view.Interest in scientific research in the field of health communication and COVID-19 is growing exponentially and the expected trend is that it will continue to increase. It should be noted that most of the publications that have faced the pandemic scenario have implemented open access policies to share their resources, which has contributed to the rapid diffusion of scientific information.In general, there is also a significant difference between the articles published in 2020 and those disseminated the following year. The scientific literature is in line with the spread of the coronavirus worldwide and the communicative actions that accompany it. Terms such as fear, anxiety, mental health, awareness, resilience or lockdown in 2020 change in 2021 to behavior, vaccination, risk perception, social distance health promotion, or telemedicine. That said, it is true that some terms such as uncertainty are maintained over time, despite the fact that the role of health communication is to avoid precisely this feeling.The information obtained from the analysis of authorship includes the references in the research with the greatest impact in the academic journals indexed in the WoS database analysed. The COVID-19 crisis was the first pandemic to be transmitted in real time. One of the great challenges has been to combat disinformation and fake news. It is therefore necessary for governments and health institutions to design clear communication strategies that are adapted to the different stages of the pandemic to avoid uncertainty, confusion or denial among the population. The lack of such strategies could lead to the failure of a correct public health policy.


The data were audio recorded and fully transcribed. Qualitative content analysis was performed using MAXQDA. (3) In both focus groups , gender-specific characteristics regarding healthy ageing were discussed. Women focused on healthy eating, while men focused on an active lifestyle and meaningful activities. Physical and social activities were considered as important for healthy ageing in both groups. (4) Important gender-specific characteristics of health in old age were identified and recommendations for gender-unspecific and gender-specific recommendations were derived. The results provide important information for promoting and maintaining health in old age. Women and men show both similarities and differences in terms of health-related needs and individual experiences. We suggest gender-specific features in nutrition and health programs for older adults.(1) The rising proportion of older adults in the population represents a challenge for the healthcare system. Women and men age differently. This study aims to examine gender-specific characteristics of health in old age from male and female perspectives. (2) Two focus groups were formed in this qualitative study of older (70+) women ( Due to an increase in the world’s demographics, the proportion of adults who are 65 years and older in populations will increase significantly in the next decades . This isSome gender differences in health and longevity are preventable and modifiable through interventions and can, therefore, be understood as health inequalities which are “unnecessary, avoidable, unfair, and unjust” and require remedial action ,5. TheseWhat opinions and attitudes exist about healthy ageing among women and men aged 70 and older?What gender-specific characteristics can be identified regarding healthy ageing in women and men aged 70 and older?What gender-specific and cross-gender recommendations for the promotion of healthy ageing can be derived?Little is known about these principally modifiable determinants in old age, as older adults are often underrepresented in research . TherefoThis study uses an exploratory qualitative approach employing two homogeneous gender focus groups and is reported according to the Standards for the Presentation of Qualitative Research Results (SRQR) . The semTo be included in the study, participants had to be to be at least 70 years old and be fluent in German. While “old age” is commonly defined as being 65 years and older , the incParticipants were recruited from the community in Leipzig, Germany. via the Senior Citizens’ Advisory Council of the City of Leipzig and posters in supermarkets, sports clubs and facilities for older adults. Participants were asked to contact the study organization directly by e-mail or telephone if they were interested in participating. Potential participants were sent detailed study information, a consent form, an account data form for the transfer of the expense allowance, and a sociodemographic questionnaire, in advance, by post. Eighteen participants  fulfilled the inclusion criteria and consented to participate. Participants were assigned to the male or female focus group based on gender self-identification.Participating men were on average 74.9 years old (standard deviation (SD) = 2.8) and participating women on average 77.1 years (SD = 4.1) see . Socioden = 8) and women (n = 10) were conducted in October 2019 in a seminar room at the Institute of Social Medicine, Occupational Health and Public Health in Leipzig. Both focus groups were moderated by a trained scientific research associate who was supported by a research assistant. Each discussion was introduced with a short oral presentation on the topic of health and age.Two focus groups comprising men  and about intermediate determinants . As one objective of the study is to derive recommendations for promoting healthy ageing, participants were also asked to discuss structural determinants of health . Finally, for each topic block, participants were asked about differences between men and women regarding the respective field.The group discussions were audio-recorded, fully transcribed and content-analyzed using MAXQDA 2018, according to a protocol for qualitative analysis as outlined by Mayring and Fenzl . Two traTo derive recommendations, two research assistants with qualitative expertise first identified themes. They then matched recommendations to themes, which were specifically mentioned by the participants. Next, a qualitative research workshop was conducted with experts from the fields of psychology, psychotherapy, sociology and nutritional sciences. The expert panel reviewed the topics and the assigned interventions and reached a consensus. Additional interventions were also brought forth and national and local considerations were integrated. The following themes were identified: nutrition, sports, social contacts, preventive health care, lifelong learning, meaningful activity, cognitive skills training, life events, and structural conditions. General recommendations suitable for both genders, as well as recommendations that take gender-specific aspects into consideration, were derived according to the findings.The key results are presented below  That’s two earlier generations and it’s a totally different image. (…) She was very old at 63. And that’s what I think is nice, that the people in this group right here, we are all different”.For men, ageing was associated with disease and struggle:“Yeah, you’re certainly aware that in old age you will always have little aches and pains, sometimes maybe something worse too”.Both emphasized that being proactive and optimistic as well as to adaptive to changes due to ageing were important:“I noticed with a friend that he became a bit frail and then began having difficulty walking. And then he stopped walking altogether and it continued in this way, and then he was dead. Yes, it happens very quickly at a certain age. And I think you should try to avoid that. Don’t give up, but fight. Fight every day”.According to all participants, healthy ageing has genetic components, but one’s own actions can influence the course of ageing to a great extent.“Of course, staying healthy is partly down to your genes. But I do think it’s important to take a lot of initiative yourself”.In terms of a healthy lifestyle, women emphasized the importance of healthy eating:“Yeah, my husband always says, ‘my wife cooks and that’s why I’m healthy.’ He doesn’t take care of such things” . .In contrast, men focused on an active lifestyle and meaningful activities:“Intellectual activity is important, as I said. But in my experience, you shouldn’t be just killing time with it, so to speak. Whatever it is you do, it should serve some kind of purpose. You should have a task, as they say”.Social activities, including intergenerational contact, were considered important for healthy ageing by both women and men:“Of course, the social environment is important. So many of us, I, in particular, sit at home alone all week without any contacts at all. There’s a nice saying: take time for your friends, otherwise time will take your friends”.However, from the perspective of both genders, maintaining and cultivating social contacts was easier for women:“Well, there are big differences. We are simply socialized differently, we women. We are more communicative, we are more open. And the men, they withdraw”.Physical activities were considered important by both groups, but women and men described different motivations for exercising and doing sports. Women associated sports with social interaction, fulfilling leisure activities, and maintaining well-being:“Yes, I am also a member in two exercise groups and we do a lot of things together. We often go on trips together or have dinner together. We play cards, things like that. We celebrate milestone birthdays”.In contrast, men were motivated by generating a “sense of achievement” and preventing diseases:“Until my heart attack about 20 years ago, I used to drive to the bakery. I didn’t get any exercise at all. I hated exercise. I still hate it, but I do it. I go to a cardio class once a week. I also go to the gym and exercise for half an hour”.Women and men generally rated health care conditions as essentially positive. This is evident in the responses given by the participants:“Our healthcare system is actually excellent, I would say. We really can’t complain about it. We live in luxury here” . “And I can’t complain at all. It’s all going well as far as medical care is concerned”.All participants say they took advantage of preventive checkups. Nevertheless, both wished for more preventive services for older adults. Mammograms for women over 70 years old was specifically mentioned since this screening is not supported by health insurers. Similarly, older people are excluded from other preventive health services which promote well-being and health instead of focusing on pre-existing diseases and physical consequences of aging, as can be seen in this example:“Yes, because everything comes to an end at 70. No more gynecological checkups, nothing. You’ve taken advantage of all the preventive services. But that’s all gone”.Men emphasize the need to differentiate between genders and age groups when it comes to medical care and medication:“It is certainly important to make a difference between medication for older and younger people (…) In many cases it has been found to be wrong. And differentiating between medication for women and men, which is also not being done”.For women, caring for relatives and the death of significant others were discussed as elemental experiences of old age:“Most often you’re caring for your spouse, or you’re having to deal with the fact that the end of your spouse’s life is not far off. That’s quite a challenge”.Men considered retirement to be a particularly critical life event:“You can read about it, it’s typical for men of retirement age. And as I said, I had a hard time coping. But thank God, with social support and also the help of my family, I’ve made it through so far”.Regarding structural conditions, both women and men saw differences between urban and rural areas. Rural areas were considered to be worse for older people:“I moved to T. (…). And I’m really glad to have relocated at an older age. Let me tell you, the village life is not what it used to be. It’s so difficult to live in a village”.Women stated that they benefit from contacts with neighbors but felt that some of these contacts were diminishing:“People walk up the stairs and disappear into their flats. With some I even have the impression that should I open my door, they would quickly close theirs. That has changed a lot”.Men focused more on insufficient transportation:“And yes, well, I still like driving. But I would also be happy if public transportation were good enough to allow me to leave the car at home more often”.Both women and men also considered the pursuit of hobbies and adult education to be an important prerequisite for healthy ageing, as can be seen in this example:“But I play poker seriously. The first few years after my retirement, I took courses at the adult education center. A computer course and an English course and such”.Women emphasized that full participation in public life depends on sufficient financial resources:“That’s what I was just about to say. You need some money if you want to keep busy three days a week”.Men expressed the wish for specific offers for male older adults, as existing offers were often perceived to be aimed to a female target group:“But what I’m trying to say is that something probably needs to be done because, on average, we men are being forgotten. There are a lot more opportunities and things for women. There’s this and there’s that. Men have other interests, generally speaking”.A guiding principle of recommendations should be to use the potential of older people by integrating their experience and resources . Offers for older adults should ideally emphasize reciprocity by providing win–win situations for children, adolescents, younger and older adults . Many recommendations  have the potential to address many purposes at once . Offers gain acceptance and effectiveness the more specific they are to regional characteristics . Further considerations include: the degree of urbanization vs. rurality  and gender specifics . For an overview of the recommendations, see In both focus groups, participants were heterogeneous in their age distribution and therefore part of different age cohorts. The youngest had not had personal childhood experiences during World War II, while the oldest in the group had experienced years of childhood and adolescence socialization during the National Socialist dictatorship. Nevertheless, all study participants had experienced incisive social upheavals including various forms of government, comprehensive changes in gender roles, significant medical progress and modifications in the concept of old age. This historical context, in conjunction with the broad age distribution, could presumably inform very different attitudes toward healthy aging . These cThe aim of this qualitative study was to identify gender-specific characteristics of healthy ageing and to derive recommendations to promote positive health attitudes and behaviors. The topics and needs mentioned are consistent with most of the research literature on healthy ageing . HoweveAlthough all participants agreed that biological factors had an influence on ageing, women and men agreed that nutrition , exercise , and mental activities  play an important role. Further, older adults actively contribute to healthy ageing and reduce the negative effects of aging by eating healthfully, maintaining an active lifestyle and keeping mentally fit, as is consistent with the findings from Harmell et al. . Our stuStudy participants reported different motivations for exercising: older men focused on improving their performance and preventing diseases, while older women wanted to maintain mental and physical fitness for their own well-being (to do “something for themselves”). Empirical research on gender-specific motivation for physical activity is still deficient and includes open questions e.g., ,30); how; how30])Although women and men were very satisfied with health care, they wanted more preventive services, which is contrary to the state of research with regards to men ,35. FurtTargeted offers could support older adults in coping with critical life incidents. For women, illnesses, caregiving and the death of relatives is particularly impactful, in line with the research of Stein et al. . For menThere was agreement between both women and men that environmental conditions are important in ageing. Although all participants lived in an urban area, they reported that in rural areas older people experienced limitations in mobility, health care, and cultural, sports and social opportunities, thereby hindering healthy ageing. Unfavorable environmental conditions also prevent older adults from engaging in physical activity ,33,37. WA strength of this study is the focus on women and men 70+. Older people are underrepresented in empirical research due to recruitment and participation problems ,41. TherThe current study provides important implications for practice and care offers. As the perception of ageing has improved over recent years, especially for women, these gains should be extended to men. Ageing could be embraced also by men, as a phase of life full of opportunities. In developing programs, the need for intellectually stimulating and meaningful activities and for  social contact should be addressed and possible side-effects emphasized . Gender-specific needs and age subgroups in the elderly population also need to be considered in medical care.Significant research implications also emerge. Recommendations developed in this study were guided by the principle that they should be based on the needs of the community. These recommendations should be further developed and analyzed concerning their acceptability, feasibility, and effectiveness. It would also be interesting to examine whether the same views, needs, and requirements for recommendations would emerge from a rural sample or among adults 70+ from migrant or other minority groups (with group discussions in other languages). Since men often seem to perceive existing services and programs for older adults as women-specific, research should explore what offers men would like to see and how existing offers can be improved so that they also feel addressed. As the focus group discussions took place in October 2019, prior to the COVID-19 pandemic, it would be of great interest to investigate possible changes in attitudes toward healthy aging and implications for recommendations in a follow-up study.


People age at different rates. This heterogeneity in aging has led to the concept of “frailty”, a state of heightened vulnerability to adverse health outcomes at any age. Frailty challenges health care providers, as frail patients are more likely than non-frail patients to experience diseases, hospitalization, and death. We showed that frailty occurs not only in humans, but also in aging rodents. It can be measured with a “frailty index” (FI) based on age-related health deficit accumulation as originally established in humans. We found that maladaptive changes in heart structure and function in late life are correlated more so with frailty than age and are closely graded by FI score, especially in male mice. Adverse effects of frailty originate at cellular/subcellular levels and scale up to organ and system levels, predisposing towards cardiovascular disease. Poor overall health, quantified with an FI, may drive maladaptive cardiac remodeling, especially in older males.


In this article, we explore how older British Pakistani people experience multimorbidity  and engage with self-management within the context of their life histories and relationships. We conducted biographical narrative interviews in Urdu and/or English with 15 first-generation Pakistani migrants living with multimorbidity, at their homes in East London. Our analysis showed that the triadic construct of family, faith, and health was central to how participants made sense of their lives, constituting notions of “managing” in the context of multimorbidity. For Pakistani patients, the lived experience of health was inseparable from a situated context of family and faith. Our findings have implications for existing public health strategies of self-management, underpinned by neoliberal discourses that focus on individual responsibility and agency. Health care provision needs to better integrate the importance of relationships between family, faith, and health when developing services for these patients. It is both a great success and a significant challenge for global health care systems that people are living longer. The aging population is accompanied by a higher prevalence of long-term conditions (LTCs) and multimorbidity—defined as the coexistence of two or more medical conditions . MultimoSelf-management is the “lifetime task” of managing an LTC and is made more complex in the context of multimorbidity . Corbin Critics identify self-management programs as constituting a “downward delegation” of work to patients, prioritizing theoretical cost-saving at the expense of holistic care . They suIt has been suggested that the self-management discourse underestimates the importance of the biographical precipitants of poor health and the socioeconomic and structural systems of inequality that create and sustain it . In pracThere are particular concerns about the effectiveness of self-management programs among ethnic minority groups that are known to carry a disproportionate burden of LTCs . ScholarIncreasingly, self-management research suggests that much of the “work” of living with LTCs is collaborative . ExistinBritain is home to 1.17 million Pakistanis, the largest Pakistani community in Europe . PakistaThe mass migration of Pakistanis to Britain started in the 1950s following the 1948 British Nationality Act, conferring British citizenship on all Commonwealth subjects and recognizing their right to work and settle in the United Kingdom . Many weSouth Asians comprise one third of the population of Tower Hamlets and Newham, the boroughs in which we conducted this research. These are two of the United Kingdom’s most ethnically diverse and deprived local authority areas . PreviouCurrent literature on self-management in the Pakistani population is mostly disease-specific and focuses predominantly on diabetes. In a separate study of accounts of diabetes causation, A study conducted by This was a narrative interview study. The aims were to explore how older Pakistani adults experience multimorbidity and to illuminate how they “manage” their selves and their health in the context of their daily lives.in their own words and in their own language.This research is novel in two ways. First, we used the Biographic Narrative Interpretive Method, an open-ended storied approach, which invited participants to respond to a single question in whatever way, and for as long as they wished . This “umultiple chronic conditions into their lives. This is particularly important, given that multimorbidity may amplify the burden and complexity of the work involved in “managing.”Second, although a body of research has shown the value of exploring the experiences of ethnic minority patients with single diseases, our study elicited narratives in which participants articulated how they integrated their A total of 15 people were recruited through seven general practitioner (GP) practices in East London. The inclusion criteria were as follows: people aged more than 50 years (to reflect the early onset of multimorbidity in this population) of Pakistani ethnicity who spoke Urdu or were bilingual Urdu–English speakers, with two or more ongoing medical conditions. A GP in each practice conducted an electronic search to identify eligible participants, sent invitation packs in Urdu and English, and sought verbal consent from interested participants for a researcher to make telephone contact to explain the study. Sampling was purposive to identify maximum diversity across the following attributes: age (53–87 years), gender , educational background , and comorbidities. Participants had, on average, four comorbid conditions and, across the sample, there were 21 comorbid conditions. Hypertension (15 people) and diabetes (13 people) were the most common conditions, but experiences included heart failure, hypothyroidism, depression, epilepsy, asthma, and osteoarthritis, for example. Three participants self-identified as fluent in conversational English and 12 participants described themselves as speaking little or no English. All were resident permanently in the United Kingdom (average 33 years). A total of 13 participants lived with adult children and one participant had a formal carer. Participants were prescribed an average of 12.6 regular medications.Fifteen in-depth narrative interviews were conducted in participants’ homes, 13 in Urdu and two in English. In comparison with academic or clinical settings, the home is a more informal environment for a biographical interview and the location of most of the “work” of multimorbidity . ParticiCan you please tell me your story of your life since you were first advised to take medicines. I would like you to tell me about all the experiences, people, and events which are important to you personally. Please begin wherever you like, and take as long as you need. The participant responded to the SQUIN uninterrupted by the researcher, who noted cue phrases on which to build the interview. After a short break, the interview continued with the researcher selecting a range of cue phrases, in the order in which they were introduced within the SQUIN to elicit further, more detailed narratives. This was followed by a short semi-structured interview, based on a topic guide to fill gaps. The topic guide included questions regarding the routines and practical arrangements for taking medication and medication reviews, and questions regarding what worked well and what were the challenges of living with multimorbidity. Interviews took place between December 2017 and June 2018 and lasted an average of 72 minutes. Interviews were audio-recorded, transcribed, and translated into English. Transcripts were anonymized prior to analysis.Interviews were conducted using We followed The study was granted a favorable ethical opinion by North East Tyne & Wear South Research Ethics Committee  through proportionate review.cause of personal ill-health. Second, family was seen as a source of emotional and practical support in managing ill-health. Furthermore, all but one participant identified the importance of their Muslim faith in making sense of, and managing their ill-health. Beyond the central triad of family, faith, and health lay a wider circle of concern, comprising the participants’ community. Our analysis further illustrates how participants presented themselves to this wider community as good patients and citizens. In the following, we discuss our findings and interpretations, linking them to the wider literature within the three themes identified above.Participants experienced, understood, and articulated “multimorbidity”  with reference to family, faith, and health. They understood their health to be affected by—and in turn, to affect—their relationship with family and with God, in a deeply connected recursive triadic interrelationship. The relationship between family and health was accounted for in two ways. First, emotional family events, particularly deaths and losses, were frequently identified as being a What happens is, you get ill because there are certain sorrows in life that settle themselves in your heart. And from that, your illnesses keep growing, from thinking about it . . . I couldn’t have children so he [my husband] got married again. That caused me a great deal of sadness . . . That almost killed me—the sadness . . . And this second marriage, remarrying—that’s when I started getting sick and all my illnesses got much worse . . . The thing is nobody knows these things about you. It’s only the person suffering who knows what they are going through.Throughout the interviews, accounts frequently attributed the onset of chronic ill-health to stressful family events. The participant, in the following narrative, was interviewed with her husband present and describes her experience of emotional distress and resultant physical symptoms she attributed to marital problems. Their multigenerational home included the children of her husband’s second marriage, which was conducted under Islamic law in Pakistan (where more than one wife is permitted) and was initially kept secret from the participant. Despite fertility treatment, the participant did not herself have children. In this extract, her reference to “getting sick” relates to the onset of valvular heart failure, which she attributes to the sorrows that “settle themselves” in her heart:Within Islamic interpretations of health, the body and mind are understood to be interconnected and Pakistani patients frequently present to doctors with physical symptoms which they themselves attribute to psychological or emotional distress . Within In 1997 my father died and that was shocking for me. He was in Pakistan—it was very shocking. My younger brother and I were here and so we went to Pakistan for the funeral. After that I told the doctor about my pains. He told me to give a sample of urine for a test. He told me I had diabetes and told me there was no medicine yet . . . . After six months he gave me a tablet . . . . it started from there and MashAllah  now I am on 22 medicines including insulin.In our interviews, narratives involving death or loss of a loved one were commonly situated in accounts of new diagnoses. One participant, who had migrated to London aged 16 years, recalls his new diagnosis of diabetes in the following extract. Although this account was in Urdu, he twice used the word “shocking” in English, placing particular emphasis on the unexpected nature of his father’s death and juxtaposing the account with his sense of geographic separation from his father in Pakistan:This participant constructs the temporal, causative interdependence (“after that”) between emotional distress and resulting somatic illness (“my pains”), which in turn becomes a diagnosis of diabetes. “Biographical disruption” was a term coined by British sociologist Michael Bury to describe the process where critical situations in life become a basis for a change in identity. According to *) It is broken into two pieces—one in Pakistan and one here. I can’t leave here and go to Pakistan . . . . In Pakistan I have no way of making any income. First thing in Pakistan is I don’t have money for any medical treatment.You cannot think how I got out of Pakistan . . . how I got here. I left two children behind. My son was five years old when I came here. I didn’t even meet him before coming. What kind of mum leaves her children? . . . Then [my children] didn’t get the visa [to join me in the UK] . . . . You know when your kids are separated, what it does to a mother’s kaleja In their studies of stroke survivors in East London, We encountered a similar embeddedness of illness narratives within stories of hardship, past, present, and ongoing. We end this section with some notes written by the interviewer in a reflexive journal :Older adults with multimorbidity are frequently reliant on the support of family caregivers, and a lack of family support has been identified as a barrier to engaging with self-management routines . Our intAt the beginning the doctor . . . he was the one who started me on these tablets. I said to him I don’t take it . . . . now without the medicine I am not at peace . . . whenever I go they ask me so many questions . . . they say your mum she takes too much tramadol . . . she does this, she does that.In our study, it was usually adult children who performed advocacy roles as spouses often did not speak English. Parents frequently described their adult children as culturally aware facilitators in navigating the health care system and seeking help when needed. Some drew particular attention to how “good” their own children were compared with “other people’s children.” Having to balance the requests of parents within the “rules” of seeking medical help was complex, as well illustrated in accounts of this female participant whose escalating tramadol use for arthritis (a highly addictive painkiller) was a source of conflict at home. She describes being started on tramadol by doctors but seems frustrated by the “many questions” she is asked by doctors for ongoing prescriptions:Note that questions from doctors about her care are posed to her son (“they say your mum”). Her son went onto further elaborate to the interviewer, the practical and emotional demands of obtaining this tightly controlled medication from his mother’s GP on a regular basis, and the considerable stress this placed upon the wider family unit.They told us [my husband] needs to go for an operation . . . [and] that if he had the operation he could die . . . or he could be paralysed. My son went, my daughter, my daughter-in-law, all of them went to the next appointment and told the doctors that he couldn’t have the operation . . . . But now he [my husband] can’t get out of the house. He has fallen over quite a few times . . . . So now the children don’t let us go out . . . But they were the ones who had the operation cancelled.Reliance on children can additionally be problematic from the perspectives of the parents. Our findings include accounts when distributed care within families may have fallen short of prioritizing the patient’s best interests. In the following narrative, a different participant describes the significant role of their children in deciding whether their father went for back surgery. There is frustration from the participant that their children’s’ involvement in decision-making resulted in a canceled operation and the ongoing problem of recurrent falls arising from this:Of note, the voices of the participant and her elderly husband are erased in this account of the decision-making process and they position their children as continuing to contribute to their ongoing difficulties because “they don’t let us out.”In family members, who are the constants in a changing plethora of health professionals and whose relations with the patient have been a part of the individual’s identity, are reminders that the patient is not a mere collection of dysfunctional body parts that require professional intervention, but a moral agent. (p. 131)Our findings consistently demonstrate that, for this older Pakistani population with multimorbidity, the emotional and practical work of living with multimorbidity was underpinned by the support of their networks; most frequently consisting of the immediate family. General sociocultural expectations within this community dictate that those at the extremes of age, namely, young children and older people, are the responsibility of those deemed to be at the peak of their mental and physical capabilities. Our interviews suggest that adult children often had a significant say in medical decisions regarding their parents as they advanced in age, even in situations in which their parents retained mental capacity to make autonomous choices. Thus, although the nature of the reciprocal relationship of the parent and “child” changed significantly through the life span, the shared moral commitment to this reciprocity as a fundamental expression of kinship remained. As one participant reflected, “I consult my son to ask him what I should do. Before I would advise my family for everything, now I consult them.” The consistent support of family networks juxtaposes with the feeling of deterioration participants often describe, from that of being an active independent healthy person to that of more dependent patients. Our analysis shows that for the older Pakistani people in this study, notions of self and agency are deeply entangled with kinship. Although largely supportive, there are contrasting examples, in our interviews, of social networks and familial support further complicating how individuals self-manage their LTCs. Nonetheless, the predominance of narratives about kinship in our findings is seemingly at odds with much of existing health policy, centered on individual choices and autonomous self-management.Praise be to God], MashaAllah ) throughout interviews reflected a shared understanding and attributed “insider status” to the interviewer as a member of the Muslim community. Arguably, while enabling a particular kind of access to this community, this may also have prompted talk deemed “appropriate” between Muslims.The importance of spirituality in the context of LTCs has been demonstrated in many populations. Even if I get unwell, well, illness is from God.” The following quote from one participant incorporates several recurring subthemes we encountered regarding faith and health: the importance of forgiveness, gratitude, and having faith in God’s plan.Many participants referred to Islamic beliefs to explain how they made sense of and coped with deteriorating health. This included being grateful for all things—even ill-health—in a frame which positioned both health and ill-health as God’s will and, by implication, to be accepted stoically: “All I ask is that God forgives me. There is nothing in my brain or my heart—just all I think is Alhumdullilah. But these worldly matters—they will carry on. They will only end when—Inna Lillahi Wa Inna Lil Rajioon (Quranic Arabic (2:156): Indeed, to God we belong and to God we shall return). They don’t end. They will carry on. I just thank God. That he gives illness because even illnesses come from him. You just keep praying and he keeps listening. Just think—if you have something of your own—would you ever ruin it? No. We are all his. We need to try and he will make it better for us.We all have to leave [this world]—He just hasn’t told us which time.” A belief in the afterlife is common among believers of many faiths. A study of Black Caribbean cancer patients similarly identified the concept of moving onto a “better life” after death, one which was “a richer existence than their mortal presence on earth” .Here, thank God, medicine is free, doctors are free, hospitals are free.” These narratives of gratitude were often juxtaposed with accounts of very poor access to health services in Pakistan where participants regarded care to be of poor quality and prohibitively expensive: “Back home, if you become ill you die because you can’t get the treatment.”Despite gratitude for the NHS and the care provided, we encountered several accounts of participants undertaking self-management practices that they concealed from their Western health care providers, so that participants could fulfill their religious obligations. Although fasting during Ramadan is an important part of the Islamic faith, it is widely recognized that older and sick believers are exempt from fasting. Existing research suggests, however, that many Muslim patients with LTCs will fast regardless. In one interview study of British Muslims’ attitudes to fasting, some respondents described both avoiding health services during Ramadan and making adaptions to their medication regimens without their doctor’s knowledge to allow them to fast . We encoIt is for asthma, when you have an attack they give you a course of it . . . . the doctor does not give it, he doesn’t know either and I don’t tell him . . . Sometimes I get it from Saudi Arabia and I save it, it lasts two or three years. From that my breathing doesn’t go wrong . . . First Ramadan I took it, I realised I cannot live without it, it’s a good one . . . . It is also a mental thing, where if I take this I feel I will be okay. If you have prayed to God to help you and then you are also taking this tablet (Laughs) . . . . It is not that if you just pray you will be fine. No. You should take medicines too. Do both.okay.” He does not appear concerned that his actions may be harmful and presents an account in which medicines are a force for “good” (“I cannot live without it”). He thus aligns his individual understanding of medical treatments with his individual needs from the perspective of his faith, bypassing conventional biomedical advice through his regular doctor.Although he acknowledges that what he is doing would not have his doctor’s approval, he feels that combined with prayer and faith, he will be “Muslim scholars acknowledge the “wholeness of being” in which health involves spiritual, psychological, physical, and moral components. The complex, and possibly risky, arrangements that this participant undertakes to contribute to his spiritual health and “wholeness” demonstrate this orientation. Individualized self-management strategies that place surveillance and management of the physical “self” at the center are frequently not consistent with Islamic values and practices in which God is regarded as the mediator of benefit in all things, and health holds meaning beyond the physical. Such individualized strategies may have limited success in this population.With reference to faith and health, our interviews highlighted the centrality of faith to our participants’ modes of sense-making and action in the context of their multimorbidity. In particular, their accounts highlight the extent to which faith practices and forms of knowledge that align with faith are prioritized over “conventional” biomedical explanations which typically lie at the center of self-management efforts within existing Western health care provision.This study explores how older adults from Pakistani backgrounds experience multimorbidity. Our overarching finding is that Pakistani patients make sense of their LTCs in a highly relational way, tied strongly to notions of family and faith. With 1.7 billion Muslims globally, our findings have relevance beyond East London, especially in situations where health care is informed by Western, predominantly secular ideologies. Our research suggests that the logics of “self management” within contemporary chronic disease management poorly reflect how these people understand and manage living with multimorbidity, especially by limiting its scope to the individual body and patients’ efforts to monitor and manage their singular selves.This is, to our knowledge, the first study that explores multimorbidity in the British Pakistani population by adopting the BNIM. The researcher’s professional role within general practice opened avenues for recruitment within local primary care networks from a population known to be hard to reach . There wWe join others in our critique of the predominance of the biomedical model as a means of understanding and caring for people with chronic disease. Scholars note that, within clinical encounters, too often “biological approaches trump biographical interpretations of patient’s problems, rendering the latter invisible or their relevance inconceivable, leading to harmful over-diagnosis and medicalization of human suffering” , p. 28. For the participants in this study, management strategies centered on personal responsibility are widely detached from how they make sense of, experience, and seek to manage their own ill-health. Western bioethics identifies respect for individual autonomy as one of the four prima facie principles. Consistent with wider literature of clinical decision-making, however, our participants’ decisions appear to be highly distributed within family networks, with the active involvement of family often appearing to be integral to their own sense of agency . These fin opposition to medical intervention. Indeed, one said, “I ask God for my medicines and my doctors deliver them to me.” But the closely entangled “triad” of family, faith, and health as a “network of value” is a construct that we believe clinicians should attend to if they seek a shared understanding of patients’ lives as a basis for prudent decision-making.Our study, furthermore, casts some doubt on whether “self” management, as it is usually intended in health policy, can achieve useful ends within a population where the self is fundamentally social, deeply interconnected with wider social networks, and committed to a faith that holds that God’s will is the ultimate influence on long-term outcomes. Importantly, our participants did not frame God’s will, nor the role of their family and social networks, looks like, at the expense of what “good” care actually is for some patients. As autonomy has been thought of as the pinnacle of human achievement . . . yet the capacity to form and maintain relationships, which has received little attention in the Western philosophical tradition, is arguably just as much of an achievement as autonomy, and just as important for moral maturity. Autonomy is one human good, and the ability to make and sustain connections with others is another; both are necessary for a full and rich human life. (p. 154)Scholars have suggested that the preoccupation of health care professionals, with biomedicine and personal autonomy, risks disregarding networks that patients most value and that this may leave patients who are managing LTCs to feel confused and conflicted . Our finOur research highlights a disconnect between “self management” as it is formalized in policy, protocols, and practice and the narratives told by older British Pakistani people who are living with and managing multiple LTCs. For our older Pakistani participants, the lived experience of health was frequently inseparable from a situated context of family and faith. The triadic construct of family, faith, and health is central to how they make sense of their lives and how they “manage” in the context of multimorbidity. Current policy and practice regarding “self management” offers a version of responsible individual self-care that does not resonate with the understandings and needs of this group. Such approaches may be both impractical and unrealistic for many and risk exacerbating systemic disadvantage.


A quality accreditation program (AP) is designed to guarantee predefined quality standards of healthcare organizations. Evidence of the impact of quality standards remains scarce and somewhat challenging to document. This study aimed to investigate the accreditation of a cancer research hospital , promoted by the Organization of European Cancer Institutes (OECI), by focusing on the individual, group, and organizational experiences resulting from the OECI AP.A focused ethnography study was carried out to analyze the relevance of participation in the accreditation process. Twenty-nine key informants were involved in four focus group meetings, and twelve semistructured interviews were conducted with professionals and managers. Inductive qualitative content analysis was applied to examine all transcripts.Four main categories emerged: a) OECI AP as an opportunity to foster diversity within professional roles; b) OECI AP as a possibility for change; c) perceived barriers; and d) OECI AP-solicited expectations.The accreditation process is an opportunity for improving the quality and variety of care services for cancer patients through promoting an interdisciplinary approach to care provision. Perceiving accreditation as an opportunity is a prerequisite for overcoming the barriers that professionals involved in the process may report. Critical to a positive change is sharing the values and the framework, which are at the basis of accreditation programs. Improving the information-sharing process among managers and professionals may limit the risk of unmet expectations and prevent demotivation by future accreditation programs. Finally, we found that positive changes are more likely to happen when an accreditation process is considered an activity whose results depend on managers’ and professionals’ joint work. A healthcare quality accreditation program (AP) is the system an independent organization uses to evaluate a healthcare provider/organization. Accreditation certifies that the healthcare provider/organization meets specific quality standards . APs werA few studies have focused on accreditation-related organizational changes reported by HPs and key individuals from a qualitative perspective ; the perThis study aimed to evaluate an accreditation process recently undertaken by a cancer research hospital in Northern Italy  from a qAmong the different programs held by OECI, the Accreditation & Designation Program (A&D) of European Cancer Centers, which aims at improving the quality of care, training, and research in oncology, is particularly significant.The authors of a European study  that assAccording to this evidence, we decided to investigate AP-related changes focusing on the individual, group, and organizational experiences that the OECI AP had initiated.We carried out a focused ethnography study (FE) , as we bThe selected setting was the Cancer Research Hospital of Reggio Emilia (Cancer Centre), located in Northern Italy, which is part of a General Hospital and further embedded in the Local Health Authority of Reggio Emilia with a catchment area of more than 530,000 inhabitants.The Cancer Centre has two hundred beds and provides diagnostic, therapeutic, rehabilitation, supportive, and palliative care for cancer patients. It performs preclinical, clinical, and translational research.The Cancer Centre was previously accredited by the institutional accreditation program of the Regional Health Authority. In 2011, the center was recognized by the Italian Ministry of Health as a Clinical Research Institute (IRCCS) that specialized in the oncology field with a specific focus on “Advanced Technologies and Healthcare Models.” According to the Ministry of Health, the IRCCS is required to participate in an international accreditation program. The OECI AP is one of the accreditation systems recognized by the Ministry.According to OECI AP, cancer centers are assessed every 5 years at two designation levels: clinical or comprehensive cancer centers.To be designated a Clinical Cancer Centre, the hospital should provide cancer care and cancer research activities, focusing on one or more aspects of basic and translational research. To be designated a Comprehensive Cancer Centre, the hospital should be characterized by a highly innovative and multidisciplinary approach, relying upon basic, translational, and clinical research, to offer efficient policies to meet patients’ emerging needs, to train HPs, to provide constant improvement in the quality of care  and to pThe OECI AP consists of standardized steps that take place over 18 months, including a self-assessment, a peer-review visit, certification, and implementation of a specific improvement plan with a one-year follow-up.The Cancer Research Hospital of Reggio Emilia started the OECI AP in 2013, and the self-assessment period took place in the same year. In 2014, peer review visits by 4 European auditors from different countries representing other healthcare professionals and functions took place.In January 2015, as scheduled, formal accreditation was achieved, and the Reggio Emilia Oncological Centre was designated a Clinical Cancer Centre. Based on the peer review visit report, the center formalized the requested improvement plan  a check of care processes rather than of activities carried out within a single ward or by a single professional.” (interview n. 9).According to interviewed hospital managers, being accredited as a cancer center meant to be driven by a patient-centered healthcare paradigm.“[ …] reasoned on aspects not considered before as they address qualitative rather than quantitative outcomes”. (interview n. 8).in line with the orientation of our oncological institute, which is characterized by the attention to care models in oncology, or with a focus precisely on the pathways of patients” (interview n. 2).From both FGs and interviews, it emerged how OECI AP changed the way HPs worked in response to oncological patients’ needs. Our participants, who all had previous experiences with other APs, declared that OECI AP was more acceptable than compared other accreditation systems because it was “[ …] mature modality for enhancing human resources (FG n. 1) and was found to be favorable because the accreditation looked at professionals’ hearts (FG n. 2).From the analysis, it emerged that participants were favorable to being evaluated, as employees, by OECI. The AP conveyed a usual care.” Their goal shifted from the strictly rehabilitative activity of functional recovery to the commitment to guarantee even small, but significant for the patient, improvements in the terminal phases’ quality of life.The majority of participants were not aware of the compulsory nature of being accredited by an international system; only three interviewees with managerial roles reported OECI AP as necessary for the center. Nonetheless, the shared perception about OECI APs regarded the opportunity to improve the roles of nurses and other HPs in terms of interdisciplinary relationships, the inclusion of new activities, functions, or even a professional reorientation within each HP discipline. One interesting note was what a physiotherapist reported during FG 4: thanks to OECI AP, the institution has been asked to provide an “oncological physiotherapist” to treat patients with palliative care needs. This remark reflected the perceived opportunity for improvement. During the FG, the oncological physiotherapist reported that she had to develop very different competencies from ““The physiotherapist usually does not deal with death. Here, however, it occurs on a daily basis, and it is a whole new perspective” (FG n. 4).cultural leap” (interview n. 6). According to most participants, patients’ needs were finally taking on as the responsibility of many other HPs, such as psychologists, psycho-oncologists, physiotherapists, palliative physicians, oncology nurses, and speech therapists.An opportunity experienced by the participants regarded the implementation of the primary nursing model, which was new for the institution even though it had been desired for a long time. In addition, participants conceived of interdisciplinary professionalism as a ““care pathways were mushrooming everywhere” (FG n. 4). Around the OECI AP, care pathways ranged from 9 to 16 . Understandably, many participants noted that OECI AP was a “catalyst” (interview n. 8) or an “accelerator” (FG n. 3).Participants recognized that during OECI AP, real, concrete and positive change for patients” (interview n. 2) has been obtained and that there has been a “creeping effect throughout the whole hospital” (interview n. 10) with benefits also for noncancer patients. Many participants ascribed OECI AP as a reason for a its “cultural shift” (interview n. 1).The managers underlined how a “Our bosses kept saying: ‘OECI wanted this!’” (FG n. 1), “‘It’s because OECI requested it” (FG n. 3). This direction was apparent in a significant change that occurred within the ICT office. The involved ICT participants indicated the OECI AP as overall gratifying since OECI considered the aspects of ICT as structural and extremely important.Our analysis showed that OECI AP boosted a bidirectional change. On the one hand, some HPs considered OECI AP as an excuse to implement top-down decisions. Many participants repeatedly said the following during FGs: “It was a race. At certain points in the journey, the organization constantly changed the requests, and it was hard [...] But the organization has changed in its course and has created more linear and clear processes, and this is always in favor of ICT” (interview n. 11).“On the other hand, some HPs found in OECI AP a chance to implement services and professional roles they have desired for a long time, in a sort of bottom-up direction.Some of the practices requested by OECI AP matched those proposed by HPs .brought up to standard” (interview n. 5). The PCU had been an experimental unit since it was implemented less than a year before the OECI AP process began. The PCU staff were asked to draft new procedures and protocols and interlace relationships with the other hospital units and wards. The “writing and rewriting of documents” (FG n. 2) that experienced PCU members reported was aimed at assuring the necessary integration with the operating procedures of the wards where according to OECI AP, the PCU activity should be set in place. These actions acknowledged and made more visible PCU activities that required formalization.According to our participants, OECI AP was an opportunity for the palliative care unit (PCU) to be “The second experience of (desired) change occurred after the accreditation and was reported by all the groups and interviewees: establishing the psycho-oncology unit. The majority of participants were satisfied to have, through OECI AP, convinced managers of the need for a more significant number of dedicated psychologists to guarantee support to cancer patients and their families.The participants also experienced obstacles during the OECI AP process. Some participants reported that it was required that OECI accreditation be performed in the English language; consequently, it was not utterly understandable by everyone. Another reported obstacle rested on a cultural ground: participants felt OECI AP modality as typical for northern European organizations, so it was not fully applicable to the Italian context.“OECI has only understood the phenomenon of Italian institutions to a certain extent” (interview n. 2).“Some flexibility is needed in applying and evaluating models in such different situations” (interview n. 5).According to the study participants, European standards struggle to take national regulations and cultural nuances into consideration:“A certain procedure regarding the will and the end-of-life provisions ... can contain certain things in Italy, while in The Netherlands it is certainly different” (interview n. 9).The absence of specific academic training in oncology for all HPs, which was recommended by OECI AP, was seen as a critical barrier specifically for nurses who, in Italy, cannot benefit from specific academic specializations in oncology.going well beyond due” (interview n. 11) in carrying on the AP process. The workload was perceived as excessive by both managers and HPs, with the fear that time for AP process was time removed from clinical activity. Additionally, the general timing of the accreditation process is described by almost all the participants as “narrow” (FG n. 4).Another perceived limitation regarded the perception of “Finally, some participants complained about the lack of rewards or benefits, even noneconomic. Nonetheless, participants in the FGs generally reported that they found some gratification in innovating for the patients.Interviewees hoped OECI AP was an opportunity for networking with other European Cancer institutions. Managers’ expectations regarded reaching greater visibility, increasing their prestige, and providing further opportunities for everyone’s professional and scientific growth.Other participants expressed the hope that OECI would influence national and regional policies regarding OECI-related regulatory aspects to be improved. The most shared expectation for the future regarded the upgrading of the OECI designation from the Clinical Cancer Centre to the Comprehensive Cancer Centre:“We have a shopping list with things to work on to improve” (interview n.1).This showed the willingness and desire to carry on the work required to accomplish the OECI AP improvement plan. Data analysis also revealed an unmet expectation: participants expected colleagues directly involved in the program to socialize the accreditation’s achievements, reporting a feeling of being left in the dark about further actions to be implemented. Many participants requested debriefing moments.It is well known that any accreditation process may generate adverse reactions among HPs . RegardiAlthough previous research  describeHPs who experience an AP process can appreciate the values and framework subtending it . In our Our study showed how an AP could induce expectations that, if not satisfied, may affect HPs’ collaboration in their commitment to the success of future AP-induced change implementation. In addition, HP involvement is a strategy for stimulating HP motivation. As reported , highly Our focused ethnography study demonstrates the usefulness of investigating AP from the participants’ and recipients’ perspectives. It allowed us to highlight what should be fostered as positive change factors  suitable