In this paper, we analyze the Fire Department of New York City’s pre-hospital emergency medical services dispatch data for the period of March 20, 2019–June 13, 2019, and the corresponding Covid lockdown period of March 20, 2020–June 13, 2020. A fixed effects negative binomial model is used to estimate the heterogeneity effects of average ambulance travel or response times on the daily volume of emergency calls, year, day of the week, dispatcher-assigned medical emergency call type, priority rank, ambulance crew response, borough and an offset for missing calls. We also address the limitations of other non-parametric Covid studies or parametric studies that did not properly account for over-dispersion. When our model is estimated and corrected for clustered standard errors, fixed effects, and over-dispersion, we found that Wednesday was the only day of the week that was most likely to increase travel response time with an odd ratio of 6.91%. All grouped call types that were categorized showed significant declines in average travel time, except for call types designated as allergy and an odds ratio of 21.81%. When compared to Manhattan, Staten Island ambulance response times increased with an odds ratio of 19.05% while the Bronx showed a significant decline with an odds ratio of 31.92% advanced life support (ALS) and BLS ambulances showed the biggest declines in travel time with the exception of BLS assigned ambulance types and emergency priority rank of 6. Surprisingly, in terms of capacity utilization, the dispatch system was not as overwhelmed as previously predicted as emergency call volume declined by 8.83% year over year. The Fire Department of New York (FDNY) is one of the largest fire departments in the United States. In addition to providing fire protection and other public safety functions, they handle emergency medical system (EMS) 911 calls for medical and non-medical emergencies and provide pre-hospital emergency medical care and transport for the residents of the five boroughs  in New York City. Dispatchers, emergency medical technicians (EMTs), paramedics, and firefighters may be among the various types of certified first responders (CFRs) that respond to medical emergencies and some non-medical related emergencies in the city.FDNY Citywide Performance Indicators. Call volume is an aggregation of the number of FDNY emergency calls that occurred within a fixed time period such as each hour, day, or week. The daily call volume—computer-aided dispatch (CAD) incidents—received by FDNY 911 emergency call centers are often modeled as counts, given the nature of its discreteness, nonlinear and non-negative values.In responding to thousands of life-threatening and non-life-threatening medical calls each month, each activity involved in the EMS call process—from the beginning 911 call initiation to a final resolution that ends with the EMT’s hospital departure—is timed and recorded and used as Gaussian linear models that were in conflict with Poisson distribution theory and some of its special cases.The modeling of EMS call center data was often non-parametric or the wrong statistical distribution was used with dubious results even before the Covid-19 pandemic appeared. For example, in their literature review of the few studies estimating EMS response times models before the pandemic, Matteson et al.  found thk-means clustering algorithm with a mean and covariance instead of a distance-based one.In a more recent study, Zhou  found thBased on logLik estimates (sometimes using ranges and other times not), Zhou  GMM estik.’ This is akin to looking for some sort of a pattern within the data, but the researchers are not sure what the pattern is; and the results can, therefore, produce misleading findings and interpretations.There is no logLik estimate for their WARP method for Toronto. Their WARP model with logLik = 7.53−7.56 is smaller than the second-place GMM method with logLik = 7.87−7.96 and seems to work for Melbourne, but there is no logLik estimate for the stKDE method. Furthermore, their methods showed mixed results and it was (confusingly) hard to make a statistical decision on which of their three methods should be used for implementation that would be stable and reproducible over time. One of the major flaws in clustering analysis is that an attempt is made to group the association between variables—that may share some similarity but their association may be unknown—by distance and the clusters are arbitrarily defined by ‘More recent Covid-19 academic studies were just as problematic as earlier works. For example, Prezant et al.  developeThe method used by Amiry and Maguire  in theirU test to validate their model.The Covid-19 study by Azbel et al.  used whaThe statistical analysis by Xie et al.  involvedThe common statistical flaws in many of the studies mentioned above were that they were mostly non-parametric in nature, important variables such as ambulance types were omitted and most failed to account for statistical issues such as over-dispersion and fixed effects. The underlying special case of the Poison distribution such as the negative binomial in EMS call patterns was not considered in some studies.Furthermore, Ioannidis et al.  have cleTo overcome some of the statistical challenges facing fire and EMS analysis—as discussed in Henderson , Ingolfsinferences made from clustered standard errors, p-values, and confidence intervals, associated with the estimated coefficients.We use extensions to Poisson distribution theory in which comprehensive public policy decisions can be decided based on Therefore, the accuracy, consistency, and reliability of estimated parameters—using Wald, likelihood ratio (LR), and Lagrange multiplier (LM), AIC, and BIC tests found in econometric literature—and model fit can be verified and reproduced in a non-arbitrary way.From a public policy perspective, our investigation was illuminating because we compared and contrasted the before and after the state of FDNY’s system-wide performance in order to improve city health services to vulnerable populations and other residents in a future crisis.fixed effects negative binomial (FENB) model as discussed in Berge , and EMT/paramedic crew data that were often omitted from previous studies. Second, we address the non-parametric limitations of other Covid studies that may include two-way contingency tables.Our model uses key FDNY EMS data that includes EMS Incident Dispatch Data Specifically, we use the following FDNY’s EMS variables: Borough, Cad_Incident_Id, Incident_Datetime, Final_Call_Type, Incident_Response_Seconds_Qy, Incident_Travel_Tm_Seconds_Qy, and Incident_Disposition_Code.1In designing our purely numerical study that did not involve human subjects, we accessed data from two primary sources. The first source of the raw data before aggregation is a subset of the FDNY’s NYC 911 Ambulance Call Types, Priority and Response report that is available through the New York State Volunteer Ambulance & Rescue Association, Inc. and it is assumed to be an accurate representation at the time of writing. Specifically, we merged the FDNY’s EMS Incident Dispatch Data with the NYC 911 Ambulance Call Types, Priority, and Response report. Table The second source is the operational  benchmarks or performance measures are illustrated. There is a relationship between the number of calls or counts and duration  with the FDNY data. In between each call or duration, ambulances and other certified first responders (CFRs) are dispatched to each event; and the critical timing of such events is recorded.In Fig. total response time  and unit response time . Travel or response time as illustrated—by the shaded area in the process flow figure—measures the proportion of emergency 911 calls that can be responded to within a predefined benchmark by EMS agencies.Two important operational benchmarks of an EMS system are the travel time portion of unit response time in which the ideal NFPA benchmark is 4 min or less in responding to an emergency will be used as the dependent variable used in this study. Paramedic and EMT response time to EMS incidents is often critical because the faster that first responders arrive on the scene, the greater the likelihood of preventing a fatality.Response or travel time is often used as an important operational or performance measure for a variety of reasons, including resource allocation decisions such as whether to open or close call centers, types of ambulance crew and equipment deployed, and staffing levels at EMS call centers. The focus of this study is on the turnout times in a dispatch center.The notification methods , staff training, dispatcher experience, facility layout, ambulances in a ready-state, ambulances that are off-service due to vandalism, EMTs and paramedics availability, tasks at the time of alarm, etc.), weather conditions, traffic congestion, and road construction are all factors that can increase or decrease mobilization, and that in turn can affect availability—the degree to which the resources are ready and available to respond; capability—the abilities of deployed resources to manage an incident and operational effectiveness, a product of availability and capability.Prior to responding to an emergency, Moore-Merrell  suggestsThe faster emergency medical crews arrive on the scene, the more likely the number of injuries, deaths, property damage, and other losses can be minimized. Therefore, a lower time interval in an EMS response to emergencies is associated with the efficient allocation of call center staffing, EMTs, paramedics, and ambulances. On the other hand, higher EMS travel time may be linked to internal financial, crew, training, or equipment inefficiencies and the drastic need for improvement  methods based on the works of Berge (There have been recent advances in improving the efficient estimation of NB models with of Berge  and Cameof Berge . Thus thyijt is the average travel time (ATT) that is represented by the shaded area in Fig. t = 2019 and 2020; i = Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday; and j = Bronx, Brooklyn, Manhattan, Queens, and Staten Island. year, day and boro are three sets of fixed effects and xijt is a data frame of FDNY’s call volume data including aggregated call types, clinical priority, ambulance response  for the periods March 20, 2019–June 13, 2019 and March 20, 2020–June 13, 2020, respectively. β0 is an intercept term that is estimated separately and the other θ is an estimated over-dispersion parameter for the entire model.Using Berge ’s methodentclass1pt{minimaIt is worth noting according to the FDNY guidelines that both initial_call_type and final_call_type are usually the same and “[do] not reflect the actual condition of the patient. It is a determination based on information obtained from the caller for the purpose of defining severity and resource allocation. The call type does not change based on the findings of the on-scene ambulance crew.”Other to create the non-medical related category. The reference or base level for each categorical variable is Year = “2019”; Day = “Fri”; Category = “Other”; RespPrior = “BLS7” and Boro = "Manhattan”. The reference level for Call types in 2020 only is “CallTypeNo2019”, which is used as an ‘offset’ to account for a substantial number of call types that appeared only in the Year 2020 and there was no matching data for 2019. The column labeled “Estimate” contains the log(mean) or estimated elasticities of the independent variables in the model with different sets of uncorrected and corrected FE standard errors. The column labeled “Odds Ratio”, sometimes called an incidence rate ratio (IRR), is the estimated elasticities that have been exponentiated to simplify the results explanation. For example, log(Incidents) has an estimated value of −0.0300 which gives us an odds ratio of exp(−0.0300) = 0.9705 and an odds ratio (%) of 2.9544%.Table p-value = 0.8400), statistically speaking, there appears to be no significance between the two years. Wednesday is the only day that is significant when compared to the omitted day of Friday and it is the day with the largest increase in response time of 6.91%.We can interpret the estimated coefficient on the log(Incidents) as follows. The estimated odds of average travel time is equal to 2.9544% or close to 3% for each additional emergency call, given that all the other variables are held constant. The other elasticities are interpreted in a similar manner. Looking at the Year 2020, we see that the unit change in average travel or response time declined by −1.3526% when compared to the pre-lockdown year in 2019 and the FE standard errors were uncorrected. However, when the FE standard errors are corrected Y2020  had no statistical significance when compared to the omitted level of BLS7. However, travel times increased with all the other levels with DUAL 1 (61.6140%) and DUAL 2 , income, education, employment and unemployment, uneven emergency call patterns during the year, month or day, the priority assigned to the call, the ambulance or CFR crews assigned to the call, seasonal factors, geological or weather conditions, unpredictable events such as the Covid-19 Epidemic and other unknown factors—and they tend to increase over-dispersion within the EMS call volume process.θ)—that pertains to the whole model as opposed to non-parametric pairwise estimates—is shown in the table and it is significant, in which case we can conservatively assume there is substantial over-dispersion.The estimated over-dispersion parameter  is “partitioned into different clusters, treating each observation as independent from the others leads to [underestimating] the variance of the coefficient.” In other words, you get standard errors that are too small, narrow confidence intervals, inflated s Berge, .To correct for fixed effects, the model is re-estimated with clustered standard errors that are shown as the second set of standard errors in the column labeled ‘Std. error clustered FE’. This adjustment produces accurate standard errors which in turn is a critical component when making statistical inferences. It is important to point out that the estimated coefficients remain the same with or without the corrected errors. However, the expected values of the corrected standard errors are now much higher than in the uncorrected case when the observations were considered independent.In this study, we used an aggregated sample of 33,949 FDNY’s EMS calls for the pre-lockdown period of March 20, 2019–June 13, 2019, and the and post lockdown periods of March 20, 2020–June 13, 2020, with the goal of determining the system-wide effects of FDNY’s EMS key City Performance Indicators data such as daily call volume, year, day of the week, call types, clinical priority rank, ambulance types, NYC boroughs, an offset parameter and a dispersion parameter in predicting ambulance crew travel or response time using a fixed effects negative binomial regression model. Ambulance types  were often omitted from previous studies and this may be one of the recent studies to include those variables.Specifically, in estimating a fixed effect negative binomial (FENB) model, we used recent econometric methods that efficiently estimate maximum likelihood (ML) models with any number of fixed effects and easily obtained clustered standard errors with an algorithm that is based solely on the concentrated likelihood Berge, . This meThe modeling of EMS call center data was considered problematic, rudimentary, and quite often mis-specified, depending on which statistical method was used. More often some of these studies used a mixture of non-parametric and parametric methods that did not capture the key underlying properties of the associated statistical distributions and the complex processes involved in a modern EMS system , we see that Fridays with a count of 91,938 calls 15.04 (%) followed by Wednesdays with a count of 90,056 (14.73)% calls and Thursdays 88,385 (14.46%) were generally the busiest days of the weeks for emergency calls into the FDNY with a cumulative total of 44.23%. Every weekday—except for a minor increase on Saturday—saw declines in call volume, with major declines appearing to have occurred on Thursdays (18.69%) and Wednesdays (17.57%). A drill-down of the data in Table In creating the cross-section panel for model estimation, it was necessary to aggregate the raw sample of 611,276 observations by call or incident type because ambulance crews could have been dispatched to the same type of call on multiple occasions on the same day in different boroughs. Following data aggregation, the raw data was reduced to 33,949 observations that were used for model estimation.The daily call volume received by the FDNY’s emergency call centers is often modeled as counts, given the nature of its discreteness, nonlinear and non-negative values, and such calls are said to follow a negative binomial distribution when the outcome variables may be over-dispersed. This is the case where the conditional mean and conditional variance of 911 emergency incidents by medical and non-medical call type per second are not equal. The negative binomial is considered a special case of the Poisson distribution with an extra parameter added to account for over-dispersion. It is often difficult to tell if over-dispersion is significant in a model without estimation.per emergency incident call type or thousands of calls each month for a city with 8.4 million residents. The “clumping” around 1–10 daily calls per call type suggests that the variance is likely larger than the mean and this could result in over-dispersion.A high-level overview of Emergency CAD Incidents or call volume from our initial data set is shown in Fig. In Moller et al.  study ofp-values were reported in a format similar to ours in Table Having found that their over-dispersion parameter was inadequate, they then performed a ‘sensitivity analysis, modeling the data with a negative binomial distribution, resulting in a dispersion parameter of 1.16.’ It was hard to evaluate this study for comparative purposes because no standard errors, test statistics, or θ = 3.2171, std. err. clustered FE = 0.7770, Statistic = 4.2000 and p-value = 0.0000) in the model with corrected clustered standard errors. More importantly, our dispersion parameter was estimated using the full information from the entire sample and it is only in post-estimation analysis that over-dispersion can really be determined to be significant or not.One important distinction between this paper and many of the non-parametric studies is that over-dispersion was justified by the pattern first observed in Fig. In addition, when faced with the decision criteria for model selection involved in nested designs, the summary statistics criteria shown in Table For comparative purposes to two-way contingency tables  of categorical variables and the ratios of various cell’s proportions, average travel time, the dependent or outcome variable is actually a count, which is the average travel time per call type on a given day and borough.β)’ in Table β) = 1.4172 and explained in the “Results” section. This is the adjusted ratio of the average travel time for cardiovascular calls when compared to the average travel time for call types that were aggregated into levels labeled Other and served as the omitted, base, or reference level when all the other variables are held constant.The column labeled ‘Ratio exp, Lagrange multiplier (LM) along with AIC, BIC, and pseudo-d Engle, . Table 5Further graphical analysis is sometimes conducted to assess the appropriateness of model fit following estimation, even though it is rarely reported. A visual residual analysis would include a check for skewness, outliers, and other influential observations that would indicate specification errors in the chosen distribution. There are several options when it comes to plotting residuals following a negative binomial estimation and a Deviance residual plot is among the various classes that would also include Pearson and Quantile residuals. We used the Deviance residual class because it tends to reveal patterns that may not be apparent in other classes as discussed in Dunn and Smyth .Figure θ dispersion parameter, the Wald tests, and Deviance residual graphical analysis are combined we can safely assume that the negative binomial model is more appropriate in this case rather than the Poisson model when the presence of over-dispersion is detected.When the results from the estimated wed level in the day variable and this analysis is shown in Table The real interest in developing statistical models is quantifying which variables are relatively important in predicting a likely outcome. Day of the week would be likely important in predicting the demand for pre-hospital care at least from a call center (training and staffing) administrative perspective. Is there a demand for pre-hospital care on certain days of the week or times during warmer weather versus colder days or on the day before or after major holidays? For example, in our model when we controlled for each day of the week, Wednesday (WED) was the only day that was significant in the reduced model with the corrected standard errors. This raised an important specification question as to whether this was caused by a possible correlation among the independent variables. One method to assess whether this is the case is to estimate the reduced model with and without the This study has several methodological, data availability, and time period limitations, some of which will be addressed in a future article. First, each emergency call is associated with an individual person and as such, there is an associated name, race, gender, age, marital status, a particular location in a zip code, other socioeconomic factors , and related illness associated with each person or call that are not considered in this model specification.There was a huge disparity in Covid death rates that differed by gender, age, and race/ethnicity in 2020, according to the Centers for Disease Control and Prevention (CDC). In the United States, provisional nationwide death certificate data for January–December 2020 showed that ‘COVID-19 death rates were highest among males, older adults[≥85], and [minorities]. The highest numbers of overall deaths and COVID-19 deaths occurred during April and December. The mortality ranked order changed when COVID-19 became the third leading underlying cause of death  in 2020, replacing suicide as one of the top 10 leading causes of death’  were reported for the weeks ending April 11, 2020, and only if those patients received pre-hospital ambulance care by first calling the FDNY 911 call center. The second wave that followed around December 26, 2020, in which 80,656 is said to have died is excluded  or temporary field hospitals instead of over-crowded hospital emergency rooms during a Federal Emergency Management Agency (FEMA) crisis.Supplementary Information


Although exclusive breastfeeding is recommended for the first six months of life, a large number of women worldwide do not practice it successfully. Our study aimed to investigate the perceived support from health professionals for women who experienced difficulties in breastfeeding. Furthermore, we examined women’s knowledge about breastfeeding and motivation to breastfeed. We conducted a qualitative exploratory study (June to October 2019) among 15 women who had experienced breastfeeding problems in Germany. Semi-structured interviews were audiotaped, transcribed verbatim, and analyzed using qualitative content analysis following Mayring’s approach. Prior to giving birth, the women’s motivation to breastfeed and theoretical knowledge were high, and breastfeeding problems were not anticipated. Difficulties in breastfeeding after giving birth created a highly demanding situation for the mothers. Health professionals were either perceived as very supportive, for example, by providing helpful technical advice or being emotional assistance, or they could be perceived as nonhelpful, thereby worsening the situation, for example, by pressuring the women to breastfeed or making improper remarks. Adequate support for young mothers in childbed consists of the provision of useful and realistic information concerning breastfeeding and a sensitive treatment when breastfeeding problems occur. Paying attention to this specific group of women who are experiencing difficulties in breastfeeding may improve maternal and child well-being and potentially enable breastfeeding. Breastfeeding problems are a common phenomenon in mothers and children ,2. Up toOne aspect that may help reach a higher breastfeeding rate is support from health professionals. According to Leeming et al. , qualitaPrevious studies have shown that knowledge about breastfeeding and pre-birth intention to breastfeed is positively associated with the onset and duration of breastfeeding ,27,28,29We conducted a qualitative study among women who had problems with breastfeeding . We usedRegarding the sample size, theoretical saturation was attained. We reached a point of saturation around the 12th interview, and this indicated that additional interviews would not lead to an increase regarding the gain of information being obtained. Therefore, we stopped recruiting participants after the 15th interview. We used semi-structured interviews with open-ended questions that were conducted either face-to-face or via telephone. This manuscript includes an analysis of the following main themes and their subthemes: intention to breastfeed, state of knowledge regarding breastfeeding in advance, and support from health professionals regarding breastfeeding and breastfeeding problems.The interviews were conducted between 6 June and 22 October 2019 by the first author  . Prior tThe interviews lasted between 27 and 90 min . For the interviews, participants suggested locations where they felt comfortable talking and could not be disturbed. The same was suggested for interviews conducted via telephone. No third parties—except in some cases, the newborn or infant—were present during the interviews. All interviews were audiotaped and transcribed verbatim. Prior to the interviews, the participants were informed about the study’s procedure and data protection. All participants provided either written (face-to-face interviews) or oral (telephone interviews) consent to participate in the study. After the interview, all participants were provided with a €20 gift voucher as reimbursement for their time. Approval was obtained from the Ethics Committee II of the Medical Faculty Mannheim, Heidelberg University, on 26 March 2019 (number 2019-640N).To analyze the 15 transcripts, we used qualitative content analysis following Mayring . After hSince qualitative research is not able to apply statistical methods to establish validity and reliability  of the rFifteen women who had problems with breastfeeding or could not breastfeed participated in this study. All women had problems with breastfeeding their first child. Two mothers had breastfeeding problems with the second child, too , while two mothers were able to breastfeed their second child . Women were interviewed on average 33 months after breastfeeding problems occurred for the first time .The presumed main reasons for these problems included the baby itself, early start of  bottle-feeding, an insufficient amount of breast milk, and the mental condition of the mother. Further reasons were problems with correct latching, delivery through cesarean section, separation after birth, painful breast, potential genetic reasons, and health problems of the mother. The mean age (SD) of the mothers was 32.6 (5.3) years. The majority of them had one child (73%), three women had two children (20%), and one woman had three children (7%). When the participants gave birth to their first child, their mean age (SD) was 29.7 (5.3) years. The detailed demographic characteristics are shown in has always been clear” (M13) that they wanted to breastfeed . The others  told the interviewer that their wish to breastfeed had emerged during the early stage of their pregnancy. They had not questioned their decisions at all. It was a general opinion to take breastfeeding for granted. Reasons for wanting to breastfeed were as follows: positive effects on the health of the child, more convenience than bottle-feeding, lower costs, positive effects on mother-infant attachment, positive effects on the health of the mother, and meeting social norms , and one woman mentioned the influence of maternal diet on the composition of breast milk (M10). Regarding practical skills, only one woman (M11) said that she had already known how to latch the newborn correctly, and M05 told the interviewer that she had already gathered a lot of experience with the children in her family. Others  tried to learn about breastfeeding positions by reading guidebooks.Women had a general knowledge of the positive health outcomes of breastfeeding for children and mothers . However, M04 said, “learn by doing” (M14). “To be honest, I didn’t think about it at all beforehand, and that is exactly how I tick. I believe it is a stepwise procedure. First, the child has to be here, and then we will see how it works”. (M10). In retrospect, M14 recognized that she “could not imagine that it  would be so difficult”. Others had been surprised that breastfeeding was not easy at all for them. M07 noted, “Maybe I should have done a little more research [on breastfeeding]” and:Many participants stated, however, that they spent only limited time learning about breastfeeding in particular. They had believed that breastfeeding would come to them naturally and they would “I always believed it works automatically. At first, I actually did not know what I was going to do with the child (laughs): where and how to/not to position the child in order to breastfeed. Somehow, one is more unprepared than one thinks”.“(M09)Retrospectively, I must say that I am quite astonished because it really is a very large part of a mother’s first tasks to breastfeed a child; the birth preparation course did not play a role in this”. Some women had mentioned that health professionals ignored them when they asked for further information. “They just said, ‘Don’t worry about that. It will all work!’” (M04). Undergoing practical exercises on how to breastfeed with a doll during the course was rare .Attending a birth preparation course was popular among the participants . While most of the women had received, at least to some extent, information on breastfeeding in these courses, others did not obtain as much information as they desired or any preparation at all. M12 had not been able to attend the course to the end due to preterm birth, and M03 stated that “During the birth preparation course, they always said, ‘Yes, there can be breastfeeding problems.’ However, the details of the problem were not clear to me”. (M09).M01 clearly indicated that information on formula-feeding was limited, and a few participants  conceded that later on when they experienced breastfeeding problems, they were overwhelmed with bottle-feeding their children. M09 retrospectively also wondered why breastfeeding problems had not been addressed in the birth preparation course. “So the midwives and nurses I had in my ward provided help regarding breastfeeding; I would go there repeatedly. They provided the best support and advice and they were there for me”. (M11), and “The nurse was just wonderful. She tried everything and provided support with breastfeeding”. (M10).After giving birth, participants reported being technically advised concerning breastfeeding by health professionals during their hospital stay  and being supplied with useful materials, such as nipple shields, nipple ointment, or a breast pump . Gratefulness for the helpful counseling was occasionally expressed during the interviews: “They were all super friendly, and they said if I needed help, I should let them know. The implementation was not so great, because everyone had a lot to do, of course”. (M07). M08 was completely disappointed with the overall care in the hospital and said that it was “[…] bad. Very, very bad”.However, some participants reported asking for help to no avail. “What made me insecure right from the start was, um, that, at the hospital, […] about three pediatric nurses came into the room during the day and each one somehow had a different opinion from the others on how this  should go”.“(M03)Some of the women were irritated by health professionals who had different opinions regarding breastfeeding , e.g.,:[…] they were also of divided opinions . One said, ‘At least every four hours’, the other, ‘No, let him sleep’, the other, ‘Just not at night!’, and the other, ‘Yes, definitely at night!’”.M07 stated that “And when we were at home, the midwife simply said to me, ‘breastfeeding often doesn’t work after a cesarean birth’ and didn’t really help to try anyway”. When M02 tried to at least partly meet her breastfeeding goals by pumping breast milk for her firstborn, who had a cleft lip and palate, she did not find the physician supportive. “The oral and maxillofacial surgeon more than belittled my effort to pump breast milk”. (M02). Moreover, mothers felt pressured . For instance, M07 subsumed, “I was exposed to a lot of pressure, from the pediatrician among others”. This even led to misinforming women to encourage them to breastfeed at any cost . “She  then said, ‘Yes, when you pump, the milk goes back.’That is not true at all, as breast milk is stimulated”. (M15). Very negative and devaluating situations with health professionals were experienced when breastfeeding did not work, such as being confronted by strong breastfeeding supporters . “When I was asked if I was still breastfeeding and I said no, the only reply from the pediatrician was ‘What are you doing to your child? Breastfeeding is the best thing that you can do.’” (M05). M15 experienced one particular situation in the hospital in which she was completely exhausted from breastfeeding and in which the midwife refused to provide her the amount of formula as requested but imputed her a lack of desire to breastfeed. “And then she  looks at me and says, ‘If you don’t want to breastfeed, then stop.’ You felt so bad that you decided you don’t want to breastfeed anymore, because you cannot. That was so reproachful”. (M15).When experiencing breastfeeding problems, several women felt as if they were not taken seriously and found the health professionals to be insensitive . M13 said, “However, luckily, I had a really great midwife who said, ‘Come on, relax and do not stress yourself. Do not focus so much on the fact that he is drinking now, but focus on the fact that you get a feeling of what it is like to deliver milk, first.’”“(M08)Other women said that they did not have the impression that not being able to breastfeed changed anything in the treatment they received from hospital staff . However, participants also emphasized the emotional support they received from health professionals , especially from their midwives at home . M08 summarized:Midwives were often seen as the most helpful conversational partners when talking about the difficult breastfeeding situation , whereas none declared a physician or a specialized breastfeeding advisor as an important dialog partner. Furthermore, M09 found a nurse working with an aid agency to be the most helpful assistant.the midwives or the nurses did not agree with one another” (M01). M15 mentioned that there was a difference between the hospital staff and her aftercare midwife, in which the latter was “completely relaxed [regarding the breastfeeding topic]” (M15). However, M04 told the interviewer that her midwife favored formula-feeding, and two women stated that the health professionals in the hospital were rather neutral regarding how to feed the newborn .Altogether, the entirety of health professionals was considered to be strong breastfeeding supporters . However, others had the impression that health professionals saw breastfeeding as the best option but also knew that in some cases, formula-feeding was justified . Yet, however, others reported experiencing both very supporting and differentiated views from health professionals concerning breastfeeding . M01 and M07 mentioned that “Many of the participants wished that the health professionals would provide more help and advice to them. This was also related to the women’s wish for the health professionals to create more time for their needs. Several women also mentioned the lack of competent advice as something to improve on. More sensitive treatment and, in particular, the reduction of pressure were desired changes for the better. However, some also emphasized that they were satisfied with the overall care and actually had no real suggestions for improvement .Our study showed that the participants wished to breastfeed and were mainly motivated by the potential positive health effects for the child. The women were well-informed, as many of them attended a birth preparation course, where they gathered theoretical knowledge; however, practical knowledge was low. Based on this, most participants perceived breastfeeding as being natural and were surprised when they were confronted with problems.After giving birth, nearly all women received technical advice on breastfeeding from health professionals and experienced emotional support when breastfeeding did not work, especially from their aftercare midwives. However, some participants also experienced negative situations with health professionals and perceived, for instance, insensitive, pressuring, and devaluative treatments. In many cases, the women felt as if their needs and questions were being ignored at the hospital. Some reported that different health professionals had different opinions on breastfeeding, and this irritated the women. Overall, the participants in this study would wish for more attention to be paid to them and advice, in addition to the consensus and empathy from health professionals in potential future pregnancies.In line with our findings, previous studies have shown that the intention to breastfeed is often developed before or during the early stage of pregnancy ,33. ManyIn line with another study, the most frequent reasons for intending to breastfeed were the benefits for the infant’s health, whereas the benefits for the mother herself did not play such an important role . This shWe found that midwives play an important role in the overall care of young mothers in this very vulnerable phase in a woman’s life. In a previous study, two main types of midwives were identified: those who are rather “breast centered” and mainly provide technical advice to women on how to feed the child and those who are rather “women centered” that accompany young mothers and have a greater focus on the woman’s well-being . HoweverOur participants’ experiences with various health professionals when they perceived breastfeeding problems ranged from very positive to quite negative. In line with this, previous research showed that, while some health professionals were very sensitive toward women in childbed and were, therefore, quite helpful ,40,43, oInconsistent and different information on how to breastfeed, as some of the participants in our study mentioned, was also reported in other studies ,40,45,49Based on our findings and the findings from previous studies, different ideas for future research can be developed. In our study, different aspects were mentioned in the interviews that we were not able to investigate in detail, for instance, the variety and nature of different breastfeeding problems. Moreover, further research may focus on the effect of different care models for women in childbed and which impact a home care system with one responsible midwife can have on breastfeeding compared to other care models.First, as our qualitative study consisted of a convenience sample extended by snowballing, the generalizability of our findings may be limited . HoweverOur study provides important suggestions for handling women with breastfeeding problems. Providing balanced and realistic education concerning breastfeeding, potential problems, and bottle-feeding as an alternative during pregnancy may help young mothers to anticipate difficult situations when it comes to breastfeeding. Spending enough time with the women and providing them with support  without pressure may help them overcome problems and successfully breastfeed. It might also be helpful to address potential breastfeeding problems and the alternative of formula-feeding during birth preparation courses, which was not thematized in the courses attended by our participants. Mothers who know the details about specific problems that can occur during the first time with a newborn may be able to better cope with potential problems. Since mothers’ intention to breastfeed is high, education on potential problems and alternative forms of feeding will probably not weaken this motivation. However, informing all women about formula-feeding in the birth preparation course may help those mothers who have to formula-feed to feel less stigmatized .Midwives in the aftercare have great influence and should be aware of their impact. They are an important person of trust and, therefore, a helpful player in the situation when breastfeeding problems occur. Home care midwives are able to provide advice that suits the individual situation.It is important to provide a sensitive way to deal with this specific group of women who aim to breastfeed and are informed about the positive health outcomes for the child but are totally devastated due to the inability to breastfeed. Providing them the feeling of being a good mother, whether they breastfeed or not, might help them to overcome this situation. Informing these women that breastfeeding problems are quite common and that it might not always work out as easy as believed may help them to cope with potential feelings of guilt and self-blame.We found that women can be faced with breastfeeding problems, although they intended to breastfeed, are highly motivated by the potential positive health outcomes for the child, and are well-informed. These women require specific and sensitive care in hospitals and during aftercare. Additionally, they need information, support, and time to overcome the experienced disappointment and, possibly, be able to breastfeed in the long run. Therefore, inconsistent opinions and pressure from health professionals may be counterproductive. Particularly, midwives play an important role, as they act as trusted persons.Health professionals and especially midwives in aftercare can be a valuable help for mothers experiencing breastfeeding problems. Their support can be the key to improving maternal well-being and potentially enabling breastfeeding in the end.


In Japan, there is an imminent threat of major earthquakes and floods. Children’s health is increasingly at risk from climate-change-related disasters. The purpose of this study was to identify factors related to mothers’ worries about the effects of evacuation on their children. Participants were mothers whose children attended a childcare center in one municipality in Ishikawa, Japan. A cross-sectional design was used. A questionnaire was developed based on previous studies, and it was used to conduct a survey. A total of 1298 individuals who provided valid data were included in the analysis. The following factors were related to mothers’ worries about the effects of evacuation on their children: not having prepared a grab bag as a disaster risk reduction strategy, having no neighbors to help them in case of disaster, having children aged <3 years, and having children with allergies. The mothers of children <3 years old with allergies who are unprepared and have no social support are likely to worry about evacuating their children. Policymakers must be aware that the mothers of children aged <3 years and the mothers of children with allergies experience substantial concerns about the effects of evacuation on their children. In recent years, the imminent threat of a Nankai Trough earthquake or an earthquake directly under the Tokyo metropolitan area has become apparent in Japan. The Noto Peninsula Earthquake in March 2007 had a seismic intensity of 6 and killed one person . In DeceChildren’s health is increasingly at risk from recent climate-change-related disasters . During Parental anxiety, mental instability, a poor family environment, irritability, and violence in post-disaster evacuation settings increase stress transmission to children  and incrThere have been several studies of parental anxiety about evacuating with children during a disaster. For example, after the Great Hanshin-Awaji Earthquake, the parents of medically vulnerable children expressed concerns about the availability of medical treatment at evacuation centers. During the Great East Japan Earthquake, the parents of children with disabilities avoided evacuating to public shelters because they worried that their children would become confused and disturb others with disruptive behaviors, such as screaming . The parTo ensure that mothers and children respond calmly and cooperatively to disaster evacuation, it is important to try to clarify and resolve any fears or concerns that mothers have during normal times. Preparedness strategies are central to coping with disasters, such as preparing disaster supply kits for children and families, participating in evacuation drills, and mutual support within neighborhoods ,28,29,30This was a cross-sectional study that used self-administered questionnaires. All parents whose children attended a childcare center in one municipality in Ishikawa Prefecture were included in the study. Childcare centers in Japan are defined according to the Child Welfare Act, and they are facilities that care for children aged 0 to 5 years at the request of their parents ,37. TheyTo assess mothers’ backgrounds, the respondents were asked their age, their length of residence, whether they were pregnant, and whether they had evacuation experience. The possible responses were “no” or “yes.”To assess disaster preparedness and support, respondents were asked to reply “no” or “yes” to the following questions: Can you visualize yourself living in an evacuation center? Have you prepared a grab bag for disaster risk reduction? Do you have parents or relatives who can help you in case of disaster? Do you have neighbors who can help you in case of disaster? Are you worried about the effects of disaster evacuation on your children? The aim of this latter question was to assess concerns about evacuation to a public shelter in Japan in the event of an earthquake and/or flooding. As such, the intention was to measure a level of worry other than the normal low-level constant anxiety that mothers have about their children.To assess children’s background and allergies, the respondents were asked about the number of children and the children’s sex, age, whether they were breastfeeding, eating baby food, allergic to any foods, or had any non-allergic conditions.There were multiple response options for the question about food allergens. Parents were asked to select from chicken egg, milk, wheat, peanuts, buckwheat, shrimp, and crab and to note down any other allergies that their children had. The respondents were asked whether they used allergy-free foods (“no” or “yes”); whether they stockpiled allergy-free foods ; if their children took medication for allergies (“no” or “yes”); and if they stockpiled medication . The respondents were asked to state if their children had atopic dermatitis (“no” or “yes”). If they responded “yes”, they were asked to select from moisturizing lotion or steroid ointment and to note down any other treatments that they used.Of the participants, those who responded to all the items regarding the mother’s background, disaster preparedness and supporters, children’s background, and factors related to worries about children in case of a disaster were included in the analysis.After the Great East Japan Earthquake, it was recognized that mothers who have to evacuate with their children are particularly vulnerable during disasters, and they require greater consideration during the evacuation process . AlthougThe current years of residence were categorized as “less than 5 years” and “more than or equal to 5 years”; the number of children was categorized as “one” and “two or more” ; and chiThe chi-square test or Fisher’s exact test was performed to examine the relationship between mothers’ worries about the effects of disaster evacuation on their children, mothers’ background, disaster preparedness and supporters, and children’s background. A binomial logistic regression analysis was performed to examine factors associated with mothers’ worries about evacuating their children. The independent variables were tested using chi-square, and the following variables, which had a statistical significance of less than 5%, were selected as predictors: “not having prepared a grab bag for disaster risk reduction”, “having no neighbors to help in case of a disaster”, “having one child”, “having children aged under 3 years”, “breastfeeding”, “having children still eating baby food”, “having children with an allergy”, and “having children with an illness other than an allergy”. Each variable was checked for multicollinearity (coefficient of variance expansion ≥10) prior to performing a binomial logistic regression analysis. Maternal age was selected as a potential confounding variable. Variable input was performed using the forced input method. The Hosmer–Lemeshow test was used to assess the model fit. The significance level was set at 5%. SPSS Ver27  was used for all statistical analyses.This research was conducted in accordance with the Declaration of Helsinki, 1995 , and it was carried out with the consent of the university medical research ethics review committees at the authors’ universities (No. I400). The participants’ freedom to refuse to participate, freedom to withdraw their cooperation, anonymity, and privacy protection were explained in writing, and consent was assumed by participants depositing the survey form in the collection box.Responses were obtained from 1908 parents (a 72.4% response rate), of which 1790 (93.8%) were mothers. Of these, 1298 (72.5%) provided valid responses for all survey items.Of the participants, 798 (61.5%) reported anxiety about the effects of disaster evacuation on their children, and 583 (38.5%) did not. Data on the reported demographic characteristics of the participants are shown in Data on reported allergies and the stockpiling of food and medication are shown in n = 917, 88.8%; p = 0.01), having no neighbors to help in case of a disaster , having one child , having children under 3 years old , breastfeeding , having children who eat baby food , having children with some kind of allergy , and having children with an illness other than allergies .The purpose of this study was to identify factors related to mothers’ worries about the effects of evacuation on their children. Almost two-thirds of participants expressed concerns about the effects of disaster evacuation on their children. The main findings of this study were that mothers were likely to show evacuation anxiety if they were unprepared for evacuation, had no social support, had children younger than 3 years, or had children with allergies. Policymakers need to be aware that the mothers of children younger than 3 years and the mothers of children with allergies experience anxiety about how evacuation may affect their children.In a previous study of the mothers of children attending childcare facilities in Japan, the average age of mothers was 35.7 years , and in The present findings suggest that the mothers of children younger than 3 years old with allergies who have not prepared a grab bag for disaster risk reduction and have no one to rely on may be living with anxiety about the effect of evacuation on their children. It has long been reported that medically fragile populations are less prepared for disasters despite their concerns ,51,52. SThere were some limitations to this study. The target population was a childcare center in one municipality of Ishikawa Prefecture. The timing of the survey encompassed part of both the summer and autumn seasons, and so the risk of disasters varied over this period. In addition, we were unable to obtain data on the prevalence and treatment of chronic diseases other than allergies. This may have affected the responses. Regarding disaster preparedness for children with allergies, the mothers of children with newly diagnosed food allergies may have planned to adopt measures to address the allergies but had not done so before the survey. This was a cross-sectional study, so it was not possible to establish causal relationships between the variables under investigation. Despite these limitations, our study provides some considerations for policymakers in developing evacuation environments in response to disasters. The collection of data on chronic illnesses in children and concerns and anxieties in mothers is important in the preparation of shelter environments and the development of stockpiling strategies. It is also important to ensure that children with chronic illnesses are identified and that appropriate support measures are put in place during evacuation. Additional studies are needed in the future that investigate a larger number of target municipalities and that obtain more representative samples.Municipal policymakers need to be aware that mothers with children younger than 3 years and those whose children who have allergies experience anxiety about the effects of evacuation on their children. Measures that identify children with allergies and provide allergen-specific provisions for evacuation shelters are recommended. For example, the stockpiling and delivery of allergy-free food are possible solutions to support evacuees with food allergies. In addition, the establishment of an environment where the mothers of children attending childcare centers can interact with other community members, share information about their children’s condition, and discuss countermeasures is recommended. In addition to fostering community-level connections and addressing mothers’ worries, the preparation of a disaster risk reduction grab bag tailored to each child’s pre-existing conditions and characteristics would be useful. A related recommendation is to prepare a minimum amount of supplies that are carefully selected, rather than a generic grab bag, to help children survive and recover in the event of an evacuation. However, the selection of such supplies must take into account the possibility that carrying more supplies may prevent a child from evacuating quickly.


The coronavirus disease 2019 (COVID‐19), which has caused a global pandemic, is brought on by the Acute Respiratory Syndrome coronavirus 2 (SARS‐CoV‐2). Since the COVID‐19 pandemic started so recently, dealing with complications that emerge years later and have the potential to cause several crises for humanity is one of the issues we face in the post‐COVID‐19 age. Therefore, we wish to discuss a theory and potential dangers surrounding the probability of schizophrenia following COVID‐19 infection in this study.The literature search for this article has been entirely internet‐based. Information was gathered using the Web of Science, PubMed, Scopus, and Google Scholar databases.The results showed that multiple immune system changes brought on by COVID‐19 have been identified as potential causes of schizophrenia.It is predicted that one of the long‐term effects of COVID‐19 is an increase in the risk of schizophrenia incidence based on the results of this study, which looked at the pathophysiology and etiology of schizophrenia as well as the pathogenic mechanisms of the SARS‐CoV‐2. Therefore, healthcare staff should be prepared to handle any potential risks in future. Globally, this pandemic has caused serious problems, and our knowledge of this disease is still developing.2Delusional beliefs, hallucinations, and changes in thought, perception, and behavior are all characteristics of the functional psychotic disorder schizophrenia. Positive symptoms, such as hallucinations, delusions, and formal thought disorders, and negative symptoms, such as anhedonia, poverty of speech, and lack of desire, have traditionally been separated into two primary categories.2.1Regarding schizophrenia developments, there are three primary theories. According to the neurochemical abnormality hypothesis, an imbalance of dopamine, serotonin, glutamate, and GABA causes the disease's psychiatric symptoms. The presence of anomalies in the cerebral structure, the absence of gliosis, which suggests in utero changes, and the finding that motor and cognitive impairments in patients occur before the commencement of the illness are additional indications that schizophrenia is a neurodevelopmental disorder. The disconnect hypothesis, on the other hand, emphasizes the changes in neuroanatomy. Schizophrenia results in a decrease in grey matter volume that affects both the parietal and temporal lobes.2.2Toxoplasma gondii infections increases the risk of schizophrenia.The etiology of schizophrenia has not been clearly defined. According to several studies, alterations in numerous neurotransmitters, such as glutaminergic and GABA hypoactivity or dopaminergic, serotonergic, and alpha‐adrenergic hyperactivity, contribute to the development of schizophrenia. Genetics also has a substantial impact.3Initially, it was assumed that COVID‐19 only had an impact on respiration. However, rising evidence reveals that COVID‐19 is also associated to a variety of neurological disorders. Patients with COVID‐19 may experience neurological symptoms as a result of a cytokine storm and an intensified state of inflammation.Although the pathogenic processes causing CNS invasion are yet unknown, it appears that SARS‐CoV‐2 enters the brain via a hematogenous pathway. Alternative routes, such as the cribriform plate of the ethmoid bone close to the olfactory bulb, should be taken into account. In addition, the isolation of SARS‐CoV‐2 from cerebrospinal fluid implies that the virus might directly infect the neurological system and harm nerves.The severe, occasionally deadly pulmonary and cardiac consequences of COVID‐19 infection are believed to be caused by a profound inflammatory response, and it has been hypothesized that this response also triggers neuropsychiatric symptoms via immunological processes. In the pathophysiology of psychiatric diseases including schizophrenia, depression, and psychotic disorders, viruses' infection, and immune‐based triggers have long been thought to play a role. C‐reactive protein has been investigated as a potential peripheral measure of immunological activation, which is suggested to have a causative or triggering function in schizophreniform psychosis. Human coronaviruses have been demonstrated to possess neuroinvasive properties as a result of either autoimmune or viral replication, leading to the hypothesis that they may function as opportunistic infections of the CNS. In fact, additional coronaviruses have been associated with neuroinflammation and CNS penetration in psychotic disorders.Eventually, it can be said that COVID‐19 can cause several changes in the human immune system, which are known as possible etiology of schizophrenia. Besides the biological effects of COVID‐19, which can increase the risk of schizophrenia, the COVID‐19 pandemic may be contributing to an increase in reactive psychotic disorders since it is so stressful.4Overall, we should think about conducting studies that investigate the incidence of schizophrenia due to COVID‐19, and also health activists should be prepared for possible threats. Previous studies have shown that COVID‐19 has various psychosocial effects on schizophrenia patients, which makes these patients show worse mental recovery and worsen their symptoms such as stress, anxiety, fear, sadness, and loneliness. Thus, schizophrenic patients should be specially cared for and supported against COVID‐19. As a result, it is suggested to conduct more studies on the psychosocial symptoms of COVID‐19 on schizophrenia patients at the same time as studying the incidence of schizophrenia following COVID‐19.Mohammad Pourfridoni: Conceptualization; writing – original draft; writing – review and editing. Hedyeh Askarpour: Writing – review and editing.The authors declare no conflict of interest.The lead author Hedyeh Askarpour affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned  have been explained.


This study clarifies the concept of illness intrusiveness in patients with a chronic disease using the hybrid model method. To clarify the dimension, attributes, and definition of illness intrusiveness in chronic disease, three phases of analysis were conducted. In the theoretical phase, a working definition was devised through a systematic review. In the fieldwork phase, individual in-depth interviews were conducted with nine participants with chronic diseases. In the final analytic phase, the results were integrated through comparison and review. There are four domains and eleven attributes of illness intrusiveness in chronic disease. The domains include physical, psychological, social/contextual, and spiritual. The physical domain consists of four attributes: pain, fatigue, physical malfunction, and change of body image. The psychological domain consists of three attributes: psychological weakness, uncertainty, and stigma. The social/contextual domain is made up of three attributes: withdrawal of role play, limit of daily life, and burden of changing health habits. Finally, the spiritual domain had one attribute: unstable spiritual state. Thus, based on the study findings, it is necessary to develop a suitable illness intrusiveness in chronic disease assessment scale to assess chronic disease patients. In modern society, the prevalence of chronic diseases has been increasing due to population aging, lifestyle changes, and environmental pollution . In KoreChronic diseases refer to persistent, latent, and incurable pathological conditions that require long-term treatment and care for at least six months . In otheA study on the influencing factors of QOL in patients with a chronic disease by Devins  presenteRegarding previous global studies on perceived illness intrusiveness, a study by Renn et al.  on levelRegarding previous studies in Korea on perceived illness intrusiveness and the significant influencing factors thereof, Son’s  study onIn Korea, illness intrusiveness is also referred to by various other terms, including “illness-induced changes”, “perceived illness effect”, and “illness disability”. Illness intrusiveness is an important concept with respect to the QOL or subjective well-being of patients with chronic disease; therefore, it is necessary to use consistent terminology. For this, it is necessary to identify the attributes of perceived illness intrusiveness experienced by patients with chronic diseases. Furthermore, a review of available literature, including literature from the field of nursing, and others is necessary. The hybrid model concept analysis used by Schwartz-Barcott and Kim  enabled Derive a working definition of perceived illness intrusiveness in patients with chronic diseases through a review of literature;Derive the definition of perceived illness intrusiveness in patients with chronic diseases through in-depth patient interviews;Combine the comparative analysis results on data obtained through the above methods to derive the final definition of perceived illness intrusiveness in patients with chronic diseases and present the empirical evidence.The primary objective of this study is to clarify the definition and empirical evidence of perceived illness intrusiveness in patients with chronic diseases through the hybrid model concept analysis used by Schwartz-Barcott and Kim . The speThis study is a methodologies study that used the hybrid model concept analysis method consisting of three phases  to examine the domains and attributes and confirm the definition of perceived illness intrusiveness in patients with chronic disease.In the theoretical phase, the domains, attributes, and a tentative definition of the concept were derived through a systematic literature review. The theoretical part of the study was a systematic review conducted in accordance with the stages proposed by the Centre for Reviews and Dissemination (CRD) guidance for conducting reviews in health care .First, the review question was focused on “the essence at the core of illness intrusiveness” and “domains and attributes that can be reflected in defining the essence of the concept”.Second, the article type was that the current study examined every original article published on the topic of illness intrusiveness, including quantitative, qualitative, mixed-method, and instrument development studies.PubMed, CINAHL, SCOPUS, and Embase for foreign literature and RISS, DBpia, and KCI for Korean literature. The search terms were “chronic disease or illness” and “illness intrusiveness” in English and Korean. The inclusion criteria for the articles analysed in the present study were those including survey studies, qualitative studies, literature review studies, and reviews that examined perceived illness intrusiveness in patients with chronic diseases. Two researchers reviewed and organised the searched articles. Exclusion criterion was non english language.Finally, the search strategy was that Korean and foreign academic articles published between January 1995 and July 2021 were selected through a search using a combination of search terms. For this, databases (DBs) were divided for two researchers to perform the search. The search engines used included The search yielded a total of 1004 articles (919 foreign and 85 Korean articles), of which 258 duplicates were excluded. Subsequently, a total of 702 articles were excluded based on a title review for the following reasons after first review. We searched additional records through hand searching key journals and trial registers. No further data could be found. A title search was used as the primary review, and 702 documents were excluded: In English, 662 documents unrelated to “illness intrusiveness”, 3 documents from the acute phase, 4 cases from paediatric disease, and 4 study designs that did not fit the topic were excluded. In Korean, 27 documents unrelated to “illness intrusiveness”, 3 documents related to the acute phase, and 27 documents unrelated to “illness intrusiveness” were excluded. In the second review, abstracts were searched, and three foreign and four Korean literatures that were not related to illness intrusiveness were excluded. The full texts of the remaining 40 articles were reviewed. Then, the Transparent Reporting of Evaluations with Non-randomised Designs (TREND) checklist was used to assess the quality of the quantitative articles and the Consolidated Criteria for Reporting Qualitative research (COREQ) checklist for qualitative articles . At thisa.Data collectionIn a hybrid model, the fieldwork phase involves the observation of phenomena related to a concept; furthermore, the meaning and attributes of the concept that appeared in the theoretical phase must be verifiable and in-depth interviews must be conducted appropriately . In the The participants in the study were convenience sampled by posting announcements on the bulletin boards of an apartment complex in Jinju city. For the fieldwork phase of a hybrid model, three to six individuals who can be contacted repeatedly would be appropriate . BecauseData were collected between 15 and 30 July 2021. Those who consented to participate in the study were given the option between face-to-face or telephone interviews considering the COVID-19 pandemic and other precautions. For the three participants who opted for face-to-face interviews, the interviews were conducted in an independent space (café or office). For others, the interviews were conducted over the telephone. Each individual in-depth interview was conducted for approximately 50–60 min at an agreed time. The interviews were conducted in a quiet place, ensuring that the interview could be recorded, and the participants could talk comfortably. Structured key questions and non-structured questions were asked for verifying the attributes of perceived illness intrusiveness to be analysed in the theoretical phase. These include: “Do you have difficulties due to your illness?”; “Can you tell us about changes in your daily life while having to treat and manage your diagnosed illness?”; “What is the most difficult part of living with an illness?”; “What is the most difficult part of the treatment process?”; “If you feel you are having more difficulty than others, what is the reason for this feeling?”; and “In your mind, what is the meaning of living well with a chronic disease?”b.Data analysis and rigorTo assure the rigor of the study, validity was established by testing the credibility, transferability, dependability, and confirmability, which are the assessment criteria for qualitative studies proposed by Lincoln and Guba . For creAmong various Korean terms used, the term for illness intrusiveness that best reflects the characteristics of Korean culture was used to conduct the concept analysis.c.Final analysis phaseIn the final analysis phase, the results from the theoretical phase and in-depth interviews in the fieldwork phase were crosschecked. The attributes identified in the theoretical phase were reviewed to derive the final empirical evidence for perceived illness intrusiveness in patients with chronic disease.Regarding data collection from participants, the study received approval from the Institutional Review Board (GIRB-G21-Y-0035). Before starting the interviews, all participants were informed of the study’s objectives and methods: their right to withdraw from the study at any time; the use of interview contents for research purposes only; the security and confidentiality for the protection of personal information: the anonymity of personal information; and the disposal of recorded data after a set storage period. Written informed consent or verbal consent over the telephone was obtained from each participant. All participants who completed the interviews were given a gift as a token of appreciation.The first author acquired knowledge about chronic diseases through twenty years of clinical fieldwork and coursework on self-care for patients with chronic disease and empirical knowledge from encountering and caring for patients with chronic disease in the field. In addition, they learned in-depth interview methods and key points by completing courses on nursing theory development and qualitative research methodologies in graduate school. The second author has taught graduate courses on nursing theories, concept analysis, and qualitative research and has experience in various qualitative research projects through 18 years of clinical experience.The term “illness intrusiveness” inherently contains an “illness” aspect and an “intrusiveness” aspect. The “illness” aspect refers to a state of not being able to function normally due to acute or persistent impairment of a part or the entirety of the mind and body, and “illnesses” can be divided into infectious and non-infectious diseases .In Korean, the term “illness intrusiveness” is translated and used in various words, so integration is needed.The literature review shows that, regardless of the field of study, illness intrusiveness in patients with chronic disease was analysed as a multidimensional concept that can be classified into physical, psychological, and social/contextual domains. The attributes analysed by specific fields, such as nursing, medicine, and psychology, are as follows:In nursing, the physical domain of illness intrusiveness in patients with chronic disease included physical pain , weaknesIn medicine, the attributes of the physical domain of illness intrusiveness in patients with chronic disease included being affected by the illness due to pain ,24,25,26In psychology, the physical domain included patients experiencing disease-related pain ,40 and pBy combining the attributes of illness intrusiveness in patients with chronic disease identified in each field, a working definition of illness intrusiveness in patients with chronic disease in the theoretical phase can be given as follows: “Negative changes experienced physically, psychologically, socially, and contextually within the illness and treatment process, which could threaten the well-being of patients who are unable to respond effectively to such changes” .A total of nine participants  participated in the interviews during the fieldwork phase. The average age of the participants was 63.4 years old. Moreover, eight participants were married, one participant was unmarried, and three out of nine participants were employed. With respect to the types of chronic disease, three participants had diabetes; two participants had hypertension; one had a combination of chronic rheumatoid arthritis and hypertension; two had a combination of chronic irritable bowel disease and diabetes; and one was receiving conservative treatment after completing 15 rounds of chemotherapy for gastric cancer. The duration of illness varied between 2–30 years .The study used the content analysis method by Elo and Kyngäs , which uThe participants experienced various “changes in body image” due to chronic disease, including muscle loss and change in skin colour, with darkening of the tips of the hands and feet, and damage to the peripheral nervous system, such as numbness in the hands and feet. The participants also experienced “loss of fitness” due to persistent fatigue and sweating caused by the illness as well as “sleep disturbance” that caused them to wake frequently during the night, preventing deep sleep. The patients suffered from discomfort caused by their illness as well as other forms of pain due to haemorrhoids or neuropathy caused by adverse treatment effects. The following excerpts from the interview transcripts outline this theme:I can’t live like this with numbness in my hands and feet… But, there’s nothing I can do except go to a bathhouse… Drugs that I take don’t work and it doesn’t come back… The doctor… Look, look!! The tips of my hands and feet are dark, right? It’s dead.(Participant D)As if my hands and feet being numb all the time wasn’t enough, I sometimes feel pain like being poked with a needle. It’s not going to get any better since it’s an adverse effect from chemotherapy, but that suffering can be more severe at times than any surgery.(Participant D)My job is that of a building cleaner. My fingers and joints are swollen and painful in the morning, so I have to soak my hands in warm water for about an hour before I can squeeze and open them. Moreover, because the fingers are already bent, holding a small tool is inconvenient.(Participant I)As participants experienced their diagnoses of the chronic diseases and lengthy treatment processes, they faced “sorrow about the stigma of being a patient” from the words and actions of others, along with “self-blame about the disease” in believing that they did not take good care of themselves.One time, I was taking insulin inside the dressing room at work, and even my superior knew it was diabetes, the look that he gave me… I guess the sight of injecting insulin into the stomach looked strange.(Participant E)Getting diabetes at a young age, people would assume that I did not take good care of my body. Since then, I’ve been hiding my condition.(Participant A)[To the friends] I was so sorry…. I felt like a sinner.I was traveling with my friends when I realised I had not brought my medicine suddenly. We had been gone for two hours by car, but we had no choice but to return to my house to pick up my medicine. (Participant H)The patients with chronic disease believed that they had become “worrisome beings” who are dependent on others, causing stress to others and even needing care from others.Especially my daughter worries a lot. But, when we talk on the phone, maybe she’s busy, but it seems like she doesn’t want to hear what I’m saying and seems bothered… So, I felt disappointed. I felt miserable from feeling that I’ve become a person that just causes worries..(Participant B)The participants experienced the feelings of relinquishing control over their lives, including activities of daily living, to the illness and being “overwhelmed by the disease”. They considered the illness as “external shackles,” and believed that they were no longer the owner of their own lives as the illness had taken over.I hate looking at myself, not being able to eat whatever I want and having to be careful. I have to calculate each and every thing before eating, which gets frustrating at times. I feel happy when my outpatient test results are good, but if the results are bad, then I feel like it’s all over. This disease has swallowed me whole.(Participant A)The fact is that I have to live the rest of my life receiving treatment. This disease will torment me until I die. I think it’s meaningless to make future plans. It’s obvious that I won’t be able to do anything if the disease gets worse(Participant B)The participants described their withdrawal from their lives due to their chronic disease. They had a “fear of new challenges,” that is, being afraid to start something new, and they stated that their withdrawal due to the illness and looks from others had caused them to feel like an “outsider” rather than being at the centre of their own lives. Moreover, they experienced “withdrawal from the role within the family” as the role that they had played within their family structures changed or disappeared. Furthermore, they reported experiencing “financial constraints” during the disease treatment processes. The following quotations express these attributes:Healthy people can do a good job no matter what work they do, but people with an illness like me must be a bit more careful. Starting new work can be intimidating.(Participant B)People used to like me… I was always at the centre of gatherings and played a leader role. Now, I feel like an outsider.(Participant C)[rather than] a regular mom.I feel sorry about being a sick mom, and I hate the fact that my kids think of me as a sick mom (Participant A)I used to be a very outgoing person. But after I got sick, I was in a lot of pain and didn’t have much energy, so I avoided going out on my days off. As a result, I felt pushed out and withdrawn at times, even among my friends.(Participant I)The patients faced various changes that they needed to accept in their daily lives as they were diagnosed with the illness and being treated. Prime examples included “refraining from food”, “escaping from past lifestyles”, and “work restrictions”. Moreover, they accepted new health habits and felt the burden of integrating them into their daily life.I used to eat within five minutes, but now they tell me to take over 40 min to eat, no matter what. There’s no answer… Even the doctor said that is the answer.(Participant D)I have to take various medicines prescribed by the hospital three times a day. In the middle [of the day I must take] the medicine before a meal. I also have to exercise. I lost so much muscle after my last hospitalization, so I try not to skip muscle exercises.(Participant F)People like healthy people. Who likes someone with hypertension or diabetes? They had pity on me as they asked whether I am able to work even with diabetes.(Participant B)I enjoy spicy and salty foods, but since becoming ill, the number one food I should avoid is spicy and salty foods. It can be difficult to bear at times.(Participant G)Instead of a positive attitude while trying to overcome their illnesses, the participants experienced a “lack of hope” from repetitive and continuous negative experiences. At one point, they expressed having experienced the “self-perception of being a patient”.There’s no hope for getting better… I think only worst things will come from now… When I got hospitalised after things got bad, I had the scary thought of “will I get out alive?”(Participant F)I don’t do anything except go to the bathhouse when my hands and feet get too numb at early hours like the break of dawn. I have pity on myself because I’m a cancer patient.(Participant D)The definition of illness intrusiveness in patients with chronic disease identified in the fieldwork phase is: “the experience of persistent physical discomfort, psychological suffering, and a decline in value of existence due to the chronic disease; and psychological sadness from relinquishing control to the illness, as well as the difficulty of having to accept changes in daily life and social withdrawal in an unstable spiritual state”.In the final analysis phase, the results from the previous two phases were used to compare, review, revise, and combine the empirical results to determine the attributes of illness intrusiveness in patients with chronic diseases .Specifically, the final attributes of illness intrusiveness in patients with chronic disease can be divided into physical, psychological, social/contextual, and spiritual domains. Regarding the physical domain, “physical pain”, “fatigue”, “physical dysfunction”, “sleep disturbance”, and “sexual dysfunction” were identified in the theoretical phase. However, “physical dysfunction” and “sexual dysfunction” were not identified in the fieldwork phase, while “changes in body image” emerged in the fieldwork phase. In the final analysis phase, “physical pain” from the theoretical phase and “pain” from the fieldwork phase were confirmed, while “fatigue” from the theoretical phase and “loss of fitness” from the fieldwork phase were combined and named as “fatigue”. Moreover, “physical dysfunction”, “sleep disturbance”, and “sexual dysfunction” were named as “physical dysfunction”. Furthermore, “changes in body image” that emerged in the fieldwork phase was confirmed.Regarding the psychological domain, the attributes of illness intrusiveness identified in patients with chronic disease were “depression”, “loss of self-esteem”, and “loss of willpower” in the theoretical phase and “self-blame for the diseases” and “worrisome beings” in the fieldwork phase. These attributes were renamed as “psychological weakening”. Moreover, “eternal shackles” in the fieldwork phase was combined with and renamed as “uncertainty”, which was identified in the theoretical phase. Furthermore, “sorrow about being stigmatised”, which emerged in the fieldwork phase, was revised to “stigma”.Regarding the social/contextual domain, “escaping from past lifestyle” and “burden of accepting health habits” were identified in the fieldwork phase, while “restricted leisure activities” from the theoretical phase was not identified in the fieldwork phase. In the final analysis, “fear of challenges”, “outsider”, and “withdrawal from the role within the family”, identified in the fieldwork phase, and “role impairment” from the theoretical phase were revised and renamed as “withdrawal from role playing”. Moreover, “dietary restriction”, “financial burden”, “restricted leisure activities”, and “work restrictions” from the theoretical phase and “refraining from food” and “financial constraints” from the fieldwork phase were revised and renamed as “restrictions in daily life”. “Escaping from past lifestyle” and “burden of accepting health habits”, which emerged in the fieldwork phase, were revised and renamed as “burden of changing health habits”.Lastly, “lack of hope” and “self-perception of being a patient”, identified in the fieldwork phase, were grouped together with “self-concept” and renamed as “unstable spiritual state”.This study’s conceptual framework of illness intrusiveness for chronic disease by hybrid model is as follows : PatientIn the present study, the concept of illness intrusiveness in patients with chronic disease was analysed using a hybrid model proposed by Schwartz-Barcott and Kim , which iA diagnosis of chronic disease can not only cause physical suffering and psychological problems as a result of a long-term struggle with the disease but can also have an effect on the overall QOL of an individual, as it affects all aspects of life . In addiWith respect to the physical domain, “loss of fitness” and “fatigue” were attributes of illness intrusiveness in patients with chronic disease commonly identified in both the theoretical and fieldwork phases. A study by Park and Lee  on fatig“Uncertainty” in the psychological domain was an attribute identified commonly in both the theoretical and fieldwork phases. The uncertainty of not being able to form subjective judgment during the disease and treatment processes due to a lack of information and the unstable situation of disease progression  caused tAmong the attributes in the social/contextual domain, “burden of changing health habits” was newly identified in the fieldwork phase. For patients with chronic disease, change in health habits represent a prerequisite for long-term prevention and management of illness that must be sustained not only in clinical settings, such as the hospital, but also in their daily lives. However, it is difficult to change the long-held habits in their daily lives for various reasons. Firstly, short-term behavioural changes often do not produce noticeable results, and in such situations, it can be difficult to maintain motivation and they may easily turn back to their old habits due to familiarity with the past and preferred desires. In this process, most patients experience guilt . In the Lastly, the patients with chronic disease showed unstable spiritual states with “lack of hope” and “recognition of themselves as being stuck as a patient”. Hope helps to activate motivation to overcome adversity, reset goals, and find various solutions ; howeverThe limitations in the present study include the fact that in-depth interviews were conducted on only nine participants in the fieldwork phase and that there was a limited number of chronic diseases involved. Consequently, there are limitations in explaining illness intrusiveness for all chronic diseases. In particular, patients with mental illness, which have the characteristics of a chronic disease, were not included in the study. Therefore, future studies should include various chronic diseases to expand the concept of illness intrusiveness in patients with chronic disease. The attributes of illness intrusiveness in patients with chronic disease identified through the hybrid model concept analysis were derived by reflecting the negative state inherently contained in the concept of illness intrusiveness. Therefore, positive states that may develop during the treatment process were not analysed. In addition, the attribute “sexual dysfunction” could not be derived in the physical and fieldwork phases due to the limitation of interviews not providing enough opportunities to build rapport between the researchers and participants. Therefore, future qualitative study with more repeated interview sessions is recommended. Lastly, this study has limitations in that only papers written in English and Korean were used for the theoretical phase and in analysing illness intrusiveness by Koreans during the fieldwork phase. More research will be needed to determine how illness intrusiveness can be defined and what attributes are available in other cultures.The present study used the hybrid model concept analysis method by Schewartz-Barcott and Kim  to derivThe significance of the present study is that it identified the multi-dimensionality and attributes of illness intrusiveness in patients with chronic disease to present empirical evidence for each attribute and a definition of illness intrusiveness in patients with chronic disease suitable for Korea. Furthermore, attributes of illness intrusiveness that patients with chronic diseases experience, such as “changes in body image”, “feeling like an outsider”, and “lack of hope”, were newly identified in the fieldwork stage, which also represent key significance of the present study.